Prescribing & Medicines Management
page PM3
June 2005

Features

Prescribing in a rheumatology clinic

In 2003 I took a supplementary prescribing course at Sunderland University. This allowed me to augment my skills in drug and medical history taking and phlebotomy, and to further my experience in prescribing, patient consultation and critical analysis. In March 2004, the opportunity arose to develop a rheumatology supplementary prescribing clinic at my hospital. This was discussed at a number of committees within the trust, and a pilot clinic was established for two months. As a result, we developed a combined pharmacy and physiotherapy rheumatology clinic, which is now almost a year old.

How the clinic works

A consultant rheumatologist reviews the notes of patients referred to the hospital by GPs. There are a number of different clinical pathways into which patients can be directed. One of these is to attend the supplementary prescribing clinic. The clinic accepts patients with mechanical back pain, radicular back pain or neck pain. It runs once a week, concurrently with independent prescribing rheumatology clinics. In our clinic, a supplementary prescribing pharmacist and a clinical specialist physiotherapist work together. We have 15 to 20 new referrals and 11 review appointments each month. Patients are given various questionnaires (eg, EQ5D questionnaire or a Rowland Morris questionnaire) that allow us to gauge their perceived pain and its impact on their quality of life. By analysing these measures at each visit, we can monitor the effect of interventions.

Supplementary prescriber My role as the supplementary prescribing pharmacist is to perform a thorough medication review, to screen for any possible contraindications, to agree a clinical management plan (CMP) with the patient and the clinic consultant, and to prescribe. Most new patients are offered a number of follow-up appointments, at which I review the effectiveness of any pharmaceutical intervention, and either dose titrate existing medicines or introduce new medicines, according to the CMP.

The CMP allows me to prescribe any appropriate medicine, within limits of the British National Formulary, evidenced-based practice and local protocols. The most commonly prescribed medicines include analgesics, amitriptyline, gabapentin and carbamazepine, with adjuvant agents, such as lansoprazole, calcium and bisphosphonates. Amendments to The Misuse of Drugs Regulations 2001 enabled supplementary prescribers in secondary care to prescribe Controlled Drugs from 14 March 2005. Before this, a patient group direction was in place at the trust to allow the supply of codeine phosphate and other weak opiates. This amended legislation has extended the scope of the clinic and gives patients a more diverse range of treatment options.

Clinical specialist physiotherapist The role of the clinical specialist physiotherapist is to assess the patient’s symptoms and to support (or oppose) the suspected diagnosis. Our physiotherapist has undertaken several courses on back pain management. She recommends appropriate physiotherapy for the patient and can refer patients for magnetic resonance imaging.

Independent prescriber The clinic consultant acts as the independent prescriber for the CMP and is available to offer advice and guidance.

Communication After the clinic, a letter detailing the findings of the consultation, the pharmacy and physiotherapy treatment plans and follow-up arrangements is sent to the consultant, the GP and the patient. Carbon copies of any prescriptions issued by the clinic are also sent to GPs to keep them informed of any medication changes. The CMP is kept in the patient’s medical notes with the patient’s letter. At the end of each clinic, there is a short case-conference with the consultant rheumatologist. This provides a useful forum for discussing any difficulties.

Clinic success

We commissioned a user survey to assess the perceived value of the clinic. Questionnaires were given to all patients who attended the clinic between November 2004 and January 2005. Twenty-four patients responded:

· All were “happy to be seen by a physiotherapist/pharmacist team instead of doctor”

· All were “happy to have medicines prescribed by a pharmacist instead of a doctor”

· 78 per cent thought that the supplementary prescribing clinic was “excellent”

· 75 per cent thought that their CMP would have an “extremely positive impact” on their condition

Secondary care provides an ideal environment in which to implement supplementary prescribing and offers excellent outpatient facilities, such as physiotherapy. Running supplementary and independent prescribing clinics concurrently facilitates communication and seamless care and reduces patient waiting times. In addition, the more extensive use of my clinical skills has given me increased professional satisfaction and illustrates how pharmacists can breakdown many of the barriers that exist between medical and allied health disciplines.

Future opportunities

With the success of the clinic comes an increased expectation and demand. I have recently been asked to extend the clinic to offer a pharmacist review slot, enabling the rheumatology team to refer patients with other rheumatic conditions and who require a holistic medication review.

The pharmacy department at Gateshead Health Foundation Trust is progressive and innovative, and has been expeditious in making use of the supplementary prescribing initiative. We now have eight pharmacists qualified as supplementary prescribers, all of whom are actively engaged in establishing a range of supplementary prescribing clinics in areas such as elderly care, diabetes, intermediate care and pharmacy manufacturing. Establishing a large pool of supplementary prescribers will allow all potential clinics to operate smoothly and help to maintain a high level of pharmacist-led patient care.

ACKNOWLEDGEMENTS Thanks to Jennifer Hamilton, consultant rheumatologist, Maureen Motion, clinical specialist physiotherapist, and other colleagues from the pharmacy and rheumatology team at the Queen Elizabeth Hospital, Gateshead.