Learning from practice experiences
| In this article, Nina Barnett, specialist
pharmacist for older people, North West London Hospitals NHS Trust,
and Jane Nicholls, project lead, London Pharmacy Supplementary
Prescribing Team, describe a two-year-old supplementary prescribing
service for older people in Harrow |
Supplementary prescribing in the care of older people is now
growing across England, and similar initiatives for other patients are recognised
across the UK. One of us (Nina Barnett) is a supplementary prescriber at the
Denham Unit Nursing Home in Harrow Primary Care Trust and a previous article
described the training that was undertaken in order to adopt this role (PJ,
22 November 2003, p715).
In light of the developments across England, we decided to report on how supplementary
prescribing works at the Denham unit. At present, few nursing homes receive
this service, perhaps because of the complicated co-ordination of clinical
management plans (CMPs) that would be required with multiple GPs — the
Denham unit has one GP and one consultant.
Patient consultation
The supplementary prescriber visits the nursing home weekly.
The main focus of her work is to solve problems around drug therapy. In the
past, this would
often have entailed discussion with the doctor and the nurses about the
patients’ care.
Talking to patients, their carers or their relatives was less common. Now,
discussion is more frequently with
patients first. This includes talking to them about their general well being
and the changes in their health, which leads to the consideration of how medicines
impact on those changes.
Discussions may include issues, such as what patients understand about their
medicines and what problems they may be experiencing. These are in the context
of a patient’s whole situation rather than focusing solely on medicines.
Over the past year, patient consultation has become a more important part
of the prescriber’s skills portfolio. This is illustrated by the case of
Mr A, who had suffered multiple strokes. Over a few weeks, the muscle spasticity
in his arms had worsened and was causing him increasing discomfort. Treatment
of spasticity was specified in his CMP and a starting dose of baclofen was
initiated. Mr A’s situation was reviewed after a week and, although there
had been some improvement, the dose was increased with a review scheduled after
a further week. Mr A’s symptoms improved steadily and he is now on a
maintenance dose.
When discussing supplementary prescribing with patients, the term “team
prescribing” can be helpful. This is because supplementary prescribing
is a legal concept not always easily understood by patients and carers. The
supplementary prescriber explains that a plan is produced for drug treatment
and that appropriate drugs can then be prescribed by the team member available
(ie, the doctor, pharmacist or nurse). Patients and carers accept this as a
collaborative effort to optimise care. Patients and relatives are also encouraged
to go through the plan with team members, if they wish.
The supplementary prescriber often uses data from assessments performed by
other team members. This saves patients from being unnecessarily re-examined
and uses the detailed knowledge held by staff who care for them daily. In
the case of Mr A, this system worked well. However, the need to understand
more
about assessment processes has been identified. For example, to assess whether
or not a patient needs a laxative, there is a need to know what questions
to ask (eg, what examinations have been done?) and how to interpret the answer.
As a consequence a physical assessment training course has been undertaken
and local GPs shadowed. This is now an additional
aspect of continuing professional development. Clinical management plans
The foundation of supplementary prescribing is the CMP, based
on an agreement between the consultant or GP, the pharmacist (or other health
care professional)
and the patient. It
allows a delegation of prescribing responsibilities from the doctor to the
pharmacist.
The long-standing professional relationship
between the doctor and the supplementary prescriber has greatly facilitated
the successful introduction of supplementary prescribing at the Denham unit.
When CMPs are produced, the pharmacist’s view of his or her own competence
should be matched with the doctor’s assessment and this is most easily
achieved when practitioners have worked together for some time.
The introduction of CMPs has improved practice for the whole team and has
benefited patients because it has provided an opportunity for review. For
example, there
were previously no specific guidelines on the treatment of hypersalivation
but, because the supplementary prescriber needed to be able to provide care
for a patient with this problem, the team was motivated to produce a protocol
for hypersalivation suitable for use within a CMP. This has helped to ensure
that future patients with this problem receive
evidence-based care, whether prescribed by a supplementary or an independent
prescriber.
Some new disease treatment protocols are added to a general template suitable
for inclusion in a CMP whereas others, such as a direction from a specialist,
would be written only in the CMP for a specific patient.
Even with a procedure for production, a template for managing common conditions
and IT support, CMPs can be onerous to produce and update and this has been
reflected by the experiences of prescribing colleagues. It is
important to set aside time to produce guidance whether as a CMP for supplementary
prescribing or to support independent prescribing. Clinical governance issues
Pharmacists play an important role in assessing doctors’ prescriptions.
One concern was that this safety mechanism would be lost if clinical pharmacists
became supplementary prescribers — there is no “extra” clinical
pharmacist at the unit to check prescriptions. However, systems have been developed
to ensure that safe prescribing is not compromised. All the supplementary prescriber’s
prescriptions are checked by a another pharmacist as part of the dispensing
process and, in some situations, the medication chart is faxed to the pharmacy
for an additional clinical assessment. In others, the supplementary prescriber
will prescribe and then undertake another activity before returning to the
chart to order medicines and to perform the clinical check.
The importance of this process was highlighted in the case of Mr A, who also
has epilepsy. When assessing the prescription and ordering the baclofen the
caution required for use in patients with epilepsy was identified. As a result,
a low dose of the drug was prescribed and advice given to the nursing staff
on the monitoring needed. This incident reinforces our view that the pharmacist’s
role in safe use of medicines is essential. Conclusion
The Government’s stated aim of the new prescribing initiative was to
improve patients’ access to medicines, to optimise skill mix and, ultimately,
to help doctors with an increasing workload. On the Denham unit, patients
have access to a
prescriber more frequently than before and the skills of the pharmacist are
used fully.
In this account, we hope to have conveyed that reflective practice is of
paramount importance to prescribers. In addition, the relationship between
the doctor
and the new prescriber is a key feature for the success of this new prescribing
initiative. The doctor has to have confidence that new prescribers will
work within the limits of their competence and will complement the role
of other
health professionals
involved in patient care. ACKNOWLEDGEMENT We thank David Webb, director of clinical pharmacy for London,
SE and Eastern Specialist Pharmacy Services, for his contribution to this article. |
