Health Services Research and Pharmacy Practice
Measures of competence now required
Objective and reliable measures of pharmacists’ competence in
history taking and diagnosis must be developed and applied as part of
the prescriber
registration process, according to researchers at the Robert Gordon University
and the University of Aberdeen. This, they say, will dispel the concerns
of doctors and others regarding pharmacists’ ability to progress
to independent prescribers.
Lesley Diack presented the results of a study, which concurrently explored
the views of pharmacist supplementary prescribers, their corresponding
independent prescribers (doctors) and patients recruited by the pharmacist
prescribers. Dr Diack and colleagues conducted telephone interviews with
nine supplementary prescribers in Scotland, eight doctors and 18 patients.
The pharmacists worked in a variety of areas, including respiratory,
cardiovascular, rheumatology and oncology.
Pharmacists and doctors were asked about the perceived benefits and challenges
of supplementary prescribing, changes in pharmacists’ roles, relationships,
support structures, continuing professional development and independent
prescribing.
Patients were asked about their understanding of supplementary prescribing,
their expectations of and experiences with a pharmacist prescriber and
satisfaction with the service.
The researchers found that all three groups were supportive of supplementary
prescribing. They identified benefits for patients and further integration
of pharmacists into the healthcare team. The patients interviewed did
not raise any concerns. However, they had little idea of what to expect,
which in turn led to feelings of anxiety. But overall, they felt the
consultation met their needs and were satisfied.
Both pharmacists and doctors were worried about a lack of funding for
service development and a lack of appropriate CPD. In addition, pharmacists
believed that there was a lack of pharmacist support networks.
A tension between pharmacists and doctors emerged with respect to independent
prescribing, with pharmacists being keen to undertake it but doctors
being less supportive, citing worries around inadequate history taking
and clinical examination skills. In contrast, patients had no views about
pharmacist independent prescribing.
“Perhaps what needs to be developed is some objective methods to assess
pharmacists’ competence,” said Dr Diack. “This is one
of the things that we are now developing. The next stage of our research
is to look at pharmacists’ competence using videos and to try to
see if we can get a competence base.”
Richard Cooper, of the University of Nottingham, presented findings from
a study of pharmacists’ views on their supplementary prescribing
training. A postal questionnaire was sent to all pharmacists registered
as supplementary prescribers in England in April 2007 and 411 responses
were received.
Respondents were generally positive about the training but suggested
some improvements that could inform course development. These included
more training on patient examination, clinical, consultation and diagnostic
skills, as well as more learning from practising non-medical prescribers
and guidance on implementing supplementary prescribing.
Some respondents criticised the amount of pharmacology training received,
which they viewed as a waste of time.
Paul Buckley: pharmacist prescribing supported
by hospital trusts
|
A third study on supplementary prescribing
was presented by Paul Buckley, of the pharmacy department at Leighton
Hospital, Mid Cheshire NHS Trust.
This study investigated implementation of prescribing within five NHS
trusts in the north west of England.
Mr Buckley and colleagues found that pharmacist prescribing was supported
within the trusts and was implemented to varying degrees. Being a foundation
trust or a teaching trust did not affect the extent of implementation,
he said.
The study identified that clear governance arrangements and good interprofessional
relationships were key supporting factors in the introduction of pharmacist
prescribing. A potential barrier to implementation identified was the
attitudes of pharmacists within the trusts.
Reasons for not prescribing
included perceived bureaucracy and reluctance to undertake a conversion
course to become an independent prescriber.
Reclassification of sumatriptan
Most pharmacists are confident to sell sumatriptan over the counter
but few have the opportunity, according to a study of pharmacists’ early
experiences of selling the drug after its switch from prescription-only
status.
Melanie Tasker, a preregistration trainee, presented the results of
a study she conducted as part of her MPharm final-year project at the
University
of Nottingham. Semi-structured interviews were carried out with 20 community
pharmacists in January and February 2007, around six months after sumatriptan
became
available over the counter.
Participants were generally positive about the reclassification but felt
that the volume of sales had been low.This was attributed to the high
cost of the medicine, the availability of alternative medicines and a
lack of awareness among customers that they can buy sumatriptan’s
over the counter. Respondents were happy with the training material they
received from the drug’s manufacturer.
Ms Tasker noted that the drivers for reclassification — cost control,
brand awareness and self-care — had not yet been met in this case.
A poster on the same subject, with similar results, was presented by
researchers from the Robert Gordon and Cardiff universities.
Simulated patients
Using simulated patients (SPs) is an acceptable and suitable way of
assessing pharmacy practice in Britain but to determine whether it improves
the
quality of consultations will require large-scale trials, say researchers
at the University of Aberdeen.
The researchers randomised 20 pharmacies
in Grampian to receive three covert visits from SPs who presented them
with three scenarios — a direct request for ibuprofen, an advice
request for indigestion and a direct request for omeprazole.
The pharmacies were given immediate feedback from the SP or feedback
from a pharmacy educator (a middleman between the SP and the pharmacist).
The researchers found that, although the outcome of consultations was
appropriate, the way pharmacists and their staff derived their recommendations
needs to be improved.
Can antenatal care be provided by community pharmacists?
Pharmacists are well placed to provide support in pregnancy but confidence
levels, and time and premises constraints, need to be addressed, according
to researchers at Brighton University. Mike Ellis-Martin presented
findings from a survey of 105 community pharmacists in the Brighton,
Worthing and Eastbourne areas conducted in February 2007.
