Prescribing & Medicines Management
page PM2-3
July 2004

Features

How supplementary prescribing is working for pharmacists in practice

Supplementary prescribing by pharmacists started at the end of March when Neil Frankland, lead pharmacist for surgery at North Tyneside General Hospital, North Shields, wrote his first prescription (PJ, 27 March, p369). A month later, Fiona Reid became the first pharmacist to prescribe in primary care at Newbyres Medical Group surgery in Gorebridge, Midlothian (PJ, 1 May, p533). This was quickly followed by the first community pharmacist prescriber, Campbell Shimmins of Woodside Pharmacy, Doune, Perthshire (PJ, 8 May, p559).

A number of pharmacists have started prescribing since. So how are they getting on? Those working in primary care are surging ahead: supplementary prescribing is being used to add value to pharmacist-run clinics, many of which were already set up in GP surgeries. In hospitals too, pharmacists have started to use supplementary prescribing successfully in both clinics and on wards.

The pharmacists facing the most difficulties are those in the community. Although some community pharmacists are choosing to use their qualification to undertake sessional work in GP surgeries, it is proving difficult for them to prescribe in their own premises.

It has been said many times before, but the lack of access to patients’ medical records at community pharmacies is a barrier to prescribing. It can be overcome (as two pharmacists have proven, see later) but it is certainly an important issue. Another difficulty for community pharmacists is funding. In order to leave the shop floor so they can have a consultation with a patient, a second pharmacist is needed. And this costs money. Pharmacists also need to have access to a prescribing budget, something that is much easier to address when a clinic is run in a GP surgery or a hospital.

Asked how these barriers would be overcome, a Department of Health spokeswoman said: “One of the fundamental principles of supplementary prescribing is that the supplementary prescriber should have access to the common patient record. We recognise that in the first instance, there may be some problems for community pharmacists wanting to prescribe from their own pharmacies.” In terms of the funding issue, she commented: “The DoH allocates funding to strategic health authority workforce directorates to implement supplementary prescribing who determine how funds are used. Access to a prescribing budget is also a pre-requisite for pharmacists prescribing in the community or in primary care. Funding issues should be settled, prior to candidates undertaking prescribing training courses.”

Health is a devolved issue, so how supplementary prescribing is implemented in Scotland will differ. For a start, there is more of a focus on getting community pharmacists trained as prescribers than in England.

Frank Owens, chairman of the Scottish Pharmaceutical General Council, says: “So far 160 pharmacists, over 100 of whom are community pharmacists, have either completed or are completing the training programmes.” He comments: “This will provide a very solid foundation for the clinical and patient care components of the new community pharmacy contract in Scotland. The SPGC and the Scottish Executive are continuing to work together to ensure further initiatives with community pharmacists will be forthcoming, utilising the skills of these prescribers as we move towards the implementation of the new contract.”

Guidance for supplementary prescribing pharmacy practitioners is expected to be published by the Scottish Executive next week.

Hospital pharmacy

Hospital pharmacists have started to use supplementary prescribing in two situations: on wards and in out-patient clinics.

Emma Graham-Clarke has been prescribing since the middle of April. She is a locum consultant pharmacist within the division of anaesthesia and critical care at City Hospital, Birmingham. “I can prescribe anything and everything on the critical care ward,” she explains. “Most commonly I am prescribing longer-term drugs used in intensive care, such as for treating infections, hypoglycaemic control, prevention of stress ulcers and DVT, and for bowel motility.” However, her prescribing is not limited to these areas: “I include anything that might require a dose change when the independent prescribers are not around.”

Miss Graham-Clarke uses a generic clinical management plan (CMP) which is then customised for each patient, and prescribes according to the hospital formulary and guidelines stated on the CMP. She says that the CMP can be restrictive: “We always forget to put something on it that I want to prescribe.” The other problems she has faced have been over the current restrictions on supplementary prescribing: neither Controlled Drugs or unlicensed medicines can be prescribed. “We use a lot of Controlled Drugs in intensive care and not being able to prescribe them is a problem.” Overall, Miss Graham-Clarke says that supplementary prescribing has helped to take her role forwards. “It has made me more involved in the ward team, given me confidence within the unit and improved my working relationships.”

