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Pharmacists who prescribe: the reality

Two projects in Scotland are demonstrating the roles that pharmacists can play in prescribing. In one, pharmacists are already prescribing medicines for common conditions. In the other, a pharmacist runs a clinic to manage hypertension, and repeat dispensing by local community pharmacists will be added to this project in the next couple of weeks. Clare Bellingham reports

Clare Bellingham

Pharmacist prescribing is no longer a dream, certainly not in Scotland where pharmacists have been signing specially designed prescriptions for nearly a year.

Pharmacists in Patna, Ayrshire, prescribe certain medicines on “CP1” prescription forms. They are part of a “Direct supply of medicines” pilot project.

According to “The right medicine”, the Strategy for Pharmaceutical Care in Scotland, pharmacists should be able to prescribe by the end of 2003. It states that pharmacists in both primary care and hospitals will benefit from supplementary prescribing status. “Supplementary prescribing would enable pharmacists working in community pharmacy to make dosage adjustments on repeat prescriptions as a result of, for example, therapeutic drug monitoring,” it says.

The “Direct supply of medicines” pilot started before the launch of the “The right medicine” and the strategy recognises its potential. It states: “Community pharmacists are often the patient’s first port of call when feeling unwell. A pharmacist has three options: offer advice, sell an over-the-counter medicine or refer the patient to his or her general practitioner. In some instances, patients cannot afford to buy the OTC medicine and therefore must be referred to their GP. This often requires an appointment at the GP surgery, followed by another visit to the pharmacy for the prescription to be dispensed. Allowing pharmacists to prescribe will improve patient access to health care and help reduce inequalities in the current system.” The strategy states that the Scottish Executive will introduce schemes between GPs and community pharmacists to allow certain patients to use their pharmacist as the first port of call for NHS services for the treatment of common illnesses by 2005.

In the pilot project in Patna this is exactly what is happening. Neil Duff, pharmacist at Patna Pharmacy, said: “It makes better use of our expertise and frees GPs for more important matters while allowing patients easier access to simple remedies.”

He explained that the pilot started in April last year. It was originally intended to last for 12 months but has been extended for a further six months until the end of September to allow for collection of data that will be analysed by Scottish Health Feedback, an independent research organisation. Pharmacists prescribe using a CP1 prescription form and also fill in a data collection form for each patient on which information about the presenting condition, the outcome of the consultation and the patient’s reason for exemption are recorded.

Two sites were chosen for the pilot with different population characteristics. Mr Duff explained that Patna is a self-contained mining town with high morbidity and prevalence of various chronic conditions. Only a small percentage (3 or 4 per cent) of patients pay for their prescriptions. In addition, there is little leakage of prescriptions to other towns. A similar pilot is under way at a second site at Arbroath, Angus.

In order to participate in the scheme, a patient has to register with both the GP practice and the pharmacy. At the moment, approximately 400 patients are registered to use the “Direct supply of medicines pilot” out of a potential 2,600.

If the pilot is rolled out, Mr Duff said that, in his opinion, it would be best for patients to be registered with one pharmacy unless a system of patients having one record on the NHSnet is introduced. Patna Pharmacy is one of the pharmacies to be connected to the NHSnet in Scotland as part of the Scottish Executive’s plan to have all community pharmacies in Ayrshire and Arran connected to the NHSnet by the end of 2002.

The pilot mainly covers supply of OTC medicines listed in a limited formulary that was agreed with GPs before the pilot began. However, patient group directions have also been set up for the supply of some prescription-only medicines. These include supply of larger quantities of OTC medicines, such as a month’s supply of loratadine and cetirizine and 96 paracetamol tablets. “A PGD for fexofenadine is currently being prepared to replace the one for loratadine,” said Mr Duff.

Prescribable items: Some of the items that can be prescribed by pharmacists participating in the “Direct supply of medicines” pilot project are:• Lactulose, loperamide, Dioralyte, Anusol • Chlorhexidine mouthwash• Menthol crystals, simple linctus, pseudoephedrine• Paracetamol, ibuprofen, co-codamol • Clotrimazole cream, fluconazole capsules, aciclovir for cold sores• Aqueous cream, Oilatum, Conotrane, hydrocortisone cream (0.5 and 1 per cent)• Hypromellose eye-drops, fucithalmic eye-drops

Mr Duff added that he prescribes about 70 items a month and that the number is increasing. The most common items he prescribes are for colds, children’s complaints (such as teething), head lice and stomach upsets. Other conditions that he can prescribe for include headache, constipation, earache, thrush, mouth ulcers, conjunctivitis and athlete’s foot. Emergency hormonal contraception can also be supplied. Some of the items that can be prescribed are given in the Panel. Consultations involve standard questioning for supply of OTC medicines and checking of patients’ records.

If Mr Duff believes that it is not appropriate to prescribe a medicine, he can indicate on the data collection sheet that he has given advice or referred the patient to their GP. He is able to use a form to refer patients urgently if required.

Mr Duff is paid a professional fee on a per capita basis to participate in the pilot. The fee, paid on a quarterly basis, covers up to 700 patients. If the number of patients registered to use the service increases above this then a supplementary payment is made. No limit is placed on the number of times a patient can consult the pharmacist.

Although this payment is for the pilot only, it indicates a model for payment of services that might be introduced in the future as part of the new contract for pharmacists.

Some pharmacists might be concerned that offering such a service would lead to a loss in OTC sales. In Patna, where patients are more likely to consult a GP for a prescription for OTC medicines than to purchase them, this amount is small. However, it might be more of a problem in other areas where pharmacies have a large retail business.

