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From back seat passenger to driver

The decision to become a prescriber was a natural next step in my career. Since 2003 I have worked as a medicines management pharmacist at North Somerset Primary Care Trust, which involves providing prescribing support to GP practices.

This allowed me to gain an insight into how they operate and understand how a pharmacist prescriber could work symbiotically with other health care professionals, providing pharmaceutical care to patients, and the potential benefits of this.

The prescribing course at the University of Bath was part-time so I was able to continue to work full-time at the PCT and as a local pharmacy tutor for the Centre for Postgraduate Pharmacy Education. There were 11 face-to-face learning days, 14 days in the prescribing practice and additional study time.

The course gave me an excellent foundation and support to begin the ongoing development of the skills and knowledge pharmacist independent prescriber (IPs) require. Guidance with more practical issues, such as professional indemnity insurance, was also given. (I am a member of the Pharmacists’ Defence Association and kept it informed of my progress, both during training and on qualification.)

Now I work as an IP at Riverbank Medical Centre in Weston-super-Mare, running two clinics a week to review and manage hypertension, cardiovascular risk, minor ailments and some other long-term conditions (eg, coeliac disease). In addition, I perform medication reviews and initial health checks for new patients at the practice with any long-term condition or repeat medicines.

A local agreement between the PCT and the practice allows these clinics to be provided during my PCT working hours for six months in return for the time provided by my mentor GP during my course.

My first prescription

Once I had registered as an IP with the Royal Pharmaceutical Society and completed all relevant documents for the NHS Business Services Authority, I was ready to write a prescription. I had been preparing for nearly a year and now the time had arrived.

The first prescription I wrote was for felodipine 5mg tablets. During a hypertension review I established that the patient’s blood pressure was not at target and a dose increase (from 2.5mg od) was necessary. It was all about conducting the consultation professionally, despite the nervousness and excitement I felt, as well as keeping hold of my pharmacological knowledge.

I discussed the dose increase with the patient, gained his agreement, counselled appropriately, input the data to the computer and the prescription was printed. All I needed to do was sign it, but should I sign it Alison Doherty or A Doherty? … My next action felt even more unusual: handing the prescription to the patient, rather than the other way around.

My next prescription initiated treatment with simvastatin for the primary prevention of coronary heart disease (following blood tests) and it has continued from there. No consultation is the same because each patient is different. The outcomes can, therefore, vary considerably and have included:

• providing information
• collecting data (eg information relating to lifestyle factors, family history)
• altering current medication
• prescribing a new medicine
• ordering blood tests
• arranging home loans of blood pressure meters
• addressing issues with non-compliant and tablet-averse patients
• referring to another health care professional
• arranging follow-up appointments.

Tools

Once a diagnosis has been made, pharmacist IPs are well placed to consider the need for medication, provide treatment, manage responses to treatment (adjusting treatment accordingly), provide counselling, combat side effects and address therapeutic monitoring.

In my work, I follow treatment plans that I have written for long-term conditions and minor ailments. These reflect national and local prescribing guidance. Treatment plans can help provide a structure to a consultation as well as ensuring clear documentation of the consultation, both of which are important in terms of clinical responsibility and professional accountability. Treatment plans also aid follow up at future consultations, either by myself or another health care professional.

As well as treatment plans, I have found other tools developed during my training useful, for example, a patient information leaflet explaining the IP role. An aide memoire that I developed, and now use regularly when making prescribing decisions, is the mnemonic PAIN:

Patient (think about age, pregnancy, ethnicity, genetics, underlying conditions)
Adverse effects
Interactions
Need

This ensures that I apply a similar thought process to each decision and, with practice, it has become second nature. My prescribing decisions so far include:

• Initiating treatment for patients who have had several raised BP readings

• Gradually stopping atenolol 50mg and starting amlodipine 5mg in a 59-year-old woman whose BP was elevated and who had a family history of diabetes

• Stopping atenolol in a 43-year-old woman who had been first prescribed it in her early thirties when she began to experience headaches and raised BP while on an oral contraceptive, which she was now no longer taking

• Monitoring and gradually decreasing valsartan from 160mg od in an 80-year-old on four different medicines to manage her BP when she complained of dizziness and light-headedness

• Diagnosing ACE inhibitor-induced cough and switching ramipril to candesartan

• Recognising gout as a side effect of bendroflumethiazide and suggesting it be stopped with full monitoring of BP

Pharmacist IPs can diagnose minor ailments if they feel competent to do so. For example, I have diagnosed an infected cut during a hypertension review (I prescribed flucloxacillin 250mg capsules) and otitis externa during a new patient health check (I prescribed Otomize spray).

Progress

Encouragement and support from all staff at the GP practice have played (and continue to play) a major part in the success of my new role. In the past year, I have gone from observing to partaking in and then leading patient consultations — from back seat passenger to front seat passenger, and now driver.

And I am gently gaining speed as I encounter new landmarks and my confidence increases. Reflection on a daily basis helps me to recognise my strengths, address my weaknesses and know my limitations.

I have started to audit my work as an IP and I plan to use patient questionnaires so that I can further reflect on my competencies as well as market the role. This is important because I believe the role is still not fully understood by other health care professionals and, as a result, its impact and potential have yet to be fully recognised.

I love the challenge that being an IP presents and highly recommend it to other pharmacists.