Justifying my prescribing decisions

Primary care has formed a major part of my career in pharmacy. I have been working in the sector since 2002, first starting as a practice pharmacist for the primary care trust (PCT). In those days I spent most of my time conducting medication reviews using patients’ notes and suggesting drug switches to help save money for the PCT.

My role changed substantially once I became an independent prescriber. Now, I am often torn between what is best for the patient and what is most cost effective or in the local formulary, as well as following national guidelines. I also know that I may be asked to justify my prescribing decisions.

Prescribing is not always straightforward and often I seek advice from my colleagues or specialists when a discussion may help me look at other options that I may not have considered.

Recently, I undertook an audit looking at the newer medicines for diabetes and came across a few patients to whom I have prescribed some unusual combinations. One complex diabetes patient is now on a glucagon-like peptide-1 agonist injection, metformin, gliclazide and, more recently, a sodium-glucose co-transporter 2 inhibitor. The decision to start the latter medicine was not taken lightly. After a long conversation with the local community diabetic specialist nurse and diabetologist, I decided that the benefits of the medicine far outweighed the risks for this particular patient because he would not be able to manage insulin independently, owing to his chaotic eating pattern and lifestyle. Hopefully, in this case I have done what is best for the patient after considering all the options available.

Prescribing is not always straightforward and often I seek advice from my colleagues when a discussion may help me look at options I may not have considered. Likewise, my colleagues come to me with prescribing queries to check they are in line with the local formulary and national guidance.

Frequently, my GP colleagues ask if they are ‘allowed’ to prescribe a drug. They know that searches, audits, prescribing data, etc, will reveal medicines they are not supposed to prescribe.

This culture has developed since I have been working full-time at the practice and it has kept us within our prescribing budget for many years. Pharmacists’ knowledge of medicines can be useful in a GP surgery where hundreds of medicines are prescribed every day and getting involved in prescription clerk training, reauthorising repeat prescriptions and medication reviews are ways of using our expertise to benefit patients.

In addition to this, pharmacist prescribers can make an even greater impact on patient care, especially in the management of long-term conditions. In light of the current shortage of GPs, we should, as pharmacists, offer our skills to primary care. This is one way that practices can relieve their workloads since not every patient needs to be seen by a doctor.

Next year, my practice will be piloting the first pre-registration placement split between hospital, community and primary care which, if successful, will be rolled out on a larger scale to develop primary care pharmacists for the future.