Prescribing & Medicines Management
Issue no 5, p5
September/October 2003

Features

What pharmacist prescribers can learn from those who have gone before

Now that the first pharmacists have embarked on supplementary prescribing training, Professor Judy Cantrill revealed at a session at the last month’s BPC that there is a body of research that pharmacist prescribers should be aware — in order to avoid some of the traps into which others had fallen.

How doctors do it
Professor Cantrill, of the School of Pharmacy and Pharmaceutical Sciences, University of Manchester, drew attention to various pieces of research that revealed that much of GP prescribing is irrational, unscientific, inappropriate and unnecessary. A paper published as recently as this year confirmed that GPs admit that one in five prescriptions are not necessary.

Other research has revealed that the reasons for this include patients’ demands and expectations, and the fact that effective prescribing is time-consuming.

Prescribing is not considered a risky intervention by junior doctors. In addition, little attention is devoted to therapeutics for medical students and their prescribing skills are not assessed at all at undergraduate level.

How nurses do it
Lessons can also be learnt from nurse prescribers. The programme started to be rolled out in a significant way from 1996 onwards. As of a year ago, nearly 22,000 nurses were able to prescribe, but currently only about a half are actually doing so. “We do not want to see pharmacists getting into that position,” Professor Cantrill emphasised.

One of the reasons is that nurse prescribing was not linked to local needs — something that has been dealt with explicitly with pharmacists’ training: anyone applying for a place on a course has to demonstrate there is a patient need. The impact of not putting into practice a skill you have just learnt is well recognised: if you do not do it you quickly lose the competence and confidence to try.

Those nurses that do prescribe tend to prescribe wound care products. They express some anxiety about prescribing for the very young and the very old (incidentally an anxiety shared by doctors); a lack of adequate clinical information on which to base the prescribing decision; a reluctance to prescribe for patients not well known to the nurse; and, just like doctors, they feel under pressure from patients — either because the prescription requested is unnecessary, or the reason patients want the product is to avoid having to buying it OTC.

In addition nurses are fearful that they might be missing a serious diagnosis — they are happy to prescribe provided they know that the diagnosis has been made elsewhere first.

Nurses who prescribe do so from a limited range of products with which they are already familiar (pharmacists, on the other hand, will be familiar with a much wider range of products). But because nurses do not have experience with products they do not have the confidence to prescribe them and they worry about litigation. In the early stages of prescribing they like the support of their peers and like to talk to other nurse prescribers.

Another significant factor, and one which links back to what doctors find, is that they do not have enough time. Nurses find every stage of prescribing takes time: they check everything in the British National Formulary. Some even deny — in busy clinics — that they are prescribers: they will claim they are not allowed to prescribe a particular product and tell the patient to go to the GP instead. They also find it hard to deal with the paperwork as they do a great of prescribing in patients’ homes and need to record what they have done in the patients’ notes held at the surgery.

What do patients want
What do patients want from a prescriber? They want a professional who is competent, who offers continuity of care and a personal service, and they want total support. This does not necessarily mean they need a doctor. But with more professionals prescribing steps must be taken to ensure that care does not become fragmented and patients end up having to consult a different person for each condition.

Lessons for pharmacists
So what are the main lessons for pharmacists? It is crucially important that prescribing pharmacists prescribe on a regular basis — so they retain both confidence and competency. Contin-uing professional development is essential, and in the early stages, and for lone practitioners, peer support networks need to be put in place.

“And remember you are not prescribing for a clinical management plan, you are prescribing for a patient,” Professor Cantrill concluded.