Pharmacist prescribing in Scotland: how we did it and what we have learnt

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Pharmacist prescribing in Scotland how we did it
and what we have learnt

• Christine Bond
• Head of Centre of Academic Primary Care
• University of Aberdeen
• and
• Consultant in Pharmaceutical Public Health
• NHS Grampian
• 
  

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Overview

• How we got there- the cultural change
• National infrastructure
• Local implementation-challenges and solutions
• Underpinning research findings
• Future research agenda

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How we got there- the cultural change
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Pharmacists role?

• Pre-NHS
• Dispensed private prescriptions from GPs
• Advised on minor ailments
• Compounded and supplied medicines
• Chemists nostrums
• NHS 1948 (health care free at the point of
  delivery)
• Decreased demand for advice
• Increased demand for dispensing
• Reduced demand for compounding
• Increased potency of drugs on prescription cf OTC

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Traditional contracts

• Dispensing of prescriptions
• volume driven payment
• Displaying leaflets
• Providing opportunistic advice on dispensed
  medicines
• professional fee
• Locally negotiated services
• eg drug misusers, nursing homes, compliance needs
  assessment, smoking cessation
• Recognition of other private health care roles
• Sales of OTC medicines

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Drivers for change
Culture change Society NHS
Research data
Practice norms
Policy need
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The state of the NHS 1990s

• Policy issues
• GP overload
• Emphasis on convenient access to medicines
• Pressure on drug budgets
• Changing social culture
• Relationship with professionals
• Expectations of the NHS
• Professional aspirations and evolving norms
• Acknowledged under utilisation of skills
• Multiple pilot studies
• Creeping changes

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Prescribing role for pharmacists?
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Prescribing role for pharmacists?

• OTC supply is a private prescribing role

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Key UK switches since 1983
OTC supply is a private prescribing role
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Key UK switches since 1983
Minor self limiting conditions
OTC supply is a private prescribing role
Chronic conditions
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Prescribing role for pharmacists?

• OTC supply is a private prescribing role
• Equity?
• Minor ailments scheme in UK contracts

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Minor Ailments scheme

• NHS supply of
• P and GSL medicines
• POMs listed under a PGD
• For conditions presented in the pharmacy
• To patients exempt from prescription charges and
  registered with the pharmacy
• Pharmacy will maintain patient record
• (name, address, exemption, advice and treatment
  provided, date)
• Supported by the NHS net
• Linked to CHI
• Local formulary
• Annual capitation fee

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Prescribing role for pharmacists?

• OTC supply is a private prescribing role
• Minor ailments scheme in UK contracts
• POM medicines
• Repeat supplies
• Medicines Management/pharmaceutical care
• Patient Group Directions (PGDs)
• Supplementary and independent prescribing

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Regulation follows practice!

• Crown Reports
• Crown J. Review of prescribing, supply and
  administration of medicines. Final report.
  London. Department of Health 1999.
• Review of administration and supply of medicines
• Designed to provide better regulatory framework
  for current practices
• Patient group directions
• Supplementary prescribers
• Independent prescribers
• Changes to legislation and regulation

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Supplementary prescribing

• Supplementary prescribing (SP) is defined as a
  voluntary partnership between an independent
  prescriber (a doctor or dentist) and a
  supplementary prescriber to implement an agreed
  patient-specific clinical management plan with
  the patients agreement.

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Independent prescribing

• Not really supported by research or practice
• Evolutionary increase in prescribing rights of
  nurses
• Supplementary prescribing experience of
  pharmacists
• Independent prescribing rights for pharmacists
• With additional training
• Within own level of competence
• Separate from dispensing role
• More flexible-less medical control

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New UK community pharmacy contracts(Smoking,
Health and Social Care (Scotland) Act 2005)

• Scotland (from July 2006)
• Four core services provided by all pharmacies
• Minor Ailments (MAS)
• Public Health (PHS)
• Chronic Medicines Service (CMS)
• Acute Medicines Service (AMS)
• Pharmaceutical Care Services Plan
• Performers List
• Expectations of
• Supplementary (and Independent) prescribing
• OTC sales function still not NHS

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National infrastructure
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How implemented in practice in Scotland

