Prescribing & Medicines Management
Issue no 2, p7-9
March/April 2003

Features

Supplementary prescribing — opportunity of a generation

"The biggest opportunity for a generation" is how Clive Jackson (chief executive of the National Prescribing Centre) describes supplementary prescribing which, carried out by pharmacists and nurses, will be a reality within months.

The scheme aims to reduce doctors' workloads in dealing with common, chronic medical conditions, such as diabetes and asthma, freeing up their time so they can concentrate on patients with more complex needs.

It is also intended to provide patients with quicker and more efficient access to medicines and to make the best use of pharmacist and nurse skills.

What it means

The plan is now well publicised. Pharmacists and nurses will act as supplementary prescribers in close partnership with the patient's doctor — the "independent prescriber" — and, with the patient's permission, but only after initial diagnosis and assessment by the doctor.

"The relationship between independent and supplementary prescribers is the key to safe and effective prescribing," says recent guidance from the Department of Health.

Before supplementary prescribing can begin for any patient, an individual clinical management plan (CMP) for the individual patient and each specific condition has to be drawn up and agreed by both independent and supplementary prescribers.

The plan will specify the range of medicines that can be prescribed for the patient and the range and circumstances in which dose, frequency and formulation can be varied. Patients must be reviewed at least annually by the independent prescriber, ideally with the supplementary prescriber present.

Who will prescribe?

Before becoming a supplementary prescriber, a pharmacist or nurse will have to undergo training through an accredited programme. This involves around 25 taught days and 12 days "learning in practice" with an independent prescriber as a mentor.

Central funding to meet the costs of training is being made through local workforce development confederations (WDCs). PCTs and NHS Trusts, together with WDCs, will decide which pharmacists and nurses will be put forward for training. The decision will be made "in the light of potential benefits for patients and local NHS needs", according to the DoH.

Gul Root (principal pharmaceutical officer, Department of Health) says that if a WDC and local PCT think that, for example, an anticoagulant clinic will improve the situation for a heavily burdened surgery, they may identify a pharmacist or nurse who could run this as a supplementary prescriber.

"There is an expectation of how many pharmacists and nurses in each area will be trained, although there is some flexibility in the way these funds are used," says Ms Root alluding to the issue of remuneration.

When is it starting?

Although spring was given as a tentative date for the start of prescribing, no training schemes are, as yet, up and running with accreditation finalised. Ms Root is expecting some courses to start soon.

There has been some surprise at the length and weight of the course, especially for pharmacists, who are, after all, already trained to be experts in medicines and therapeutics. But Ms Root defends the time deemed needed for training.

She lists several aspects of prescribing that might need addressing by pharmacists:

• Assessing a patient

• Monitoring progress and response

• Physical examination

• Different models of consultation

• Psychological influences on prescribing

She adds that, although pharmacists are expected to attend most parts of the course, some may be exempt from certain days if they are able to demonstrate their proficiencies to their learning centre.

Working in practice

Ms Root envisages that early candidates for supplementary prescribing will be those already working closely with GPs or with hospital doctors. The former might include community pharmacists who work with GPs on a sessional basis, as well as practice pharmacists.

Ms Root emphasises that there is "no agenda whatsoever to exclude community pharmacists". "We are keen to see some community pharmacists in the first tranche of pharmacist supplementary prescribers," she says.

"We know many PCTs are doing lots of work with community pharmacists," she adds, suggesting these professionals will become more involved as time progresses.

This is the scenario according to community pharmacist Tim Hames from Uttoxeter. His PCT has been funding pharmacists to work half a day a week in each practice in the trust area. For the rest of their time they work for independent or multiple pharmacies.

It is these pharmacists who are most likely to become supplementary prescribers, Mr Hames believes, describing them (and himself) as "early adopters" — keen to try something new, particularly projects that are rewarding professionally.

Mr Hames has close links with his local GPs who are "always fully booked" and he hopes to take some of the pressure off them through supplementary prescribing. Patients may also be keen on a system that gives them more time with a health professional, he adds.

In hospital

"Patients like and trust pharmacists here," says Alison Ewing . She is director of pharmacy at Royal Liverpool and Broadgreen university hospitals, where pharmacists are the health professionals responsible for taking medication histories.

Although Ms Ewing does not believe that supplementary prescribing lends itself terribly well to the hospital setting, she believes it a huge opportunity and has submitted the names of several senior pharmacists for training to her trust.

"If chronic illness is properly managed we shouldn't see it in hospital," she comments. But in the real world, she sees the scheme used in clinic settings for conditions such as rheumatoid arthritis, chronic respiratory disease such as asthma and COPD and diabetes. Supplementary prescribing could continue when patients are admitted. "It would be great in home care management too," Ms Ewing adds.

She emphasises her belief that supplementary prescribing is for specialist, senior pharmacists. Many already have postgraduate qualifications and are effectively prescribing already, with the doctors' signature.

Medicines management

So how will supplementary prescribing affect medicines management? "Supplementary prescribing is medicines management" according to Christine Macrae (director of prescribing and medicine management, Broadland PCT).

"It involves establishing treatment pathways and the most appropriate treatment for the diagnosis. It is also about talking to and educating the patient," she says.

