It makes good business sense
Views on why pharmacists should prescribe, what training
they should receive, how supplementary prescribing will work in practice
and what
legal responsibilites prescribing brings were all presented at the seventh
annual Hospital Pharmacist conference held in London on 30 October. Gareth
Jones and
Rachel Graham (on the staff of Hospital Pharmacist) report
Jatinder Harchowol: pharmacist prescribing can lead to improved patient safety |
The business case for supplementary prescribing was presented
by JATINDER HARCHOWAL, assistant director, clinical pharmacy services,
Barts and the London NHS Trust. Mr Harchowal described the benefits that
pharmacist prescribing are likely to bring to both patients and the NHS,
drawing on studies and other evidence from the United Kingdom, the United
States and Canada to back up his views.
The potential benefits to patients of pharmacist prescribing include
increased choice and quicker access to care. There is also the potential
to increase patient supervision, Mr Harchowol said. Patient safety should
also improve (or will at least be maintained) and greater patient involvement
should improve treatment outcomes, he added. For the organisation, supplementary
prescribing by pharmacists has the potential to optimise skill mix and
resources, help trusts meet national service framework targets, reduce
the amount of money spent on wasted medicines and aid good clinical governance.
For these benefits to be received, and the business case to be made,
pharmacists need to be effective prescribers. Mr Harchowal pointed out
that there are not many controlled evaluations of how effective pharmacists
are at prescribing. But those that exist are positive. For example, a
US study1 showed that pharmacists were “as effective as, if not
better” than doctors at prescribing in the mental health field,
he said.
Although not controlled evaluations of pharmacist prescribing, other
studies2,3 show that pharmacists have good drug therapy management. In
the UK, there is evidence of the effectiveness of pharmacists’ prescribing
from situations where they are, in essence, already taking on prescribing
roles, Mr Harchowal added.
In addition, an evaluation report from the Alberta College of Pharmacists
(ACP) in Canada looked at some of the roles pharmacists can do, their
effectiveness when doing them and how those roles were developing. It
shows that pharmacists market themselves as experts in drug treatment
and are capable of recognising the limits of their own competencies.
It gives several examples of how chronic conditions can be managed well
by pharmacists. In particular, it refers to a study showing that pharmacist
prescribing in an asthma clinic improved patients’ symptoms and
lung function by 50 and 11 per cent respectively. Drug-related hospital
admissions also reduced by 75 per cent.4 This is “tangible evidence
of the impact pharmacists can make” stressed Mr Harchowal. He noted
that the ACP report highlighted that pharmacist prescribers operated
within strict guidelines on accountability and competency profiles. This
type of monitoring would be a key factor in taking pharmacist prescribing
forward in the UK, Mr Harchowal added.
Another key issue brought out is that the evolution of pharmacist prescribing
depends on the practice being accepted by patients, doctors, pharmacists
themselves and other health care professionals. Mr Harchowal told delegates
that patients basically want a safe, quick holistic service. The basic
message from patients is that they did not really mind who prescribes
for them, “so long as the prescriber is competent”, he said.
For hospital doctors, the acceptance rate of pharmacists’ recommendations
is greater than 90 per cent.5 But hospital doctors and other health care
workers do have some issues with pharmacists prescribing, Mr Harchowal
said. For example, in studies where health care workers were asked for
their views on pharmacist being given prescribing rights, both doctors
and nurses expressed concern that pharmacists would not have enough knowledge
of the patient and their clinical condition, that doctors would lose
the opportunity to review the patients’ drug treatment and that
there would be communication problems,6,7 Mr Harchowal said. These issues
will need to be addressed when making out a business case for supplementary
prescribing. For some concerns, Mr Harchowal added, pharmacists just
need to improve the understanding among others of the skills they already
have and the contribution they already make.
Mr Harchowal went on to discuss an example from a trust in his own area
where a successful business case was made out and a pharmacist is currently
undertaking training to become a supplementary prescriber. The pharmacist
concerned is working in a high-risk drug (eg, methotrexate, sulphasalazine)
monitoring clinic. She takes blood, monitors drug levels, advises on
alterations to doses, educates patients and communicates with primary
care providers. Her involvement has improved patient safety, increased
clinic capacity by 20 per cent, and reduced the total time patients took
in hospital from an average of 95 to 45 minutes, Mr Harchawol added.
The positive perceptions of the service as it stands from both patients
and practitioners meant that she was encouraged to become a supplementary
prescriber, so that she can take the final step forward in providing
a “complete package of care”.
Going forward, Mr Harchawol stressed that pharmacists have to take the
opportunity to make sure supplementary prescribing works. That includes
making sure that there is a need for them to prescribe before undertaking
training, and that their work and competencies are effectively monitored.
Mr Harchawol added that it is important to ensure that the shortcomings
seen now with prescribing by medical staff do not apply to pharmacist
prescribing in two to three years time.
References
1. Stimmel GL, McGhan WF, Wincor MZ, Deandrea DM. Comparison
of pharmacist and physician prescribing for psychiatric inpatients. Am
J Hosp Pharm
1982; 39:1483-6.
2. Leape LL, Cullen DJ, Clapp MD, Burdick E, Demonaco HJ, Erickson JI,
Bates DW. Pharmacist
participation on physician rounds and adverse drug events. JAMA 1999;282:267-70.
3. Hanlon JT, Landsman PB, Cowan K, Schmader KE, Weinberger M, Uttech
KM, Samsa GP, Cohen HJ. Physician agreement with pharmacist-suggested
drug therapy changes for elderly outpatients. Am J Health Syst Pharm
1996;53:2735-7
4. MacLean W. Clinical, economic and holistic evaluation of community
pharmacists’ enhanced
asthma care. Can J Clin Pharmacol 2001:8(Suppl):27
5. Strong DK, Tsang GW. Focus and impact of pharmacists’ interventions.
Can J Hosp Pharm 1993;46:101-8.
6. Child D, Cantrill JA. Hospital doctors’ perceived barriers to
pharmacist prescribing. Int J Pharm Pract 1999;7:230-7.
7. Child D. Hospital nurses’ perceptions of pharmacist prescribing.
Br J Nurs 2001;10:48-54. |
