Prescribing & Medicines Management
page PM2
December 2005

Features

Supplementary prescribing one year on

I have delivered a pharmacist-led cardiovascular risk reduction clinic in two general practices in Midlothian since 2001.¹ In addition to initiation and titration of medicines for hypertension and cardiovascular risk reduction according to clinical guidelines,² individualised lifestyle counselling is provided together with patient education and holistic medication review. Patients are referred to the clinic by GPs, nursing staff or themselves and the clinic population encompasses those with multiple illnesses, including mental illness, as well as those with learning disabilities.

Before legislation allowed pharmacists to prescribe, I made recommendations regarding initiation of drug treatment, after ensuring appropriate assessment, to the GP, which were then implemented via a GP prescription. I monitored, titrated and reviewed therapy at subsequent reviews. Patients are referred back to the practice nurse or GP for monitoring when their pharmaceutical care needs had been addressed, although many choose to continue attending the clinic.

Implementation

In January 2004, I completed the first supplementary prescribing course for pharmacists at the Robert Gordon University in Aberdeen and began to provide a routine service in April 2004, when prescription pads were available. In the period between I designed two standardised clinical management plans (CMPs) based on the British Hypertension Society guidelines2 and the local (Lothian) joint formulary, and these were agreed by the 16 independent prescribers in the two practices. One CMP covers hypertension and primary prevention therapy and the other covers hypertension and secondary prevention therapy, including the management of patients with diabetes. These reflect different target blood pressure (BP) levels and cardiovascular risk reduction management strategies. The CMPs are individualised based on a patient’s concurrent illnesses, biochemistry and previous adverse drug reactions before agreement by the independent prescriber.

Because the clinic had been in place for three years before the introduction of supplementary prescribing, some patients had already received appropriate evidence-based pharmaceutical care. I decided, therefore, to use pharmacist prescribing for all patients who were new to the clinic and for those who required initiation of therapy based on new recommendations within the revised British Hypertension Society guidelines. Patients who could be appropriately managed through titration of drug therapy, resolution of compliance issues or lifestyle changes alone were managed using the existing system.

Supplementary prescribing in practice

A clinical audit of the service is conducted annually. Between August 2004 and May 2005, 404 patients regularly attended the clinic. Of these, 52.2 per cent (211) had pharmaceutical care delivered through supplementary prescribing. All patients offered the prescribing partnership model agreed to it. However, I decided that five patients could not consent to this service because of severe language problems or learning difficulties and these people were managed through the existing system. Of the patients adopting the supplementary prescribing service there was no requirement for referral to the independent prescriber and only predictable adverse drug reactions were identified.

Clinical outcome results were similar to previous years with significant improvements in both BP control, despite more stringent targets,² and appropriate prescribing of antiplatelet and statins for both primary and secondary prevention of cardiovascular disease. The Table illustrates the change in BP control as a result of patients attending the clinic.

Challenges

One of the major problems facing pharmacist prescribers in primary care is the prescription pad. The current pads do not facilitate electronic prescribing and, as a result, prescriptions have to be handwritten, with a second electronic entry then being made on the patient record. This is a major potential for error and is currently being addressed.

Other problems I was required to resolve surrounded issues of logistics, which have been addressed. Some examples are:

· Including the CMP in an electronic record in a paperless practice
· Ensuring laboratories send blood results direct to me
· Agreeing CMPs when my clinics run simultaneously with those of the independent prescribers
· Ensuring annual review of the CMP by the independent prescribers

Service developments

The standardised CMPs cover most of the pharmaceutical care issues identified in the clinic. However, other pharmaceutical needs identified are currently addressed by a prescription from an independent prescriber. I am hopeful, therefore, that independent prescribing by pharmacists is legislated for so that I can offer patients a one-stop service, within my clinical competencies, and allow GP appointments to be used more appropriately.

Currently a local community pharmacist is undertaking his period of learning in practice with me and I have secured funding to allow him to run the clinic from the practice, on qualification, for nine months. It is expected that, after that, he will manage a cohort of patients from a community pharmacy. The clinic also supports other pharmacists and nurses training as supplementary prescribers.

Pharmacist supplementary prescribing appears to be supported and accepted by both GPs and patients in this setting. A qualitative research project is currently assessing patient and GP opinion and will identify ways in which this service could be improved.

ACKNOWLEDGEMENTS Thanks to all the GPs at Newbyres Medical Group, Gorebridge, and Newbattle Medical Practice, Mayfield, and colleagues in the pharmacy department, Lothian Primary and Community Division.

References

1. Reid F, Murray P, Storrie M. Implementation of a pharmacist-led clinic for hypertensive patients in primary care — a pilot study. Pharmacy World and Science 2005;27:202–7.

2. Williams B, Poulter NR, Brown MJ, Davis M, McInnes GT, Potter JF, et al. Guidelines for the management of hypertension: report of the fourth working party of the British Hypertension Society- BHS IV. Journal of Human Hypertension 2004;18:139–85.