 | Dr Linda Bryant (PGDipPharm, MPharm, DPharm(Auck), FACPP, FNZCP, FPSNZ, MCAPA) |
Linda is a New Zealand Clinical Advisory Pharmacist working as part of a team with GP's and nurses, in a medication advisory role. New Zealand clinical pharmacists get some encouragement to work independently in a variety of settings not necessarily tied to a community pharmacy. Through her company, Comprehensive Pharmaceutical Solutions, she contracts to Primary Health Organisations, lecturing postgraduate students in Clinical Pharmacy and undertaking evaluations of services. Linda's PhD thesis involved investigation into the barriers of implementing Comprehensive Pharmaceutical Care (clinical medication reviews) in primary care. | |
The opportunity for pharmacists to prescribe independently may be upon us sooner than we realise – like by the end of 2010.
Yes, that is this year.
I am very supportive of pharmacist prescribing, though personally would prefer collaborative prescribing because I doubt that pharmacists have, or wish to obtain, the extensive diagnostic skills required by a medical practitioner.
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But overall this has to be a way forward for pharmacy if we are not to be relegated to the role of professional shop-keepers, as nurses and others become more knowledgeable in medicines therapy, and also gain prescribing privileges.
Pharmacists must take the high ground and use their pharmacotherapy knowledge and understanding to become the experts in optimising the use of medicines – not just trying to get patients to comply with what another health care provider has prescribed.
Our practice nurses appear to be good at providing this adherence support role and working in nurse clinics that are now part of general practice, having time to spend with the patient.
Pharmacists must establish themselves as the health professionals with a high, and relatively unique, knowledge base and skill set relating to pharmacotherapy – our supposed area of expertise.
This is what differentiates us from other health care providers.
So, what thorny issues is pharmacist prescribing going to raise? (The following refers to prescribing in primary care rather than secondary care.)
Conflict of interest – access to third party payer funding
The first question is, can you prescribe and then benefit financially from the dispensing of the medicine?
There has always been a tacit agreement that ethically a medical practitioner cannot benefit financially from the dispensing of a medicine he / she has prescribed – from the perspective that if a third party (government) is paying, then the system is open to rorting and the over use of medicines.
I believe Japan had this problem when they allowed doctor dispensing.
This means that proprietors and their employees cannot prescribe and have the medicines funded through a third party.
Therefore, a prescribing pharmacist will need to be independent, preferably working closely with general practice.
We should be working towards having clinical pharmacists funded to work in general practices now, doing clinical medication reviews so that they become well placed to switch to prescribing pharmacists.
Qualifications
Nurses require a Master of Nursing degree, plus supervised experiential work to become a nurse practitioner (with prescribing privileges).
For pharmacists it is expected that a Postgraduate Diploma in Clinical Pharmacy, plus experiential learning will be the requirement.
One of the concepts that pharmacists will need to appreciate is that prescribing is for an individual, not a population.
While guidelines are useful for a general population, we need an in-depth knowledge of the medicines and the researched studies in order to individualise treatment … knowing when not to follow the guidelines.
If medicines therapy was simply following an algorithm, then an intelligent layperson could treat themselves (as indeed some try to do via the Internet).
Information sharing / collaboration
With concerns about the fragmentation of health care and current lack of coordination between health care providers, especially between primary and secondary care, then creation of yet another independent prescriber is potential hazardous.
Think of the patient under the care of a cardiologist, diabetologist, respiratory physician and rheumatologist, plus a general practitioner, nurse practitioner and a dentist, all prescribing independently and with the added possibility of these prescriptions being used in conjunction with OTC medicines and CAMs.
The risk of a drug therapy problem resulting in drug-related morbidity or mortality is great.
We don’t really need to add in another independent prescriber.
An electronic shared patient record is almost here, but the question still remains – who’s prescribing takes priority?
Therefore it is important that the pharmacist be prescribing within what is currently the most complete patient record – that of the general practice.
We will need to position ourselves within this collaborative environment, which is likely to be less threatening to medical practitioners than a competing independent prescriber located in the community pharmacy nearby.
I also see the prescribing pharmacist working as part of the team with the practice nurse, who focuses on the lifestyle issues for people.
Prescribing situations
So, how could prescribing pharmacists be helpful to general practitioners and help resolve some of the workload issues for general practice?
I imagine that repeat prescribing will be an important role – with the pharmacist managing the prescribing for people with long term conditions for three of the four quarterly visits, and a medical practitioner reviewing the patient annually.
Currently all our eligible patients have a cardiovascular risk assessment.
We could target those with a risk greater than 15%, and initiate what is currently guideline-based treatment and then monitor and individualise therapy as necessary.
The practice nurse could concurrently be addressing the lifestyle issues.
Similarly, the District Health Board I work in is considered the “gout capital of the world”, so the prescribing pharmacist could audit and then manage people with gout to achieve the target of serum uric acid concentrations less than 0.36 mmol/l. And so on ….
Responsibility and accountability
The biggest change is the move from making recommendations to taking full and complete responsibility for prescribing, and being accountable in a court of law for your decisions.
However, for pharmacists who make recommendations on changing a patient’s drug therapy, they should already realise that they are accountable.
Some general practitioners I work with, believe that if they enact my recommendations from a medication review, it is because they see me as a ‘specialist’ filling a gap in their knowledge.
Therefore I am equally accountable if my recommendation causes harm.
Prescribing pharmacists would no longer be able to hide behind the, “I only gave the information (or recommendation).
The general practitioner did the prescribing, so he / she is ultimately responsible”
Competencies
So what will be the competencies?
Having appropriate clinical knowledge and understanding, with the ability to apply it to an individual, is crucial.
To initiate pharmacist prescribing I believe we will need to use the skills of those who are the current experts in prescribing – the medical practitioners.
I have asked some general practitioners about what competencies are required for prescribing. It is not simple and is about living with uncertainty.
It is not simply knowing about the medicines.
We will need all the help we can get from the current experts in prescribing, who incidentally tell me that it takes a number of years to feel somewhat comfortable with the responsibility and uncertainty of prescribing.
I shudder to think that there is a move in the UK to have newly qualified pharmacists able to prescribe immediately.
Medical practitioners are not prescribing fully independently until they are 26 or 27 years old – and they have been entrenched in clinical patient health care in that time, not a dual role (supply and distribution).
Prescribing is not a useful ‘add-on’ service to fill in time between doing other things.
It needs to be the primary focus of the pharmacist and undertaken in an environment that is all about patient focused medical care.
We need to be establishing the environment for pharmacist prescribing now – in general practices.