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How supplementary prescribing is working for pharmacists in practice

Supplementary prescribing by pharmacists started at theend of March when Neil Frankland, leadpharmacist for surgery at North Tyneside GeneralHospital, North Shields, wrote his first prescription (PJ, 27 March,p369). A month later, Fiona Reid became the firstpharmacist to prescribe in primary care at Newbyres Medical Group surgery in Gorebridge, Midlothian(PJ, 1 May, p533). This was quickly followed by the firstcommunity pharmacist prescriber, CampbellShimmins of Woodside Pharmacy, Doune, Perthshire(PJ, 8 May, p559).

A number of pharmacists have started prescribing since. So how are theygetting on? Those working in primary care are surging ahead: supplementaryprescribing is being used to add value to pharmacist-run clinics, manyof which were already set up in GP surgeries. In hospitals too, pharmacistshave started to use supplementary prescribing successfully in both clinicsand on wards.

The pharmacists facing the most difficulties are those in the community.Although some community pharmacists are choosing to use their qualificationto undertake sessional work in GP surgeries, it is proving difficultfor them to prescribe in their own premises.

It has been said many times before, but the lack of access to patients’ medicalrecords at community pharmacies is a barrier to prescribing. It can beovercome (as two pharmacists have proven, see later) but it is certainlyan important issue. Another difficulty for community pharmacists is funding.In order to leave the shop floor so they can have a consultation witha patient, a second pharmacist is needed. And this costs money. Pharmacistsalso need to have access to a prescribing budget, something that is mucheasier to address when a clinic is run in a GP surgery or a hospital.

Asked how these barriers would be overcome, a Department of Health spokeswomansaid: “One of the fundamental principles of supplementary prescribingis that the supplementary prescriber should have access to the commonpatient record. We recognise that in the first instance, there may besome problems for community pharmacists wanting to prescribe from theirown pharmacies.” In terms of the funding issue, she commented: “TheDoH allocates funding to strategic health authority workforce directoratesto implement supplementary prescribing who determine how funds are used.Access to a prescribing budget is also a pre-requisite for pharmacistsprescribing in the community or in primary care. Funding issues should be settled, prior to candidates undertaking prescribing training courses.”

Health is a devolved issue, so how supplementary prescribing is implementedin Scotland will differ. For a start, there is more of a focus on gettingcommunity pharmacists trained as prescribers than in England.

Frank Owens, chairman of the Scottish Pharmaceutical General Council,says: “So far 160 pharmacists, over 100 of whom are community pharmacists,have either completed or are completing the training programmes.” Hecomments: “This will provide a very solid foundation for the clinicaland patient care components of the new community pharmacy contract inScotland. The SPGC and the Scottish Executive are continuing to worktogether to ensure further initiatives with community pharmacists will be forthcoming, utilising the skills of these prescribersas we move towards the implementation of the new contract.”

Guidance for supplementary prescribing pharmacy practitioners is expectedto be published by the Scottish Executive next week.

Hospital pharmacy

Hospital pharmacists have started to use supplementary prescribing in two situations: on wards and in out-patientclinics.

Emma Graham-Clarke has been prescribing since the middle of April. Sheis a locum consultant pharmacist within the division of anaesthesia andcritical care at City Hospital, Birmingham. “I can prescribe anythingand everything on the critical care ward,” she explains. “Most commonly I am prescribing longer-term drugs usedin intensive care, such as for treating infections, hypoglycaemic control,prevention of stress ulcers and DVT, and for bowel motility.” However,her prescribing is not limited to these areas: “I include anythingthat might require a dose change when the independent prescribers are not around.”

Miss Graham-Clarke uses a generic clinical management plan (CMP) whichis then customised for each patient, and prescribes according to thehospital formulary and guidelines stated on the CMP. She says that theCMP can be restrictive: “We always forget to put something on itthat I want to prescribe.”

The other problems she has faced havebeen over the current restrictions on supplementary prescribing: neither ControlledDrugs or unlicensed medicines can be prescribed. “We use a lotof Controlled Drugs in intensive care and not being able to prescribethem is a problem.” Overall, Miss Graham-Clarke says that supplementaryprescribing has helped to take her role forwards. “It has mademe more involved in the ward team, given me confidence within the unitand improved my working relationships.”

