Supplementary prescribing
pharmafile | November 6, 2003 | Feature | |Â Â NHS, healthcare, pharmacist, supplementary prescribingÂ
Supplementary prescribing by pharmacists will soon become a reality. The first wave of pharmacy supplementary prescribers begin their courses this autumn and will go towards the Department of Health (DoH) target of 1,000 pharmacist supplementary prescribers in 2004.
Although the first tranche of supplementary prescribers were expected to be primarily hospital pharmacists and nurses, it now appears that there is an active push from the DoH and indeed from pharmacists themselves to get community pharmacists enrolled.
Defining supplementary prescribing
Supplementary prescribing is defined by the DoH as voluntary prescribing partnership between an independent prescriber and a supplementary prescriber, to implement an agreed patient-specific clinical management plan with the patient agreement.
In practice, the doctor (the independent prescriber) makes the diagnosis and then hands over the management of an individual patient to a named supplementary prescriber with whom he or she has a close working relationship. The supplementary prescriber manages the patient under a clinical management plan drawn up by both the doctor and the pharmacist supplementary prescriber.
The key principles that underpin supplementary prescribing, according to the National Prescribing Centre (NPC) are:
- Communication between the prescribing partners.
- The need for access to shared patient records.
- The need for the patient to be treated as a partner in their care and being involved at all stages in decision-making, including whether part of their care is delivered via supplementary prescribing.
Working as a supplementary prescriber
The pharmacists that are most likely to become supplementary prescribers in primary care are those involved with chronic diseases and conditions such as hypertension, heart failure, pain management, ulcer management and asthma.
There is no specific formulary for supplementary prescribers to use. That means all prescription-only-medicines (POM) and general-sales-list (GSL) and pharmacy (P) medicines can be prescribed. Appliances, devices, foods and other borderline substances can also be prescribed.
The exceptions to this rule are controlled drugs and, unless they are part of a clinical trial, unlicenced drugs.
Pharmacists who already run clinics, such as for asthma, hypertension or diabetes, will already have demonstrated expertise in a particular disease area and experience of medicines management. These pharmacists are also likely to have forged a closer working relationship with local GPs. Training as a supplementary prescriber will therefore enable them to manage the patient condition based on a Clinical Management Plan (CMP) agreed with the doctor.
Clinical management plans
The aim of the CMP is to allow the supplementary prescriber to manage the treatment of individual patients within the identified parameters. The CMP is a patient specific document which is drawn up in conjunction with, and agreed by, the independent and supplementary precribers. The patient also needs to agree and be happy with the arrangement for a supplementary prescriber to be involved in their care.
The CMP should be fairly simple and quick to complete and should not duplicate a lot of the information which is in the shared medical record. CMP should have enough detail to ensure patient safety.
Pharmacists can access two template CMPs from the DoH website which they can develop to meet individual needs. The NPC has outlined the specific information that needs to be included:
- The range and circumstances within which the supplementary prescriber can vary the dosage, frequency and formulation of the medicines identified. Medicines may be listed by class, formulation or specific product, at the independent prescriberdiscretion, or be identified by reference to reputable guidelines or protocols for a specific condition.
- When to refer from supplementary prescriber to independent prescriber.
Relevant warnings about known sensitivities of the patient to particular types of medicine.
- Arrangements for notification of adverse drug reactions.
- The date of commencement of the arrangement and date for review (not normally longer than one year, and much shorter than this if the patient is being prescribed antibiotics).
Supplementary prescribing will bring new roles and responsibilities to individuals within the prescribing team. That means a new working relationship for pharmacists and doctors and nurses. All prescribers will have to view each other as equal partners.
The move from the old entrenched roles to this new working medium can therefore create a conflict of ideas and pharmacists need to recognise this. Potential conflict can be avoided through communication, equal partnerships, clarifying working practices as well as CPD.
Opportunities for pharma companies
As experts in disease management, pharma companies can make a valuable contribution to pharmacist's new role. Pharmacists will need the latest clinical and pharmaceutical knowledge relevant to their particular area of practice and help in developing CMPs. Another avenue that is being explored is sponsorship of pharmacists by pharmaceutical companies.
Some pharmaceutical companies already sponsor nurses to become specialists in particular therapeutic areas and similar arrangements for pharmacists would be a logical development.
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