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Space, time and team working: issues for pharmacists who wish to prescribe

The proposed introduction of supplementary prescribing status for pharmacists has been broadly welcomed by the profession. But what are the issues that will have to be addressed before pharmacists start to prescribe? Clare Bellingham reports

Pharmacists could become prescribers as early as next year

Moves towards the introduction of pharmacist prescribing have finally been made.

Last week’s publication of a consultation document (MLX 284 ) about pharmacist prescribing is good news for pharmacy. It proposes how pharmacists can become supplementary prescribers (formerly called dependent prescribers) and how their role will fit in with that of independent prescribers (PJ , 20 April, p521).

But the document does not provide all the solutions, and raises questions over how exactly this new way of working will be introduced. In addition, the implications for patients, the health service and the pharmaceutical industry, as well as pharmacy itself, are huge.

The proposals will allow prescription-only and pharmacy medicines to be prescribed by a supplementary prescriber as part of an agreed clinical management plan for a named patient and specific condition. The plan (agreed by an independent prescriber, supplementary prescriber and patient) will specify the medicines that can be prescribed for a particular patient and the circumstances in which the dose, frequency and formulation of medicines can be altered. Supplementary prescribers will be responsible for the ongoing monitoring of the patient and will be accountable for prescribing decisions made.

The consultation document states: “Supplementary prescribing will be of most value to patients with specific non-acute medical conditions (eg, asthma, diabetes and conditions relating to mental health), or health needs (eg, anticoagulation treatment, hormone replacement therapy or prophylaxis against heart disease).” However, it is not proposed to restrict supplementary prescribing to specific clinical conditions or to restrict the range of medicines that can be prescribed (with the exception of Controlled Drugs and unlicensed medicines outside paediatric care).

Practicalities: space and time

Perhaps the biggest hurdle for community pharmacists is having suitable premises and creating sufficient time to be supplementary prescribers. In order to undertake the role properly, pharmacists will need time and space to sit down and discuss medication issues with patients.

The obvious answer to the space problem is a private consulting room. But this takes money to build, and might not even be possible to fit into all premises, so is not a development that will be seen in all pharmacies overnight.

Availability of space is identified as a problem by a pharmacist who already prescribes in a pilot project supplying over-the-counter medicines in Scotland (PJ, 23 February, p238). Neil Duff, pharmacist at Patna Pharmacy, says that the need for a consulting room or private area within the pharmacy is essential. “Monitoring, such as measuring blood pressure, could not be carried out in the middle of a pharmacy. A quiet area away from the mainstream of the business would be essential,” he says. “Although the cost would depend on the nature of the existing premises, it could be considerable.”

And who would foot the bill for funding the refurbishment of a large number of community pharmacies?

For pharmacists working in general practitioners’ surgeries, updating premises is less of an issue because they share consulting rooms within the surgeries and so could be among the first pharmacists to achieve supplementary prescribing status.

Fiona Reid, pharmacist at Newbyres Medical Group surgery in Gorebridge, Midlothian, says that the introduction of supplementary prescribing for pharmacists is an excellent idea providing pharmacists have proved their competence to prescribe. Mrs Reid runs a hypertension clinic at the medical centre (PJ , 23 February, p239). She undertakes monitoring of patients but currently has to get a GP to prescribe their medicines. Would supplementary prescribing make her life easier? “Yes, and I know there will be support for it from the GPs here at the surgery.” She added that the surgery is currently conducting a survey to assess patients’ views on pharmacist prescribing.

Many pharmacists say that they are already pushed for time without the additional responsibility of prescribing. Mr Duff says that to provide a supplementary prescribing service, an additional pharmacist would be required. “It would be helpful to have another pharmacist to help with the build up of jobs when a lot of time is spent prescribing. It is one of the things I have been pushing for in our pilot and, without question, in terms of supplementary prescribing, another pharmacist would be needed.”

One way of addressing the time issue is to examine skill mix in the pharmacy. Sue Sharpe, chief executive, Pharmaceutical Services Negotiating Committee, says that time will come from better use of support staff and delegation of tasks. “Supplementary prescribing should not be obstructed by fear of not having time,” she says.

An additional problem that could lead to changes in skill mix is the question of responsibility. The consultation document states: “Prescribing and dispensing responsibilities should, where possible, be kept separate in keeping with the principles of patient safety and governance.” How will a sole pharmacist achieve separation of dispensing and prescribing duties?

Mrs Sharpe says that the meaning of this statement in the document needs to be unpicked. “Without an explanation of what governance means here we can’t see if there are obstacles.” Exactly what responsibility means is also unclear. However, she added: “To block the potential for supplementary prescribing in community pharmacy will be to frustrate the benefits community pharmacists can provide.”

Prescribing as a team

However skill mix within the pharmacy is approached, it is clear that the introduction of supplementary prescribing will lead to closer working relationships with doctors.

Exactly how a prescribing partnership works will have to be set out. If a one-to-one independent and supplementary prescriber partnership is decided upon, a mechanism for dealing with situations when either party is away will have to be determined. In addition, one-to-one partnerships are likely to be difficult to operate in hospitals where a number of clinicians are responsible for patients’ care.

At a Pharmacy Management seminar in London on 17 April, Professor Clare Mackie, head of centre for partnerships in medicines for health, Robert Gordon University, Aberdeen, suggested that a team approach is needed. “I think it would be more workable,” she said. The consultation document recognises this problem and asks for views on how supplementary prescribing might work in relation to teams of doctors, nurses and pharmacists.

Laura McIver, chief pharmacist, Forth Valley Acute Hospitals NHS Trust, says that the majority of supplementary prescribing will be as part of a multidisciplinary team. A clinical management plan could be quite simple, she suggests. An example of this is a team of a doctor, pharmacist and nurse conducting a ward round. A diagnosis of hypertension is made and a target blood pressure agreed. The pharmacist could then follow a previously agreed protocol of treatment choices in order to reduce the patient’s blood pressure to the target level.