Neil Frankland wrote his first prescription for an elderly patient withconstipation and is still prescribing in the same area. He has not yetbeen able to extend his role further. “We are in the process ofgetting other pharmacists through the prescribing course. Until we reacha critical mass of pharmacist prescribers we cannot do a lot more because of ensuring continuity of care,” he explains. “We are also addressingissues such as the CMPs and patient consent. Using a paper-driven systemis too cumbersome.”

A hospital pharmacist who plans to start prescribing at an out-patientpain clinic next week is Mark Thomas, lead clinical pharmacist for wardservices at the Queen Elizabeth Hospital in Gateshead. “Patientswill be seen by a consultant and then referred to me for prescribingpain relief. This will include prescribing for chronic back and jointpain, and neuropathic pain,” he explains. “I will also seepatients who are having pharmacy-related problems, such as compliancedifficulties, or side effects with rheumatoid arthritis drugs.”

Primary care

New pharmacist prescribers at Burntwood, Lichfield and TamworthPCT (left to right): Mohammed Ibrahim, Thao Lam, Helen Bates, AmandaEvans and Stephen Bullock

Of all the situations in which pharmacists can now prescribe,clinics in GP surgeries is by far the most common.

Amanda Evans, lead pharmacist for supplementary prescribing at Burntwood,Lichfield and Tamworth PCT, has just been awarded a research grant bythe research charity The Health Foundation to look at the implementationof supplementary prescribing in primary care. “I will be comparingimplementation in two PCTs and will be able to track problems as theyhappen. I will also be interviewing people to see how their opinionsof supplementary prescribing change over time,” she explains.

Mrs Evans is one of five pharmacists in the PCT who have completed thesupplementary prescribing course. All are already running clinics atGP surgeries and will prescribe within these. “In future, pharmacistswill find it easier to start prescribing because we are putting the infrastructurein place now, such as ensuring we have covered clinical governance, andworking out funding.” Funding has come from a number of sources:the new GP contract, the personal medical services contract and prescribing monies.

Mrs Evanswill start prescribing next week for patients with dyspepsia. “Ihope to branch out into other areas of chronic disease management, concentratingon targets in the new GP contract. This is the way the surgery will beable to fund me.” She adds: “Having a CMP means that patientsare partners in deciding what treatment they will have. This buy-in isimportant in terms of concordance.”

Marian Bradley is practice pharmacist at Northgate Practice in Walsallin the West Midlands where she runs warfarin clinics. “I have beenseeing these patients and monitoring their warfarin for nine years. Gettingthe CMPs written is the rate-limiting step because I want to have patient-specificCMPs,” she explains. Many patients see Mrs Bradley for all theirmedicines, not just warfarin, so a CMP to cover all their medicines hasto be drawn up.

“It is wonderful not to have to leave the patient,go up the corridor and wait outside the doctor’s door to get aprescription signed,” she comments. “Even though the prescriptionsare not computer-generated yet so I have to write each one out by hand,it is still quicker than standing outside the doctor’s door.”

Fiona Reid has been prescribing for several months now and is positiveabout her experience: “Patients and the GPs have been very supportive.No patient has refused to be managed with supplementary prescribing,” shecomments. “The biggest issue is not having computer-generated prescriptions.At the moment, we have been told that because of the small number ofprescribers it is not cost-effective to produce computer-generated prescriptions.”

Whatthis means is that pharmacist prescribers have to put the data into thecomputerso the patients’ record is updated, print out a prescription thatthey cannot sign and then write out the items again on a handwrittenprescription pad. The other difficulty that Mrs Reid has faced is thatshe had hoped to extend the clinics by employing a community pharmacistto run the existing clinics so she can set up new ones. “The problemis that I have not been able to get funding to do this,” she says.

Doncaster West PCT employs Mohammad Ahmed, a primary care pharmacist,to run hypertension clinics at Conisbrough Health Centre and Petersgate MedicalCentre, both in Doncaster. He has been prescribing for five weeks. Newpatients identified with hypertension are referred to him. “OnceI have agreed the CMP with the patient, I send an electronic messageto the GP,” he explains. “All our CMPs are on the computer,we don’t have any paper forms.” The GP then adds a code tothe patient’s CMP to confirm agreement and sends a message to Mr Ahmedwith any comments needed.