She believes that supplementary prescribing will start with hospital and primary care pharmacists and nurses. One reason for this relates to training and funding issues. "Practices already have an idea of the people who can take on tasks such as hypertension management and medication review."

Ms Macrae expects that the initial stages of drawing up management plans — the nub of the scheme — will involve a lot of work and that it will start as small steps, expanding as confidence increases.

She says that pharmacists leading or "nestling in" directorates should be "knocking on the right doors"— influencing trusts to get pharmacy prescribing on the agenda. "Be aspirational," she says.

Bearing in mind that patients have to agree to supplementary prescribing, Ms Macrae says that pharmacists should be working on how to bring patients on board. "There has been no guidance on this as yet," she says, suggesting approaches such as surgery posters to advertise possible changes in care and their advantages.

Gul Root acknowledges that patients, particularly older people, might resist supplementary prescribing, and that it is up to the prescribing partnership to explain the benefits, perhaps being seen more regularly, with more time and a proper medication review. They needed to give reassurance that patients could return to the independent prescriber at any time.

Patient centred care

Annie Coppel (Faculty of Medicines Management and Prescribing) comments that, in terms of medicines management, supplementary prescribing adds flexible professional resources into the prescribing arena to provide patient centred care.

"It will provide for more regular review of the patient, together with scope for earlier detection of adverse drug reactions, adverse effects and compliance problems," she says.

CMPs in particular, are patient specific. Although templates are available to be used, adapted or amended to suit local needs, the important thing is that each will be prepared specifically for a named patient, with enough detail to ensure patient safety, according to Ms Coppel.

They will also need to be fairly simple and quick to complete, and not duplicate a lot of information that is already contained in the shared medical record.

Ms Coppel also agrees that supplementary prescribing may help with concordance as patients are treated as partners in their care, involved at all stages of decision making.

Pitfalls

As mentioned earlier Clive Jackson (chief executive of the National Prescribing Centre) describes supplementary prescribing as the opportunity of a generation. While ultimately about patient care, the scheme would allow pharmacists to develop their skills, gain additional job satisfaction and be drawn more into the interdisciplinary team.

The NPC has just published an outline framework to help pharmacist supplementary prescribers.

Mr Jackson points out the findings of an early NPC survey which indicates that 70 per cent of PCTs would be putting pharmacists forward for supplementary prescribing and 78 per cent would be putting nurses forward. However, he also points out some issues that may cause problems. He believes there is relatively limited time to grasp this chance. "Services will push for nurse prescribers if they appear better," he says.

He wonders whether or not more professional guidance is needed on pharmaceutical issues and asks how pharmacists will be freed up to obtain almost 40 days' training while maintaining existing services.

Another potential problem is access to patient information. According to DoH guidance, pharmacists should not have a system of separate records. If not possible, separate records should be transferred to the common patient record within 48 hours.

Mr Jackson says that pharmacists need to have appropriate access to patient information at the right time to prescribe from a position of knowledge.

The possibilities

"If we don't go with supplementary prescribing, we run the risk of not getting another opportunity," Joe Asghar (regional pharmaceutical adviser, directorate of health and social care north) tells P&MM.

He has run a roadshow on the scheme and gives his impression of opinion. "There is definitely enthusiasm, though people recognise there are hills to climb," he says. "Those interested by no means underestimate the size of the task to get the additional educational support in place. Finding mentors is not going to be easy. But everyone recognises the value to patients and the profession"

A key issue flagged up at the roadshow was the communication between the independent and supplementary prescriber. This must be open, transparent and well-rehearsed, according to Mr Asghar, adding that if communication broke down, patients could be put at risk.

However, he did not believe that only established relationships would lead to supplementary prescribing. "Even if pharmacists had not previously had close working links with doctors, this would give you the opportunity to forge them," Mr Asghar suggests.

Liability

Although Mr Asghar mentions liability as an issue raised at roadshows, Mr Hames says that pharmacists live with liability all the time and that supplementary prescribing would just take this a stage further, as long as prescribers were properly trained and worked within reasonable parameters.

DoH guidance reminds supplementary prescribers not to act outside their area of competence and says that all such prescribers should ensure they have suitable indemnity insurance.

Mark Koziol (director the Pharmacy Insurance Agency) says that underwriters are concerned that training takes a "one size fits all" approach, adding that they are more interested in a certificate of competency.

Another ideal, from an insurer's point of view, is that patients always sign their agreement to supplementary prescribing and their management plans. However, they recognise that this is not always practical.

Regarding the costs of policies, Mr Koziol comments that independent prescribing by primary care pharmacists increases rates by a factor of 1.7, Mr Koziol believes that the shared responsibility of supplementary prescribing, would result in an uplift of less than this amount.

On a personal note, Mr Koziol says that if supplementary prescribing is really going to make a difference, moving much chronic care from the GP, "you've really got to do it in a community pharmacy setting". "It is not going to help in small handfuls," he adds

No rose tints

Supplementary prescribing could allow pharmacists and nurses to help take medicines management to a new level, with the patient the ultimate interest.

In the words of Joe Asghar "I don't think anyone is looking at it through rose-tinted glasses, but there is an enthusiasm for this real opportunity in so many ways."

Further information is available here (NHS Net address: nww.npc.ppa.nhs.uk)