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What makes appropriate prescribing?

Since the original Crown Report on non-medical prescribing, we have moved rapidly from patient group directions and supplementary prescribing by non-medical health care professionals, to the dawn of independent prescribing by pharmacists and other non-medical health care professionals. Removing the comfort blanket of the clinical management plan surrounding supplementary prescribing takes non-medical prescribers into the area of full liability for their own prescribing decisions, and self-assessment of their ability to prescribe in a given therapeutic area.

Much background work on competencies has already been done to support supplementary prescribing.¹ So what is “appropriate prescribing”? Given that prescribing is a mix of evidence-base for intervention with the drug, diagnosis, clinical judgement and a certain element of clinical intuition, it is, perhaps, unsurprising that no absolute definition exists in the literature. One could go back to the Hippocratic Oath, in particular the tenet of “First do no harm” focusing on the safety of any intervention, but this is really inadequate in the modern day health service.

Attention to budgets

It was the influential paper by Peter Parish that first started trying to define the issue of appropriateness, placing it in the context of a cash-limited health service and talking about appropriate prescribing being safe, effective and economic.² Developing on this theme, a literature review on decision-making and prescribing patterns, attempted to align variations in prescribing to the characteristics of doctors but, ultimately, the review concluded that when the decision to treat is actually considered, there is a lack of empirical evidence in this area.³

Perhaps my favourite explanation of appropriateness comes from Nick Barber’s work, which as well as dealing with appropriateness in terms of efficacy and safety from the point of view of the prescriber, develops the perspective of the preferences of the patient. His apocryphal story of the dying man receiving a change of hypnotic drug during the last days of a terminal illness, starkly shows that prescribing driven purely by a system can disadvantage patients.

Having understood the tensions that exist however, the health care professional still has to manage them. In a cash-limited health service funded by public taxation, there is always going to be a trade-off between the needs of the individual and affordability to the health service. Recent experiences with Herceptin and the media flurry around the ASTEROID trial for rosuvastatin (PJ, 18 March, p309) illustrate how media hype can raise patients’ expectations of their medicines. It is the role of the health care professional to balance these expectations with clear thinking, critical appraisal of the evidence-base and appropriate advice.

Even marginal benefits at a modest cost premium can have profound effects on affordability. Although we tend to focus on the high unit cost of medicines, it is usually the high volume, lower cost medicines that drive cost pressures inside the health service. This is illustrated by the example in the Panel below. Although a 10 per cent increase in efficacy may be desirable for the individual, if you are thinking of the needs of the population as a whole, you can treat a greater number of patients for the same amount of money.

Patients’ wants and needs

For an individual prescriber to be able to discern between a patient’s wants and needs requires care and sensitivity. Patients’ wants are subjectively determined and are likely to be closely associated with their expectations, whereas needs are more likely to be objectively determined by the evidence-base.^4,5 In the limited time available to an individual prescriber, keeping up to date with the evidence base can be daunting, and we are heavily reliant on independent sources of evidence to inform our practice. (Examples include the National Institute for Healthcare and Clinical Excellence, UK Medicines Information, and the Midlands Therapeutics Review and Advisory Committee.)

No matter how good the evidence, patients are unlikely to be convinced with the merits of the intervention unless the prescriber has persuaded them so. It follows that if they are unpersuaded they are unlikely to take the medicine and thus unlikely to realise the health gain that both the prescriber and patients, desire.

A consultation in which the patient has the opportunity to discuss their concerns is essential, and it is now widely accepted that consultation based on prescriber and patient working together to achieve concordance is the cornerstone of good practice.

What else is needed?

So, take a patient history. Be sure of the correct diagnosis. Apply the evidence-base for your chosen treatment and discuss this with your patient in a concordant manner, to your mutual satisfaction. If only life was that simple! Case history taking is a taught skill, as is diagnosis, although this requires considerable hands-on experience to refine it. Given that initially it is likely that most non-medical prescribing will take place in chronic disease-management situations, where a diagnosis has probably already been determined, this may be less of an issue.

The major factor affecting the quality of prescribing interventions — time — remains. There is just so much evidence and guidelines on proper treatment of patients about that it can become confusing — to quote a paper from Dougal Jefferies: “Until someone can clear the waters for me, I think I’ll just continue to muddle along”.⁶ Further support is obviously necessary. Formal and informal networks with colleagues to discuss prescribing habits are invaluable. Decision-support tools can help. Prodigy, the first of the computerised decision-support systems for GPs to be widely disseminated, was not popular, perhaps because it was rather too prescriptive in its directions. Perhaps what is required is a tool to support prescribers’ thinking, which helps them swiftly calculate the probabilities of risk and benefit, while leaving them free to make the final clinical decision for themselves.

One way forward is by applying decision analysis to such programmes — a pilot system is showing promising results, which was valued by the users GPs.⁷

To summarise, whatever final scheme is arrived at for training nurse and pharmacist prescribers, it is likely to be too short to equip fully a professional for independent prescribing in practice. It is going to be essential that some form of additional training support and mentorship are available after training is completed. If prescribers are to realise fully the potential of their role, their prescribing decisions must be based on the best available evidence. In this way, prescribers will ensure patients receive safe, effective and economic treatment and that they have equipped themselves with the knowledge, confidence and skill to contribute fully to the development and delivery of a changing NHS.

References

1. National Prescribing Centre. Maintaining competency in prescribing: an outline framework to help allied health professional supplementary prescribers

2. Parish PA. Drug prescribing — a concern for all. Journal of the Royal Society for Health 1973;4:213–7.

3. Bradley CP. Decision-making in prescribing patterns — a literature review. Family Practice 1991;8:276–85.

4. Gray DP. Planning primary care. London: Royal College of General Practitioners; 1992.

5. Heatlie HF. Variations in primary care prescribing: a pharmacoepidemiological study. PhD Keele University, 2000.

6. Jefferies D. Having so many different guidelines about risk is so confusing. BMJ 2000;321:175.

7. Short D, Frisher M, Bashford J. The development and evaluation of computerised decision support systems for primary care based upon a patient profile decision analysis. Informatics and Primary Care 2005;11:195–202.