• Agree curriculum and design course (RPSGB, SoP,
  SG)
• Course developed by one SoP intially
• Pharmacists only
• Financial support/training grants
• Allocation of numbers by area
• Only hospital and community pharmacists eligible

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The formal training

• 25 days total study
• 5 days at University with distance learning
• Therapeutics (12 different options)
• Medicines, prescriber, and people
• Care planning
• Prescribing and public health
• Academic prescriber qualification
• 12 days supervised practice (PLP) with DMP
• Registration with RPSGB
• Practice as prescriber
• (modification for IP)

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• First supplementary prescribers registered with
  the Royal Pharmaceutical Society of Great Britain
  (RPSGB) in January 2004

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Local implementation-challenges and solutions
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Local issues

• Selection of local pharmacists
• National criteria
• Local criteria
• Local funding for primary care pharmacists
• Identification of DMPs
• Ongoing support in practice
• Local networking meetings
• Ongoing clinics
• Local funding?
• National funding
• Need to meet local priorities
• Cultural change
• Governance framework for Non Medical Prescribing

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Pharmacist prescribers in Grampian by area of
practice (n66/300)
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Pharmacist prescribers in Grampian by prescriber
status (n66)
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Pharmacist prescribers in Grampian by practising
status (n66)
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Pharmacist prescribers in Grampian by area of
practice (n25)
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Primary Care Pharmacist Prescribing Scotland June
2007-May 08
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Top 10 drugs prescribed in Scotland June
2007-May 08
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Drug misuse case study

• Local service need, specialist support, qualified
  pharmacist
• Specialist relocated
• New postholder and team
• Professional boundaries
• Agreement of protocols
• Lack of patients!
• GP retiral-service need became acute
• National (DoH) support
• Management interest
• Bingo

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National picture our research findings
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What do pharmacists know?

• UK wider postal survey (10) (November 2005)
• Response rate 55 98 aware of SPP
• Generally aware of SPP but not courses or
  details
• 10 had taken some action and 60 had thought
  about it
• Believed SPP would
• improve- patient care, professional standing
• need additional pharmacist and technical
  support
• Innovators (19), early adopters (21), early
  majority (45), later majority (10) or laggards
  (1)

Pharmacist supplementary prescribing training a
study of pharmacists perceptions and planned
participation. Stewart D, George J, Pfleger D,
Bond C, Diack L, Cunningham S, McCaig D. I JPP
(2007)
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What are early supplementary prescribers doing?

• Postal survey -all pharmacist UK in GB (n488) in
  2005
• 82 response
• 48 had started to practice and 38 had written a
  prescription
• Main benefit perceived as better patient
  management
• Main challenges funding, no organisational
  recognition, no prescription pads
• Greater publicity required for role and support
  of medics

Benefits and challenges of prescribing training
and implementation perceptions and early
experiences of RPSGB prescribers George J, McCaig
D, Bond C, Cunningham S, Diack L, Stewart D. IJPP
2007 15 23-30
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What Scottish stakeholders think

• Purposive sample Scottish PSP (n9), case load
  gt20, experience gt3m
• Range of geography, setting and therapeutic area
• Associated MPs (n8), and patients (n18)
• Telephone interviews to explore attitudes,
  experiences, perceptions

A qualitative exploration of the views of
pharmacist prescribers, doctors, and patients on
pharmacist prescribing implementation. Stewart,
D., George, J., Bond, C., Diack. L., Mccaig, D.,
Cunningham, S. IJPP 2008 Supp. 1 A5
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Key findings

• Patients
• Little idea what to expect
• Apprehensive of first visit
• High level of satisfaction

• PSP/MP
• All supportive of PSP
• Benefits were identified for patients
• Pharmacists were perceived as becoming more
  integrated into health care team
• Some concerns about independent prescribing

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Pharmacists
Within the practice we were almost
doing prescribing role anyway so this was a
natural next step
They were really happy that they have someone
who they can just walk in to and talk to instead
of appointments.
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Doctors
The main benefit for me is that its good for
the patients. Patients get a more detailed look
at their medication and interact well with the
pharmacist.
It can simplify the process in that the
pharmacist often has more expertise and knowledge
in actual drug interactions, side effects,
contra-indications.
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Patients
I dont think there is any change in quality of
care because of it. I think pharmacists are
perfectly capable and also I am assuming that
they will liaise with the doctors.
Well that was the thing really I didnt know
what to expect. I just had to trust the practice
knew what they were doing and actually when I met
him it was fine and put my mind at ease.
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Independent prescribing?

