Considering becoming an independent pharmacist prescriber? Read on…

Johnathan Laird

Johnathan Laird

 

“A pharmacist independent prescriber is a practitioner who is responsible and accountable for the assessment of patients with diagnosed or undiagnosed conditions and for decisions about clinical the clinical management required, including prescribing”(1).

Due to the breadth of the role of a pharmacist independent prescriber, it is important to define the limitations of the area of practice, and to acquire the correct level of indemnity insurance before entering in to any prescribing activities from a recognised broker.

It is also important that a prescriber’s registration with the General Pharmaceutical Council (GPhC) is annotated to indicate that the pharmacist will be an independent prescriber before beginning to practice.

The following reflective statement outlines some thoughts on how to begin to manage risk as a prescriber considers their practice. You may read this and have feedback or suggestions. I absolutely welcome this.

I admit that it is probably not the most exciting blog I have ever written, but a sound knowledge of the legal aspects of practising as an independent prescriber is, in my view, critically important. This blog serves only as a summary.

To ensure structure and consistency to practice I think it is wise to develop a suite of standard operating systems to follow, audit and review as part of ongoing prescribing practice. Each of these SOPs addresses the elements of risk associated with practice, and serves to ensure a consistent approach to practice (2).

The concept of consent is extremely important when practicing as an independent prescriber. I have written an SOP that describes how I will acquire consent before I begin any prescribing activity. It is very important that this process is not rushed, and that the patient clearly understands the role of an pharmacist independent prescriber and exactly what it means for their care (1,2).

Privacy, and conducting consultations in the correct environment is paramount.

Pharmacist independent prescribers must act within their own level of experience and competence.1 To be clear, this means that the prescriber can carry out a complete history, make a diagnosis, and prescribe if necessary, but if the prescriber does not understand the full implications of the prescribing decisions they must refer care back to the medical prescriber.

Errors and learning from practice will happen, and I have a robust strategy to learn from significant events and will act on feedback from other prescribers. I have planned to meet regularly with other prescribers to review our practice. If an event needs to be reported, I will do so through the pharmacy error reporting system, but also through the surgery significant event analysis programme. Learnings should direct continuing professional development, which will reflect the fact that the pharmacist is a prescriber.

I will update my knowledge regularly by attending relevant courses, and as I am a member of the Royal Pharmaceutical Society (RPS) I will use this to network with other prescribers and inform relevant prescribing related CPD activities. I have also set up plans with two other respiratory pharmacists to share good practice and peer review prescribing decisions.

My area of practice is respiratory, so I have created a framework, and written an SOP to lay out exactly where my scope of practice starts and ends.

I have also written an SOP that describes the structure of the clinical pathway that patients under my care will take, and this includes arrangements to hand care back to a medical prescriber if necessary and in what circumstances this should happen.

I have laid out the structure for the brief interventions and also the structure of the review process I will go through in my clinics in an SOP.

Independent prescribing does not require such tight structures or systems, but I felt that as a new member of the extended local GP/healthcare team it would be prudent to really emphasise where my responsibility starts and stops.

At all times prescribers must work within local guidelines, Scottish Intercollegiate Guidelines Network (SIGN) guidelines and also National Institute for Health and care Excellence (NICE) guidelines, where appropriate. Sticking to these guidelines will ensure prescribing practice is not only safe, but also evidence-based.

Finally, I have developed an overarching prescribing policy for my own practice. This is based on the advice given to me by my medical prescribing mentor, my pharmacist independent prescribing mentor, and also the best practice guidance laid out in the NHS education for Scotland (NES) document: A guide to good prescribing practice for prescribing pharmacists in NHS Scotland (1,2).

I hope this blog has shed some light on the implications for pharmacists becoming independent prescribers. I think, like the dispensing process, if the risks are fully understood and importantly, properly managed, then pharmacists should feel empowered to practice as independent prescribers. Professionalism, and using all the support networks available, especially to newly qualified prescribing pharmacists, is essential.

Johnathan Laird is a community pharmacist independent prescriber with a special interest in asthma. He is based in based in Aberdeen.

Follow Johnathan @JohnathanLaird

References

1. NHS education for Scotland, a guide to prescribing practice for prescribing pharmacists in Scotland. Accessed September 14th 2014 at; http://www.nes.scot.nhs.uk/media/1457463/nesd0061_goodprescribingpractice.pdf

2. Standard operating procedures for operating an asthma independent prescribing service as a community pharmacist, Johnathan Laird, 2014.

Pharmacy is as sexy as a below knee stocking!

Ross Ferguson

Ross Ferguson

WE don’t have the political power of doctors or the huge unquestioning public support that nurses seem to enjoy.

Community pharmacy is a pair of medium, class II, beige, below-knee support stockings.

As individuals we don’t blow our own trumpets loudly enough, if we blow them at all, and unlike the majority of professionals and trades people, community pharmacists provide free services out with their contractual obligations, but under the radar of our NHS paymasters.

Every day we go above and beyond the call of duty to meet the needs of our patients (both health and social care), but we don’t make political capital from it.

It’s time we did.

It’s time we called in the favours and asked the public to support us to ensure the survival of free accessible professional healthcare advice and support in their local communities. We might not be the sexy healthcare profession, but the support we provide to patients is critical. If the strength of the network is damaged by a Government blunderbuss approach to managing pharmacy numbers, the support patients receive will be reduced and impact on healthcare, and the damage may be irreparable.

