Thoughts on independent prescribing
| In this article, Hugh McGavock,
visiting professor of prescribing science, University of Ulster,
Northern Ireland, explains why he supports supplementary prescribing
but not independent prescribing |
I have spent most of the past 25 years researching prescribing
by GPs and seeking ways of making it safer and more effective. Despite
my work and that of about 150 other dedicated doctors, pharmacists, sociologists
and psychologists in the UK Drug Utilisation Research Group, prescribing
continues to be a major source of sickness and death across the developed
world.
The only country to conduct a continuous national research programme
into drug-induced harm is the US. There, preventable prescription-related
death is now the fourth cause of mortality after heart disease, stroke
and
cancer and equal to the mortality caused by road traffic accidents.1,
2 This appalling statistic is almost certainly replicated in the UK.
In a recent report from the National Patient Safety Agency there are
840 deaths due to safety lapses in acute trusts in England each year
but, as the agency admits, this is probably an underestimation. By far
the most innovative researchers and thinkers in this field are Charles
Hepler and Richard Segal, of the department of pharmacy health care administration
at the University of Florida, whose seminal text2 exposes, in depth,
the many factors contributing to prescription-related deaths.2 To quote
Professor Hepler and Professor Segal: “Relatively safe and effective
drugs are released into a very unsafe prescribing, dispensing and consumption
environment.” Their conclusion and solution is that nobody, whether
doctor, pharmacist, or nurse, should be permitted to prescribe solo.
In an activity so fraught with danger to the patient, it is essential
that at least two qualified and experienced professionals, preferably
a doctor and a pharmacist, should have joint ownership of most prescriptions,
whether for acute or chronic conditions.
Why do I say that? Simply because safe and effective drug therapy depends
on three things:
· Accurate diagnosis
· Comprehensive knowledge of the basic pharmacology relevant to therapeutics
· Accurate compliance by the patient
There is only a limited amount that professionals can do
to ensure patient compliance. Many studies have indicated that approximately
30 per cent
of all preventable prescription-related morbidity is caused in a variety
of ways by poor compliance. However, this is not central to the this
article.
In respect of diagnosis and knowledge of pharmacology, the situation
in the UK is that doctors receive three years of intensive undergraduate
training in diagnosing illness, including the essential element of the
differential diagnosis. This is followed by at least three further postgraduate
years training in a specialty. If a good doctor can do anything well,
it is diagnosis. But this intensive training contrasts with the under-teaching
of pharmacology and therapeutics in almost all UK medical schools. Less
time is now devoted to the teaching of pharmacology than was the case
30 years ago, even though since then pharmacology has increased its knowledge
base about 50 fold. Moreover, in many medical schools, students can qualify
in medicine having failed their pharmacology examination. The General
Medical Council, the universities, and the Department of Health, appear
to be unwilling to remedy this imbalance in training. With the exception
of anaesthetists, postgraduate doctors do not have to pass a pharmacology
examination, so there is no stimulus to learn it. Hence, according to
my initial definition, doctors cannot achieve adequate efficacy or safety
alone.
Other prescribers
Pharmacists, on the other hand, spend about four years
learning pharmacology in depth. Their knowledge of the subject is much
greater than that
of most doctors. However, pharmacists know little about either diagnosis
or differential diagnosis. Any diagnosis they do is based on history-taking
and some non-intrusive procedures such as urine testing and measuring
blood pressure. Above all, pharmacists do not have access to the real
evidence — the patient’s body. Only the age-old medical
diagnostic procedures of inspection, percussion, palpation, and auscultation,
followed by other key diagnostic aids when necessary (eg, haematology,
blood biochemistry, serology, radiology, etc) can determine whether
the diagnosis based on symptoms is likely to be right or wrong. If
the diagnosis is wrong, the prescription will incur risk and zero
benefit.
Nurse prescribing, above all, is fraught with risk which will, no doubt,
become apparent as many thousands of independent nurse prescribers are
authorised over the next two years. Training comprises 25 days’ teaching,
half of it by “distance learning”, followed by two weeks’ semi-supervision
by a GP. Here we have government policy allowing people who have not
been adequately trained in either diagnosis or in the complexities of
modern pharmacology to prescribe.
The solution to this important problem in delivering pharmaceutical care
is simple and logical: doctors need to co-operate with pharmacists for
every prescription written, especially in respect of chronic conditions
and for elderly patients. Clearly, this is already happening in hospitals
on a national scale, with the acceptance of the clinical pharmacist as
an essential part of the clinical team at the bedside. Few medical specialists
feel any degree of resentment about the pharmacist’s input — quite
the reverse; many will not conduct a major ward round without a pharmacist
being present.
What about primary care? There is good evidence that clinical pharmacy
should now become an accepted part of general medical practice. Perhaps
it is not necessary in short-term monotherapy, or indeed for many standard
treatment regimens (eg, for managing asthma or hypertension). But for
patients on most long-term maintenance therapies, the pharmacist should
be involved before any additional treatment is added. This applies particularly
in the elderly patient on polypharmacy, where approximately 12 per cent
of all acute emergency hospital admissions are caused directly by the
prescribed medication.2
In summary, my opinion, backed by voluminous research across the world,
is that supplementary prescribing by pharmacists fulfils the requirements
of diagnostic and pharmacological knowledge, provided there is sufficiently
accurate and up-to-date record-keeping and regular exchange of opinions
between the doctor and pharmacist. However, I think there is good evidence
that independent pharmacist prescribing cannot be clinically justified,
just as the present solo prescribing by GPs is not clinically justifiable.
Partnership is the way ahead, and is an important way of improving the
safety and efficacy of medication. Unfortunately, this does not appear
to fit with the requirements of current UK policy, where pharmacists
and nurses are increasingly being used to make up for the shortage of
doctors. A prime example of the risks of this policy is the switch of
chloramphenicol eye drops to a pharmacy medicine. Besides simple conjunctivitis,
the red, irritable eye may be due to the following sight-threatening
differential diagnoses, which the pharmacist is unlikely to be able to
distinguish between: dendritic ulcers, scleritis, anterior uveitis, foreign
bodies and acute glaucoma.
The pharmaceutical and medical professions must assert their own pre-eminence
and the primacy of patient safety. They should also seek the changes
in regulations required to make joint GP-pharmacist prescribing a national
reality.
References
1. Huang B, Bachmann KA, He X, Chen R, McAllister JS,
Wang T. Inappropriate prescriptions for the aging population of the United
States. Pharmacoepidemiology
and Drug Safety 2002:11:127–34
2. Hepler C, Segal R. Preventing medication errors and improving drug
therapy outcomes. Boca Raton: CRC Press; 2005 |