Neil Frankland wrote his first prescription for an elderly patient with constipation and is still prescribing in the same area. He has not yet been able to extend his role further. “We are in the process of getting other pharmacists through the prescribing course. Until we reach a critical mass of pharmacist prescribers we cannot do a lot more because of ensuring continuity of care,” he explains. “We are also addressing issues such as the CMPs and patient consent. Using a paper-driven system is too cumbersome.”

A hospital pharmacist who plans to start prescribing at an out-patient pain clinic next week is Mark Thomas, lead clinical pharmacist for ward services at the Queen Elizabeth Hospital in Gateshead. “Patients will be seen by a consultant and then referred to me for prescribing pain relief. This will include prescribing for chronic back and joint pain, and neuropathic pain,” he explains. “I will also see patients who are having pharmacy-related problems, such as compliance difficulties, or side effects with rheumatoid arthritis drugs.”

Primary care

Of all the situations in which pharmacists can now prescribe, clinics in GP surgeries is by far the most common.

Amanda Evans, lead pharmacist for supplementary prescribing at Burntwood, Lichfield and Tamworth PCT, has just been awarded a research grant by the research charity The Health Foundation to look at the implementation of supplementary prescribing in primary care. “I will be comparing implementation in two PCTs and will be able to track problems as they happen. I will also be interviewing people to see how their opinions of supplementary prescribing change over time,” she explains.

Mrs Evans is one of five pharmacists in the PCT who have completed the supplementary prescribing course. All are already running clinics at GP surgeries and will prescribe within these. “In future, pharmacists will find it easier to start prescribing because we are putting the infrastructure in place now, such as ensuring we have covered clinical governance, and working out funding.” Funding has come from a number of sources: the new GP contract, the personal medical services contract and prescribing monies. Mrs Evans will start prescribing next week for patients with dyspepsia. “I hope to branch out into other areas of chronic disease management, concentrating on targets in the new GP contract. This is the way the surgery will be able to fund me.” She adds: “Having a CMP means that patients are partners in deciding what treatment they will have. This buy-in is important in terms of concordance.”

Marian Bradley is practice pharmacist at Northgate Practice in Walsall in the West Midlands where she runs warfarin clinics. “I have been seeing these patients and monitoring their warfarin for nine years. Getting the CMPs written is the rate-limiting step because I want to have patient-specific CMPs,” she explains. Many patients see Mrs Bradley for all their medicines, not just warfarin, so a CMP to cover all their medicines has to be drawn up. “It is wonderful not to have to leave the patient, go up the corridor and wait outside the doctor’s door to get a prescription signed,” she comments. “Even though the prescriptions are not computer-generated yet so I have to write each one out by hand, it is still quicker than standing outside the doctor’s door.”

Fiona Reid has been prescribing for several months now and is positive about her experience: “Patients and the GPs have been very supportive. No patient has refused to be managed with supplementary prescribing,” she comments. “The biggest issue is not having computer-generated prescriptions. At the moment, we have been told that because of the small number of prescribers it is not cost-effective to produce computer-generated prescriptions.” What this means is that pharmacist prescribers have to put the data into the computer so the patients’ record is updated, print out a prescription that they cannot sign and then write out the items again on a handwritten prescription pad. The other difficulty that Mrs Reid has faced is that she had hoped to extend the clinics by employing a community pharmacist to run the existing clinics so she can set up new ones. “The problem is that I have not been able to get funding to do this,” she says.

Doncaster West PCT employs Mohammad Ahmed, a primary care pharmacist, to run hypertension clinics at Conisbrough Health Centre and Petersgate Medical Centre, both in Doncaster. He has been prescribing for five weeks. New patients identified with hypertension are referred to him. “Once I have agreed the CMP with the patient, I send an electronic message to the GP,” he explains. “All our CMPs are on the computer, we don’t have any paper forms.” The GP then adds a code to the patient’s CMP to confirm agreement and sends a message to Mr Ahmed with any comments needed.

