Prescribing & Medicines Management
page PM4
September 2005

Features

How to implement supplementary prescribing in primary care clinics

Pharmacists working in GP surgeries are not a new phenomenon. Practice-based pharmacists have been involved in audits, developing clinical protocols and medication reviews for some time, but the introduction of supplementary prescribing has increased opportunities and has led to some pharmacists becoming partners in general practices (PJ, 5 June 2004, p700).

As supplementary prescribers (SPs) with a few months experience, we felt it would be useful to share our experience and highlight tips for setting up clinics.

Setting up a clinic

· Agree clinic times and appointment duration with the independent prescriber

· Organise your appointments to allow time at the end of the clinic for administrative work

· Identify which room you will be using. This should be a clinical room (ie, it should have most of the equipment you require). If there is a high demand for space you should be prepared to share or not have a permanent room

· Brief the clinicians and practice staff of your plans. Provide everyone with a written summary of supplementary prescribing and an outline of your clinic. This can be supported with a flow chart, which can be used as a poster in consulting rooms and at the reception

· Give copies of your clinical management plans (CMPs) to both doctors and nurses and add them to the practice protocols on the practice computer system

· Be clear about how patients are to be referred.

Patient selection

· Use the first few sessions to identify patients (eg, through computer searches, audits or referral)

· Invite patients to clinics in writing or by telephone

· A patient information leaflet explaining the clinic and supplementary prescribing can be useful

· You may want to have exclusion criteria, (eg, patients with complex mental health conditions). This will depend on your area of practice and experience

· An alert message linked to a Read code can be attached to patient records and used to identify possible patients.

Communication

Service success depends on people understanding the service and how they fit in so effective communication is important. You can use practice meetings to update everyone on your progress and developments but you should also identify how best to communicate with different people. Some will prefer emails while others will prefer a note in their post box. Encourage people to give you feedback or suggestions on how to improve service. Never be too proud to take constructive feedback — people giving feedback want you to succeed or they would not bother saying anything. A good way of increasing your knowledge and skills is to participate in practice meetings (eg, audits, clinical team meetings and random case analyses).

Doctors Although the independent prescriber may have explained the process to other doctors, the SP should build good working relationships with all doctors and encourage them to refer patients and become independent prescribers.

Nurses Nurses should be able to refer patients to you and vice versa. Develop your relationship by understanding nurses’ roles within the practice and their clinics. Running an SP clinic alongside a nurse’s clinic works well for some SPs, especially where the nurse cannot prescribe. Nurses are usually happy to have support from pharmacists, who are generally more accessible than GPs.

Practice managers The practice manager is probably the nucleus of the practice. He or she ensures that the surgery runs effectively and is an important person to know. Practice managers will be skilled at using the computer system and could assist you with developing templates and converting CMPs and patient letters to attachments. He or she could also show you how to use the system and, with time, you will become competent.

Reception staff Known as “gate keepers”, reception staff can play an important role in identifying potential patients and booking your appointments. Receptionist staff can sell your medication review appointments to patients (eg, “we can offer you an appointment with the pharmacist. She can prescribe just like the doctor and knows a lot more about medicines”).

· Organise training or briefing sessions on the SP role and how this can be used within medication review clinics. This could be informal (eg, during a quiet period at reception or in response to a question).

· During the early days use every opportunity to promote your service when passing the reception desk.

· Help staff identify potential patients using a written summary of the service and a flow chart outlining the patient’s journey for supplementary prescribing. The flow chart can include examples of conditions for which the pharmacist can prescribe and the medicines he or she can prescribe. However, also ensure staff know your limitations — make sure you are not made to run before you are ready.

Patients Patients are your greatest advocates. A positive patient experience will ensure you gain trust and support. When you achieve this, you will find that word of mouth will soon ensure that you have a fully booked clinic. Positive experiences come from listening to needs, understanding fears and removing the mystery of medicines. Use simple analogies for lay people (eg, a diuretic, takes water out of a hosepipe to make it feel slack so decreases blood pressure).

Conclusion

Supplementary prescribing is an evolving role and taking time out to reflect on your practice is an important activity. This will ensure that you can improve your current practice, critically assess your competencies and learn to manage certain ethical dilemmas. Remember, as prescribers we are inadvertently dipping our toes into a medico-legal maelstrom — you stand or fall by your decision-making.

Our experiences have been positive and enjoyable but we have had to be tenacious and persistent in order to ensure pharmacist supplementary prescribing is a success where we work. This would not have happened if we had not engaged all parties in developing our roles and in the way we work.

The initial challenge is being able to demonstrate your integrity. This means making your own independent clinical judgements in a holistic manner that benefits patient care. Once you have done this, anything is possible.