• Postal survey to random sample all community
  pharmacies in Scotland (n500) in 2004
• 43.4 response
• 91 aware of proposals for IP by pharmacists
  mainly through PJ
• Of suggested commonly presenting clinical areas
  for prescribing most confidence in conjunctivitis
  (88) and acne (81) and least for neck pain
  (62)
• Clinical training (98), and communication skills
  for patients (58) and GPs (80) were important

Independent prescribing by pharmacists a study
of the awareness, views and attitudes of
Scottish community pharmacists George J, Pfleger
D, McCaig D, Bond C, Stewart D. Pharmacy World
Science 2006 28 (2) 45-53
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What does the public think?

• Response 37.1 of 5000 (Scotland)
• gt50 on Rx medicines (median 3 )
• 978 (56.6) aware health professionals now
  prescribe
• Awareness associated with inc.age (plt0.001), a
  health professional in immediate family
  (plt0.001), self-rated general health (plt0.005)
  and higher educational level (plt0.01).
• Comfort levels highest for pharmacists and
  nurses (median 4) and lowest for radiographers
  (median 2)
• gt50 support pharmacist prescribing but
  should not prescribe the same range of medicines
  as doctors.
• Concerns about lack of privacy Acknowledged
  convenience

Stewart, G., Johnson, G., McCaig, D., Bond, C.,
Cunningham, S., Diack, ., Pfleger, D., Munro, K.
(2007). A cross sectional survey of the general
public's awareness, views and attitudes to
non-medical prescribing in Scotland. , IJPP July
2007 . B27-28
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What we still dont know from the research

• Clinical outcomes of pharmacist prescribing
  compared to doctors
• Cost effectiveness
• How to assess pharmacist consultation skills
• Comparisons with other new prescribers

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Clinical outcomes of pharmacist prescribing
compared to doctors MRC study

• Subjects are patients in primary care with
  chronic non malignant pain
• Identified through repeat prescriptions
• Based on previous uncontrolled study
• Exploratory three armed RCT
• Compare
• Pharmacist review and pharmacist prescribing in
  pain
• Pharmacist review and referral to GP
• Usual care
• Outcomes
• Pain, QoL, medication
• Finalise intervention
• Test data collection methods including health
  economics

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Assessing pharmacists consultation skills

• What are the competencies
• How to assess-validated scale?
• New scale or existing scale?
• Self assessment, observation?
• Who should assess
• Video, actual
• Patient issues

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RGU led programme early work

• RCGP Video Assessment of Consulting Skills 2007
  (12 criteria)
• Tailored for pharmacist Rx by 4 GPs and 4
  Pharmacists, 2 educationalists
• Piloted on 9 x 2 pharmacist consultations
• RCGP accredited GP assessors
• Parallel patient satisfaction score collected
• 93 of patients entirely satisfied
• Tool discriminated across pharmacists but inter-
  rater reliabilty could be improved
• GPs generally impressed by pharmacists
• Further development work ongoing

Development and validation of a tool for
evaluating consultation skills of non medical
prescribers. Stewart D., George J, Harkness, S.,
Bond C, Diack L, Cunningham S, Cleland J, McCaig
D. IJPP 2007 Supp 2. B28
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Summary

• Pharmacist prescribing represents a culture
  change which is better approached incrementally
• Should be supported by medical prescribers
  nationally and locally
• Requires consensus of need and evidence of
  benefit to establish
• Follows typical innovation graph

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No. pharmacists
Time
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No. pharmacists
Time
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Acknowledgements

• NHS Grampian pharmacist prescribing team led by
  Wendy Robertson and Airlie Bryce
• RGU prescribing research team led by Derek
  Stewart
• RGU prescribing course team
• All the participants in our research
• NHS Education Scotland for funding the research

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Thank you for listening