Mr Ahmed says that agreeing CMPs with the GP is the biggest hindrance to supplementary prescribing. Both he and the GPs run clinics in the afternoons between 2pm and 4pm and this makes it difficult to gain their agreement to CMPs during these hours. An advance agreement for the majority of patients was the solution the practice came up with. He can use supplementary prescribing for any patient who can be treated according to the Doncaster West PCT hypertension guidelines. “I only have to wait for GP approval if I want to prescribe outside the Doncaster West guidelines,” he explains.

Garry Barrett is a community pharmacist who undertakes sessional work at Winshill Health Centre in Burton-on-Trent where he prescribes for patients with diabetes, hypertension and chronic obstructive pulmonary disease. Patients are referred to clinics run by him and a nurse prescriber by the GPs at the practice. “The GPs are trying to focus on the acute side and leave chronic disease management to us,” he explains.

Community pharmacy

Campbell Shimmins was the first pharmacist to write a prescription in a community pharmacy in the UK. He is prescribing in the cardiovascular area, mostly beta-blockers, ACE-inhibitors and nitrates, at a rate of about two or three prescriptions a week. “One advantage is that patients have access to me without having to wait for an appointment. Because the number of patients I am prescribing for is still fairly low at the moment, I am seeing them without an appointment. This is one of our main strengths and I don’t want to undermine it,” he comments. “Becoming a prescriber has certainly increased my professional standing.”

Mr Shimmins has financed the service through money he was already receiving as part of the pharmaceutical care model schemes that operate in Scotland. Through the model scheme, he has been going to the surgery to review patients’ notes for some time. This allows him to identify patients with drug-related problems who need monitoring. “These are patients on five, six or seven drugs. Any blood tests needed are carried out and then I monitor them closely for the next few months, prescribing for them according to the CMP. Once they have stabilised I refer them back to the surgery to be managed through the usual repeat prescription service,” he explains.

Mr Shimmins has regular meetings with the GP to agree and update CMPs. Overall, he says that he has not encountered any barriers to introducing supplementary prescribing, although comments that communication could be better. One particular problem is finding out patients’ blood test results for which he has to telephone the surgery. “An electronic system would obviously be best. And this would be improved further if I could take the blood samples here and if I could have access to the blood testing laboratory system rather than having to go to the surgery for results,” he comments.

George Romanes, who runs a community pharmacy in Duns, Berwickshire, is about to start prescribing. He has negotiated funding to allow him to run asthma and hypertension clinics at his pharmacy and is currently writing CMPs in preparation for the first clinic. “Initially I am targeting patients with asthma who have high ‘do not attend’ rates at the surgery or who have poor control. We are hoping that they will respond better to the open-access situation that I can offer at the pharmacy,” he explains. Similar patients with hypertension are also being selected. Mr Romanes highlights the fact that some patients do not visit surgeries because they are not in town centres and because of a wait for appointments: easier access is one of community pharmacy’s strengths.

At the moment, Mr Romanes has to go to the local surgery to access patients’ medical notes and he writes the CMPs there. “I have just been connected to the NHSnet so this makes communication with the surgery much easier,” he explains. Using the NHSnet connection, he will feed back information such as changes to patients’ medicines to the practice manager who has agreed to update the notes.

Mr Romanes has managed to overcome many of the barriers facing other community pharmacists in putting supplementary prescribing into practice. He will be paid £36 an hour to the run the clinics by NHS Borders. And one of the technicians working for him is currently training to become a checking technician so this will allow him to leave the shop floor for consultations. In addition, he comments: “One of the reasons asthma and hypertension have been picked is because I don’t need to carry out invasive testing in the pharmacy.” Although he would be happy to take blood samples, using non-invasive tests initially helps to give people confidence about his new role.

These pharmacists are proving that supplementary prescribing works. It will be easier for future pharmacists to follow in their footsteps, but community pharmacists, in particular, face real issues that need to be addressed or their prescribing training will be wasted.