Prescribing for hypertension and more
| Mohammed Ahmed, a prescribing practitioner
at Doncaster West Primary Care Trust, shares his experiences of
supplementary prescribing |
Mohammed Ahmed: forward-thinking practices should make full use
of
pharmacists’ ability |
Years of frustration with not being able to prescribe dissolved
with the news that pharmacists were to be allowed to
become supplementary prescribers. Before this, my medical colleagues
would almost
always follow my recommendations (I worked as a practice pharmacist)
but I could not implement them myself. Comments like “Mohammed,
you know drugs more than me” were common.
In March 2004, after training at the University of Bradford, I became
one of the first supplementary prescribers. Once I registered with the
Royal Pharmaceutical Society, and notified the Prescription Pricing Authority,
my primary care trust (and its print department, in order to get my prescription
pads), I was keen to put my skills into practice. I am lucky to work
at a forward-thinking surgery (where I did some of my training) which,
once I had my qualification, promptly took the opportunity to set up
a supplementary prescribing hypertension clinic. I started with a weekly
two-hour clinic with
15-minute appointments and saw my first
patient in May 2004. Fortunately I received my prescription pad the same
day.
Hypertension clinic
My PCT had the vision of a single centralised computer
system and funded the EMIS PCS system in all its surgeries. This allows
a paperless system.
Clinical management plans (CMPs) are electronic and can be easily produced
because there is no requirement for a physical signature from either
the independent or supplementary prescriber as long as the agreement
is recorded on the patient’s record. A CMP can be sent to the
independent prescriber who can agree it in a few minutes while the
patient is in the consultation room. A single centralised system means
that CMPs can be implemented across the PCT.
CMPs are based on Doncaster West PCT guidelines which, in turn, are
based on clinical guidelines from authorities such as the National
Institute
for Health and Clinical Excellence and the Scottish Intercollegiate Guidelines
Network. The PCT’s formulary group, which consists of three GPs
and three pharmacists, looks at current evidence and guidelines and makes
recommendations for approval by prescribing subgroups.
The whole practice team was made aware of the new clinic and my new role.
Patients with hypertension, identified either at a routine blood pressure
check or during a visit to the GP for another reason, are referred to
me. New
patients have tests (eg, full blood count,
glucose, urea and electrolytes, liver function tests, thyroid function
tests and electrocardiography) to rule out underlying causes. There are
no exclusion criteria and home visits are offered to elderly patients
who cannot come to the practice.
At each initial consultation, I make it clear to the patient that attending
the clinic is voluntary and that he or she is free to see the
independent prescriber at any time. I try to answer any questions and
record everything discussed. I perform a clinical review and take appropriate
actions — options include writing a prescription and requesting
further tests, such as 24-hour BP monitoring — before agreeing
the next appointment date (usually in four to eight weeks). The quantity
of drugs I prescribe depends on the date of the next appointment, but
I can make provision for a repeat prescription in case the patient cannot
make the next appointment.
Once blood pressure is stabilised, patients are discharged to practice
nurses. This allows me to see more patients with uncontrolled hypertension.
A patient can be redirected to the clinic if his or her blood pressure
becomes uncontrolled. In past 15 months two patients have had a sudden
increase in blood pressure after good control for nine months. A new
CMP has to be agreed for redirected patients.
Electronic CMPs and different interventions are allotted Read codes.
Read codes can be used to retrieve information for audits. Using them
allows me to find out how many patients have had their doses increased
or
decreased, drugs started or stopped, and what advice (eg, about side
effects) and test results they have been given.
All my prescribing decisions are evidence based. Other benefits of the
clinic include better interprofessional relationships, greater compliance,
more effective use of my pharmacy skills and fewer drug errors, although
I have not audited these. So far, the clinic has not received any complaints.
Since starting the clinic, I have seen 92
patients. We have only needed to send one
reminder letter to a patient, who attended at a later date. No patients
have refused to attend the clinic. I have only suspended one patient’s
CMP because of non-compliance — the
patient was adamant that she took her medicines but when I checked with
her pharmacy, she had not had any prescriptions dispensed for three months.
This was backed up by
24-hour blood pressure monitoring.
I have needed to prescribe outside a CMP on one occasion. One patient
was intolerant to beta-blockers, already taking bendroflumethiazide 2.5mg
and felodipine 20mg and drugs acting on the angiotensin system were contraindicated.
I wanted to prescribe
doxazosin but it is not on the hypertension CMP. In order to deviate
from the CMP, I
e-mailed the independent prescriber, giving the rationale for deviation,
and asked for agreement.
Most local community pharmacists are aware that I can prescribe any drug,
including Controlled Drugs, from the British National Formulary as long
as a CMP exists. I can also write private prescriptions under a CMP,
where necessary. However, two patients told me that one pharmacist had
refused to
dispense my prescription. Later I found out that this pharmacist thought
I was only
allowed to prescribe antihypertensive drugs. Progress
The clinic has since been extended and I now hold four
sessions in three practices. Anyone at a practice who wants a supplementary
prescriber’s
input can refer any patient to me. I have seen patients with hypercholesterolaemia,
hypothyroidism, epilepsy, ischaemic heart disease and diabetes. I have
also dealt with pain management and more complex patients who can have
many of the above conditions. In addition, I look into other issues,
for example, quality and outcome framework indicators.
Supplementary prescribing is about
enhancing quality of care for patients with chronic conditions through
cost-effective, evidence-based treatment. I believe the number of “non-medical
prescribers” will continue to grow because the supplementary prescribing
system supports the new general medical services contract. It also enhances
the role of pharmacist in a clinical team.
The lead pharmacist at the PCT monitors my prescribing using PACT data
and is satisfied with my prescribing. Although I have anecdotal evidence
of satisfaction with the clinic from
patients, independent prescribers, practice nurses and other staff, my
next step is to carry out an audit in the form of a patient questionnaire. |
