Primary Care Pharmacy November 1999 Vol 1 No 1 p10-11

Prescribing advice

Working part time with a local doctor

By Gillian Hawksworth, PhD, MRPharmS

"Although I had worked for over 20 years with these local GPs, actually working in the surgery was very interesting and the relationships with staff blossomed"

Having been a community pharmacist for 25 years, with the past 14 years spent as an independent contractor, I have seen a lot of changes. I have been involved to some extent with prescribing advice and the development of primary care pharmacy for a number of years in a number of ways through an interest in community pharmacy research, continuing professional development and a self–interest in survival in this profession. In the early 1990s, being of the opinion that standing still was not an option, I realised that evidence was essential in order to influence any local prescribing. Having gone to the trouble of attending an early PACT data course and giving free pharmaceutical advice to the local surgery, which was about to go fundholding, I soon realised that much of my advice was being ignored. The only evidence I had at the time was the interventions I was making on the prescriptions I was dispensing and I began to document them in order to demonstrate the need for a rethink in the repeat prescribing system at the two local surgeries. These interventions included clinical interventions, duplication, omission, drug review and some aspects of bioequivalence. Also, specifically for one surgery and at its request, I made a retrospective analysis of all non-generic prescribing for each GP, which was fed back at the end of each current month making a great impact on their percentage of generic prescribing before their pharmaceutical advisor's next visit.

Gillian Hawksworth: a community pharmacist for 25 years

My long-term worry was about prescribing and, in an effort to influence the number of days supply prescribed and reduce waste, I began to log all the waste returned to my pharmacy and break it down into British National Formulary group, quantity prescribed (indicating length of prescription), quantity returned and cost. The health authority was obviously interested in these results and I obtained funding for a roll out to other pharmacies. The results of the interventions study, waste log and other small projects which I had undertaken were referenced in the health authority's bid to obtain top–sliced funding and persuade the local medical committee of the need for a repeat prescribing project for community pharmacists, which I then became involved with on the steering committee. It was interesting working with the key local GPs and health authority advisors on the committee to plan the project which was to take nearly two years to complete. I noticed the different reactions of GPs to the concept of community pharmacists working in GP surgeries and to what extent they would be allowed access to patient records and GP computer systems. There was great debate about which issues to address and what data to collect. The aim of the study was to determine the cost and effect of practice based pharmacists on repeat prescribing and on repeat prescribing systems. At the same time my interest in clinical guidelines drew me to take part in another research project which looked at delivering specific clinical guidelines to GPs throughout the health authority and neighbouring areas on an educational outreach basis.
Over a two-year period, I received three lots if training to develop my skills and knowledge to add to that already undertaken as a Centre of Postgraduate Pharmaceutical Education tutor and through the United Kingdom Clinic Pharmacy Association primary care development group chaired by Professor Clare Mackie. The first involved PACT, repeat prescribing systems, bioequivalence, non steroidal anti–inflamatory drugs, asthma and chronic obstructive pulmonary disease and anxiolytics and hypnotics. This information was delivered by the health authority advisors. The next stage involved a refresher of most of the first part with the addition of gastrointestinal, cardiovascular and antidepressants. The third training session ran in parallel, but was around the actual delivery of guidelines and the process involved. The north of England evidence-based guidelines covered the use of aspirin, NSAIDs, angiotensin-converting-enzyme-inhibitors and antidepressants. Armed with this information I undertook 64 GP visits throughout the Yorkshire region to 16 GPs (two visits per guideline, not all the GPs had the same two guidelines). This training was also invaluable for the repeat prescribing project which I was then currently taking part in, with my two local surgeries, half–a–day per week each.
Although I had worked for over 20 years with these local GPs, actually working in the surgery was very interesting and the relationships with the staff, with whom I had a daily telephone contact, blossomed. Also relationships with practice nurses, practice managers and the GPs themselves developed because I was attending practice meetings once a month. During the year I was contracted to work, I reviewed two repeat prescribing systems, reviewed all the repeat prescriptions for one large practice and suggested interventions for NSAIDs, asthma and COPD, anxiolytics and hypnotics. I also looked at generic and bioequivalence prescribing and discussed the use of aspirin, proton pump inhibitors and H2 antagonists, ACE–inhibitors and antidepressants. I produced an antibiotics formulary and one for NSAIDs for the other surgery at its request. Other projects involved aspirin audit and arrangements for the review of GI patients. Issues such as fraud exemption, OTC referral, malaria prophylaxis and drug misuse just fell into the conversation - so much so that major events developed from these of great mutual benefit to the local community. I found it interesting, however, that patients who saw me in the surgeries were asked about my presence there the next time they saw me back in the pharmacy, since my pharmacy was two miles from either local surgery. Initially, I felt an ownership of the patients who were "my" patients when I was in the pharmacy when I reviewed their records in the GP surgery. I was able to monitor on an on-going basis those patients who used my pharmacy because I saw all their prescriptions – acute surgery, clinic, hospital discharge, home visits, as well as their repeat prescriptions. The project has now ended. It concluded that top slicing the primary care drug budget to pay for pharmacist advice was an excellent use of NHS resources, and, not surprisingly, this was taken up by the PCG of which I am liaison pharmacist. I have been asked to help local community pharmacists and guide them with prescribing issues when working with GP surgeries. This is my current involvement and I am also a member of the district prescribing committee, drug and therapeutics committee and now PCG prescribing subcommittee. This has led to a PCG clinical governance role.

Through all these experiences I have learnt that you can view a prescription with many different eyes depending on where you are. Also, I acknowledge that being a pharmacist in primary care can take the form of many models and I have enjoyed being a part–time prescribing advisor to my local GPs. It has benefited the practices, patients and the health authority and taught me a lot in the process, but once you have travelled the road you cannot go back on how you undertake your professional review, wherever you are located.

A prescription can be viewed with many different eyes

Dr Hawksworth is a community pharmacist in Muirfield, Yorkshire