Forth Valley Hospitals is one of the first places where pharmacists already prescribe. Mrs McIver explains that from this month, a new service is being introduced in which pharmacists will prescribe chemotherapy. This follows a successful pilot of the service. Under the pilot, an oncologist and hospital pharmacist agreed a protocol for a patient’s ongoing care which was then provided by the pharmacist. This arrangement led to shorter waiting times for patients when attending clinics and comprehensive monitoring. “The pilot scheme proved that the care, safety and appropriateness of treatment under the new procedures was maintained,” she says.

Use of a single patient record

In order for clear records to be made of what both the independent and supplementary prescribers do, a single patient record to which both have access is needed. The obvious solution to this is electronic records but it might be some time before this is introduced.

“We can’t wait for the IT,” said Professor Mackie. She suggests that a patient-held record could be used now.

Frank Owens, chairman, Scottish Pharmaceutical General Council, comments: “I am particularly pleased that the Medicines Control Agency has recognised the need for prescribers to share access to the same common patient medication record. Good communication links will be essential.”

Mr Owens adds: “The recommendations for supplementary prescribing, if adopted, will provide us with further opportunities for improved levels of pharmaceutical care, particularly for patients suffering from chronic diseases,” he said.

Professor Mackie believes that pharmacists should take a general approach to prescribing and not become specialists in one or two disease areas. This is because patients who would benefit most from having pharmacists undertaking supplementary prescribing are likely to be on a number of different medicines and so are likely to be reviewed more often under a system of supplementary prescribing than under repeat prescribing. “It is better to look at the whole profile of drugs,” she said.

Currently, the mechanism for pharmacists to supply prescription-only medicines without prescription is through a patient group direction (PGD). PGDs are usually for a specific drug or class of drugs: not a general approach. Professor Mackie said that she believed that the use of PGDs would greatly diminish once supplementary prescribing was introduced.

Training needs

To take on such a major new role, pharmacists will need intensive training, but a training programme needs to be developed.

The consultation document suggests that training for nurses is likely to be based on the training programme currently used for nurses to become independent prescribers. If this is used for supplementary prescribing, nurses will be able to begin training more quickly than pharmacists. However, Professor Mackie said that there was 70 to 80 per cent overlap between the core competencies for pharmacists and nurses so there was not a great deal of work to be done on establishing the competencies for pharmacists’ training. She also pointed out that it is not just new supplementary prescribers who will need training. “It is a whole new model of care so independent prescribers will need training too,” she said.

Sue Sharpe, of the PSNC, says that she hopes the training will reflect competencies of individuals. New graduates, for example, have different skills from pharmacists who have been in practice for a long time and so training should meet individual needs.

The Royal Pharmaceutical Society has welcomed the consultation and says that it will be working to support pharmacists in this new role. The Society says that pharmacists should be in a position to use their training and expertise to prescribe in a wide range of circumstances. Marshall Davies, the Society’s President, said: “We are working to prepare and support pharmacists to play their part in this important move forward.”

Future changes

The consultation document states that the proposed changes to the POM Order will also apply to organisations providing health care outside the NHS. If this is implemented, it could lead to private clinics employing pharmacists and nurses to prescribe.

And further down the line, the pharmaceutical industry should welcome the news. Supplementary prescribing rights mean a large new group of health care professionals who can prescribe: another group for whom medicines can be promoted.

Most pharmacists will welcome the consultation document and the opportunities it brings. Perhaps not all will want to take on the new role and this is something that the document accepts. “It is not expected that all nurses or all pharmacists will undertake the preparation for, or the role of, supplementary prescriber,” it says.

And pharmacists concerned by the lack of time to take on the role will welcome Professor Mackie’s opinion that supplementary prescribing is not an add-on but should be undertaken in place of something they already do.

Mrs Sharpe says that payment for supplementary prescribing is likely to develop at a local level, rather than be included in pharmacists’ new contract because she does not expect supplementary prescribing to be in place by the time the new contract is introduced.

Certainly the introduction of a new status of supplementary prescribers will give pharmacists frustrated in their current roles a new level of training to work towards.

Pharmacists might have to wait for a year or more before they can become supplementary prescribers. A step forward now could be to improve working relationships with local doctors so that when supplementary prescribing is introduced, the concept of working as a team to produce a clinical management plan is not an alien one.

Consultation in Scotland and Wales

The consultation document is being circulated throughout the United Kingdom but the extent to which supplementary prescribing is adopted is a matter for each devolved administration.

In Scotland, health minister Malcolm Chisholm said: “I am delighted that, like the Department of Health in England, we are now consulting on this development which forms a key part of the strategy for pharmaceutical care.” He added that the proposed model would allow better support to be offered to patients with chronic conditions, such as diabetes, high blood pressure and arthritis. “There are currently around 4,000 highly skilled and extensively trained pharmacists working throughout NHS Scotland who have a wealth of knowledge about the uses and conversely the potential side effects of medicines. It therefore makes sense for them to be able to use this knowledge for the maximum benefit of NHS patients by prescribing medicines which they need.”

A spokeswoman for the National Assembly for Wales commented that the consultation process is currently being co-ordinated in Wales. “We are already committed to supplementary prescribing for both nurses and pharmacists (one of the recommendations of the task and finish report on prescribing) and we have just completed a scoping exercise on the training programme which will be required to support the introduction of the system. We expect legislative changes to be in place by December this year with training commencing in the financial year 2003?2004.”

Clare Bellingham is on the staff of the Pharmaceutical Journal

 

Citation: The Pharmaceutical Journal URI: 20006618

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