It might be expected, therefore, that the number of prescriptions would have decreased. Mr Duff said that this has not been the case: the number has remained static but he added that there is a nationwide trend for the number of prescriptions to increase.

“I feel that the project is of such value that I am prepared to risk a small financial loss for the greater good of the profession,” he added.

If the project is rolled out on a national basis, remuneration and financial consequences will have to be investigated and, if necessary, resolved. Mr Duff also pointed out that some people who have to pay for prescriptions “have made a few noises” about the project.

Mr Duff’s general belief is that the project is going well. “The project changes the emphasis on what we as pharmacists do. I am keen on the service and believe this is one of the ways forward for community pharmacy.

“At the start of the project, we had a large number of requests and were apprehensive that we would be overrun. However, it hasn’t turned out that way although we can have times when three or four people are waiting to be seen at once.” He added: “If community pharmacists are to provide this type of professional service then we will need to invest in our premises.”

Hypertension clinic

 Pharmacist Fiona Reid takes a blood sample from a patient at the hypertension clinic 

Meanwhile, Fiona Reid, pharmacist at Newbyres Medical Group surgery in Gorebridge, Midlothian, explained that her role is to run a hypertension clinic at the surgery. She is able to titrate doses without checking with a GP but if she wants to give a new medicine, this has to be cleared first.

The clinic forms part of a research project that examines the use of a multidisciplinary approach to the management of hypertension. Patients were recruited to the project if they had an existing diagnosis of hypertension (identified from records) while newly diagnosed patients were referred directly to the clinic. They were then randomised to one of two groups. The first group were seen at the clinic and the second received standard treatment from a GP. The second group are now attending the clinic. A total of 180 patients currently attend the clinic.

The project was developed with input from Pat Murray, chief pharmacist, Lothian Primary Care Trust, and researchers at the University of Strathclyde, who designed a database used in the clinic.

The clinic is open from 4pm until 6pm on four days each week. Patients are seen by Mrs Reid at 12-weekly intervals until blood pressure, and cholesterol if necessary, are controlled.

Mrs Reid uses the database to record details such as lifestyle interventions, co-morbidities, blood pressure measurements (pre-treatment, at the first visit to the clinic and ongoing levels), additional test results (such as cholesterol levels, electrocardiograms and liver function tests), and antihypertensive and other drug therapies. In addition, a 10-year coronary heart disease risk assessment is calculated and a care plan sketched out with details such as actions that need to be taken and appropriate monitoring. Mrs Reid is trained to take blood samples for laboratory testing.

 The CP1 prescription form used in the “Direct supply of medicines” pilot

Types of interventions that Mrs Reid has undertaken include starting statins and aspirin for both primary and secondary prevention, ensuring that antihypertensives are being used according to protocol, ensuring that angina patients are on glyceryl trinitrate and monitoring therapies. “Before the clinic started, these types of intervention were not carried out in a systematic way,” she said. A total of 462 interventions have been recorded of which 250 have been drug-related. Of the patients seen so far, about 20 per cent were not previously taking statins, 50 per cent were not on aspirin for primary prevention and 25 per cent were not on aspirin for secondary prevention. Many patients had not had a cholesterol test.

The project has been time consuming. “A lot of groundwork has to be done both in patient identification and in the time it takes to review medicines before seeing a patient,” said Mrs Reid. In addition, having to get every additional new medicine checked by a GP takes time: a problem that could be removed if pharmacists could prescribe.

“I would like pharmacist prescribing to be brought in,” she said. She points out that when working in partnership with other health care professionals and using a patient-centred approach that “pharmacists have the pre-requisite skills to ensure that patients receive the best possible care”. She added: “If pharmacists are to prescribe they should use evidence-based medicine and a systematic approach to therapy monitoring to ensure that the desired clinical outcomes are achieved and predictable adverse events anticipated.”

The project in Gorebridge provides evidence that this is exactly the type of role pharmacists are able to take on. And GPs at the practice agree: Dr Marion Storrie is positive about it. “The whole crux of the matter is that pharmacists do it far more completely than we do,” she says. “The pilot has shown that [the service] can be done more than competently by a pharmacist.”

She believes that this type of clinic is the future for chronic disease management, “particularly because there are not enough health care professionals around so we have got to use the ones we have got more effectively”. Patients have also been positive about the clinic. Mrs Reid said that an 86-year-old man came to the clinic recently and when she asked him who had referred him, he said his next-door-neighbour.

Repeat dispensing

The second part of the project involves repeat dispensing at local community pharmacies. Once patients’ blood pressure levels and drug treatments are stable, they can opt in to the repeat dispensing scheme. Prescriptions for three months’ worth of treatment to be dispensed at monthly intervals will be provided. Four pharmacies are taking part in the project.

Linda Russell, a pharmacist at Lloydspharmacy in Gorebridge, explained that the service will start within the next couple of weeks. “I will ask patients about problems with their medicines and take blood pressure readings. If the blood pressure is within specified limits then I will dispense the repeat prescription; if not, I will refer the patient back to the clinic,” she said. “Most patients don’t see a doctor each month when they get their repeat prescriptions. This service will give them regular contact with a health care professional.”

The “Direct supply of medicines” pilot and the pharmacist-run hypertension clinic demonstrate the new roles that pharmacists can play in the delivery of health care. Now that the pioneers are providing the evidence, the profession can start to move forward on extending these services to a wider population.

Citation: The Pharmaceutical Journal URI: 20006109

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