Mr Ahmed says that agreeing CMPs with the GP is the biggest hindranceto supplementary prescribing. Both he and the GPs run clinics in theafternoons between 2pm and 4pm and this makes it difficult to gain theiragreement to CMPs during these hours. An advance agreement for the majorityof patients was the solution the practice came up with. He can use supplementaryprescribing for any patient who can be treated according to the DoncasterWest PCT hypertension guidelines. “I only have to wait for GP approvalif I want to prescribe outside the Doncaster West guidelines,” heexplains.

Garry Barrett is a community pharmacist who undertakes sessional work at Winshill Health Centre in Burton-on-Trentwhere he prescribes for patients with diabetes, hypertension and chronicobstructive pulmonary disease. Patients arereferred to clinics run by him and a nurse prescriber by the GPs at the practice. “The GPs are trying to focuson the acute side and leave chronic disease management to us,” heexplains.

Community pharmacy

Campbell Shimmins was the first pharmacist to write aprescription in a community pharmacy in the UK. He is prescribing inthecardiovascular area, mostly beta-blockers, ACE-inhibitors and nitrates,at a rate of about two or three prescriptions a week. “One advantageis that patients have access to me without having to wait for an appointment.Because the number of patients I am prescribing for is still fairly lowat the moment, I am seeing them without an appointment. This is one ofour main strengths and I don’t want to undermine it,” hecomments. “Becoming a prescriber has certainly increased my professionalstanding.”

Mr Shimmins has financed the service through money he was already receivingas part of the pharmaceutical care model schemes that operate in Scotland.Through the model scheme, he has been going to the surgery to reviewpatients’ notes for some time. This allows him to identify patientswith drug-related problems who need monitoring. “These are patientson five, six or seven drugs. Any blood tests needed are carried out andthen I monitor them closely for the next few months, prescribing forthem according to the CMP. Once they have stabilised I refer them backto the surgery to be managed through the usual repeat prescription service,” heexplains.

Mr Shimmins has regular meetings with the GP to agree and update CMPs.Overall, he says that he has not encountered any barriers to introducingsupplementary prescribing, although comments that communication couldbe better. One particular problem is finding out patients’ bloodtest results for which he has to telephone the surgery. “An electronicsystem would obviously be best. And this would be improved further ifI could take the blood samples here and if I could have access to theblood testing laboratory system rather than having to go to the surgeryfor results,” he comments.

George Romanes, who runs a community pharmacy in Duns, Berwickshire,is about to start prescribing. He has negotiated funding to allow himto run asthma and hypertension clinics at his pharmacy and is currentlywriting CMPs in preparation for the first clinic. “Initially Iam targeting patients with asthma who have high ‘do not attend’ ratesat the surgery or who have poor control. We are hoping that they willrespond better to the open-access situation that I can offer at the pharmacy,” heexplains. Similar patients with hypertension are also being selected.Mr Romanes highlights the fact that some patients do not visit surgeriesbecause they are not in town centres and because of a wait for appointments:easier access is one of community pharmacy’s strengths.

At the moment, Mr Romanes has to go to the local surgery to access patients’ medicalnotes and he writes the CMPs there. “I have just been connectedto the NHSnet so this makes communication with the surgery much easier,” heexplains. Using the NHSnet connection, he will feed back informationsuch as changes to patients’ medicines to the practice managerwho has agreed to update the notes.

Mr Romanes has managed to overcome many of the barriers facing othercommunity pharmacists in putting supplementary prescribing into practice.He will be paid £36 an hour to the run the clinics by NHS Borders.And one of the technicians working for him is currently training to becomea checking technician so this will allow him to leave the shop floorfor consultations. In addition, he comments: “One of the reasonsasthma and hypertension have been picked is because I don’t needto carry out invasive testing in the pharmacy.” Although he wouldbe happy to take blood samples, using non-invasive tests initially helpsto give people confidence about his new role.

These pharmacists are proving that supplementary prescribing works. Itwill be easier for future pharmacists to follow in their footsteps, butcommunity pharmacists, in particular, face real issues that need to beaddressed or their prescribing training will be wasted.

Citation: Prescribing and Medicines Management URI: 11004789

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