Making the case for community pharmacy by finding higher risk asthmatics!

Johnathan Laird

Johnathan Laird

 

NOT every environment lends itself well to managing patients with long-term conditions. The work I have done in the past year with asthmatic patients has shown me that there is perhaps a need for community pharmacist independent prescribers to be supported to enable them to care for these people.

My model of care is simple: I use various tools and processes to identify, risk assess and then manage asthmatic patients. The cohort of patients of interest to me are those that are at increased risk of exacerbation. Critically, these are often patients that, for various reasons, our multidisciplinary team colleagues in primary care cannot reach.

I have written previously about the overuse of reliever inhalers, high non-attendance rates at annual asthma reviews and the need to follow up with patients who have previously had an asthma attack.

Payment has not been linked to the quality of prescribing and I suspect this type of practice has not taken off simply because effective prescribing can often mean deprescribing. With a reduction in prescribing volume comes a linked reduction in revenue for the community pharmacy contractor. There is absolutely nothing wrong with these clinics in practice, in fact they helpfully contribute to relieving the prescribing burden carried by our nursing and GP colleagues. This model of practice, however, does not make a unique case for the survival of the community pharmacy network.

The broad aim of my ambition to become an independent prescriber was to attempt to prove that the unique relationship and footfall of community pharmacy could be converted to positive clinical outcomes for patients. My story began with the need to become an independent prescriber. Without this qualification as a pharmacist, I would not be able to manage a clinical list. Operating as a non-prescriber, the process of identifying the higher risk cohort of asthmatics would be useful, but ultimately I would have to hand care of the patient back to the GP.
I did not wish to duplicate the great respiratory care work my local GP and nursing colleagues were doing — we are all too busy for that, and besides the care they deliver is excellent.

In making the case for community pharmacy, I had to use the strengths like accessibility, excellent relationships, flexibility of opening hours we as pharmacists in the community are all familiar with. The key fact that is much underexploited in pharmacy clinically, is that patients have to attend the pharmacy to collect their repeat medicines. However, that same patient must choose to present to the GP surgery based on symptoms. Strategically, case finding higher risk asthmatics within this disengaged cohort was my aim as they collected their repeat inhalers.

During my period of learning in practice, I used chronic medication service brief interventions to identify this group of more vulnerable asthmatics. Risk assessment was initially done upon receiving and clinically checking the repeat prescription. For example, I would look at the frequency of prescribing of reliever inhalers and preventer inhalers, as well as spotting oral steroids prescribed as a reaction to a recent exacerbation. Based on these parameters, I would decide whether a brief intervention could be of benefit. My local GP colleagues provided me with a list of patients who did not attend the annual respiratory review at the clinic. I used this list to further prioritise. The key factors I used for identifying higher risk asthmatics as I clinically checked and dispensed their prescriptions were as follows:

1. Patient used more than 12 reliever inhalers in the preceding 12 months.

2. Patient compliance with reliever medicine was poor in the previous 12 months.

3. Patient was prescribed an oral steroid in the previous 12 months.

4. Patient did not attended the respiratory clinic in the previous 12 months.

5. Patient is a smoker.

At this stage I flagged the need for a pharmacist conversation upon hand our of their repeat medication prescription. The brief interventions are just that, brief. I found the use of the asthma control test was useful in many cases at this stage to convince the patient of the need to present for review.

Once identified, I then invited them to the respiratory clinic where I shadowed the GPs and nurses to help better manage their asthma. I am now doing live clinics in the surgery and have the support of my surgery team to move the clinics to the community pharmacy once I feel comfortable. I hope the advantage of eventually using remote read/write access to the records within the pharmacy will mean that I can increase the level of flexibility in terms of when I run the clinic. It is useful to note that many asthmatics are of school or working age, so a community pharmacy clinic run in an evening or at the weekend may help to increase attendance rates.

This was a tremendous learning opportunity but we found it particularly enjoyable because many of the patients we invited initially were not engaged with the surgery system of review. I now read that this problem of non-attendance for review is common across the country. During my training time I managed to source roughly 10 per cent of the local asthma list. Many of these patients were, at best, disengaged with the management of their condition or, at worst, required quite urgent care.

Now that I am practicing as an independent prescriber I am using the same method to fill my clinical list of patients. To be clear, I have taken a risk in that to begin with I had no patients on my list. The challenge has been to find them using the method above. Although it is early days my clinics have been full so far.

The practice manager gives me some appointments slots to fill and I identify patients as they pick up their inhalers who I think would benefit from review or intervention. I am pleased to say that each and every patient identified so far have had a pharmaceutical care issue related to their asthma that I was able to help with.

It is a little risky to have empty appointments but it is very motivating to be able to find asthmatics that need support. Helping patients that are disengaged with the local practice team will hopefully be useful. Further research would of course be interesting to identify if the benefits are useful enough.

So as I go forward I do so with great optimism for the community pharmacy sector. Many of us in community have dabbled with case finding odd opportunistic clinal test like blood pressure. However finding cohorts of patients that are only willing to engage with you as a community pharmacist creates a compelling argument to support this type of practice within the heart of our local communities. If we can then use read/write access to the patient records and skills linked to independent prescribing to manage these patients safely in the community pharmacy we could maybe make a real difference to patients.

It’s always all about the patient at the centre of our practice. Nothing else can take precedence.

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Johnathan Laird is a community pharmacist independent prescriber with a special interest in asthma. He is based in Aberdeen.

Follow Johnathan @JohnathanLaird