The self-reported attitudinal questionnaire related to specific topics
in antenatal care and was drawn up using guidelines developed by the
National Institute for Health and Clinical Excellence on antenatal care
in the community. It was designed to test pharmacists’ confidence
in areas of advice giving and their opinions on providing certain services.
A total of 70 pharmacists responded to the survey. Pharmacists were most
confident (>90 per cent) about giving advice in pregnancy on alcohol,
smoking, heartburn and constipation. However, they were not quite as
confident at talking about medicines, with only around 80 per cent of
respondents being confident about giving advice on prescribed and over-the-counter
medicines, said Mr Ellis-Martin.
Pharmacists were least confident about giving advice on vaginal discharge,
travelling abroad, food-acquired infections and complementary therapies — over
50 per cent of respondents were “not at all” or only “slightly” confident
about advising on these issues.
Regarding which tests could be provided from a community pharmacy, respondents
indicated that weight measurements and tests for gestational diabetes
and pre-eclampsia would be appropriate. They considered breast examination
and tests that involved handling bodily fluids to be inappropriate.
In general comments made about the possibility of greater involvement
in antenatal care, respondents cited issues such as lack of time and
training, lack of confidence, liability and handling blood as possible
problems.
The researchers concluded that further work needs to be done to canvas
the opinions of midwives and patients. Mr Ellis-Martin revealed that
the research group had just completed an online survey of 16–70-year-old
women about attitudes to the provision of antenatal advice from pharmacies.
Preliminary results indicate that those surveyed had little intention
of consulting a pharmacist for advice on anything, let alone antenatal
care, he said.
Karen Rosenbloom, of King’s College London, suggested that pharmacists
should look at what they can achieve under the existing contractual arrangements,
such as providing targeted medicines use reviews for pregnant women and
those planning to conceive. However she noted that pharmacists’ lack
of confidence in this area would need to be addressed first.
Perceived costs of employing accuracy checking technicians
Accuracy checking technicians (ACTs) may not be financially viable
in small pharmacies or those within primary care trusts that have limited
pharmacy service development, said Nicola Turner, University of Manchester.
Ms Turner presented findings from a study of the perceived financial
factors affecting employment of ACTs in 33 pharmacies within a PCT area.
She said that 17 pharmacists considered that ACTs would increase profit,
seven thought that they would decrease profit, five said that they would
keep the profit neutral and four were unaware of the potential financial
impact.
Freeing pharmacists’ time to deliver additional services, improving
customer satisfaction and replacing a second pharmacist were reasons
cited for ACTs increasing profitability.
Those who thought ACTs would decrease profits gave their wages, unproductive
use of their skills and training costs as reasons.
Ms Turner said that it is a concern that ACTs may be deskilling the pharmacy
workforce by replacing second pharmacists without being able to provide
additional services and suggested that the potential affects of this
on service delivery should be assessed.
Other challenges include getting
the right balance to enable service development and ensuring financial
barriers do not prevent patient access to additional services, she said.
Medicines information on the internet
How medicines information on websites is presented determines how easily
it is found and understood by patients, according to Donald Nicolson,
of the University of Leeds.
Mr Nicolson evaluated the five most frequently accessed UK and US
health websites for ease of use and understandability of their information.
He recruited 15 medicines users over 30 years old who were randomly
assigned
to each website and asked to search for specific information about
simvastatin.
On four occasions, less than 80 per cent of participants located the
information, being hampered by site layout, including cluttered links,
and failing to notice the table of contents.
The study also identified conflict between personal knowledge and online
information, which made it difficult for participants to locate and
explain the information, said Mr Nicolson. Participants had a lack
of trust for
pharmaceutical company and US-developed websites.
Mr Nicolson recommended that sites should have no cluttering of text
links, display a warning when the user exits the site, have a find
bar and have a professional design.
Evaluation of a “do not dispense” intervention
A community pharmacy “do not dispense” scheme could be considered
as part of an NHS waste reduction strategy. This was the conclusion of
researchers at King’s College London following a four-week trial
of the scheme in two Hertfordshire community pharmacies.
Karen Rosenbloom explained that, during the study, 45 out of 14,495 prescribed
items were not dispensed. These items had a value of £483.96, with
the most expensive item being £96.60.
Most of the reasons identified for not dispensing items were processing
rather than clinical. Reasons given included repeat prescriptions being
instigated unnecessarily by medical staff, and intentional non-adherence
and hoarding of medicines by patients.
No medicines use reviews were triggered as a consequence of this scheme,
Dr Rosenbloom admitted. The researchers had hoped that MURs would support
the scheme financially.
“From analysing the data, we have come up with a funding structure for
this intervention of £2.50 plus 15 per cent of the value of the
item not dispensed. That seems to hold for items up to a value of £100
or £150,” said Dr Rosenbloom. Above that value, the funding
structure no longer works and pharmacists are unlikely to intervene,
she added. The funding structure is based on 28-day prescribing, which
is being implemented throughout the primary care trust area.
The study identified the need for GP staff to be supported to reduce
errors in prescription processing and that a way of covering the remuneration
issues for expensive items
ordered but not dispensed needs to be
developed.
Dr Rosenbloom said that one interesting observation to come out of the
study was that patients could not identify which medicines they did or
did not need from their prescription.
“We had to introduce an additional intervention where the patients physically
viewed the items and selected which ones they needed,” she explained.
We need to look at why patients don’t recognise their medicines,
she added.
The service has now been commissioned by practice-based commissioning
groups across Hertfordshire. |
The
Pharmaceutical Journal