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By Helen Williams, PGDip (Cardiol),MRPharmS

Pharmacists in primary carehave struggled to developprescribing roles since the

introduction of supplementary and,latterly, independent prescribing.The reasons are multifactorial, butkey barriers include a lack ofinfrastructure (IT systems, access topatient records, joint working withlocal GPs), time, failure to identify abudget for independent prescribersand, possibly, a lack of vision anddrive from both communitypharmacists and primary care truststo “make it happen” (see Box 1, p265).

As an experienced prescriber in myprevious role as a specialist cardiacpharmacist in a tertiary cardiaccentre, I am keen to boost and supportthe development of other pharmacistprescribers in primary care.

I tested the water, in terms ofworking in primary care, byaccepting a secondment to LambethPCT and Southwark PCT to workas part of a hypertension “hit team”in 2006. Although case managementwas part of the original plan, thesecondment was only intended to befor nine months. With this in mind, itseemed more appropriate to workwith and mentor other prescribers tobuild a sustainable system, ratherthan simply run my own clinics forthe duration of the secondment.

Now, five years later, I spendmost of my time working in primary

practice to over 80% in the bestperforming practice.

Stroke and kidney disease are alsohigh priorities for each PCT, andhypertension is a key modifiable riskfactor for both of these. There isrobust evidence that controlling BPcan reduce the incidence of stroke,myocardial infarction and thedevelopment of renal impairment.

Successful hypertensionmanagement depends on good patienteducation, rational prescribing ofantihypertensive medicines andsufficient follow-up to assess efficacyof the chosen regimen and addresspatient adherence issues. As such, thisis an ideal opportunity for input froma pharmacist independent prescriber.

First healthy heart clinicPharmacist prescribing —supplementary and independent —remains a relatively new concept in

IT SEEMED MOREAPPROPRIATE TOWORK WITH ANDMENTOR OTHERPRESCRIBERS TOBUILD ASUSTAINABLESYSTEM, RATHERTHAN SIMPLY RUNMY OWN CLINICS

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care and the development ofprescribing roles for pharmacistsremains an important goal (see Box 2,p266).

Why hypertension?Hypertension is a major cause ofmortality and morbidity in the UK.Locally we have a low detectedprevalence of this disease, comparedwith the expected prevalence basedon our local populationdemographics; we believe we haveonly diagnosed around half of ourhypertensive population, forexample.

There is a wide variationbetween local GP surgeries in howwell hypertensive patients aretreated to achieve the bloodpressure (BP) audit standard of≤150/90mmHg. This ranges from50% of patients achieving thistarget in the worst performing

By ensuring that chronic conditions are diagnosed and managed appropriately pharmacists can play amajor part in improving patients’ health. But first they need to demonstrate their value to local GPs

How independent prescribing canbe nurtured in primary care

Helen Williams is consultantpharmacist for cardiovasculardisease, Southwark Health andSocial Care, LondonE: helen.williams11@nhs.net

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primary care. GPs are more familiarwith the role of nurse prescribers.The first hurdle was therefore topersuade practices that thepharmacist had something to offer,with the onus on my colleagues andI to demonstrate our value in ahypertension clinic.

To maximise the value ofpharmacist input, it was agreed that:

� We would work with practicesfailing to achieve quality andoutcomes framework (QOF)targets for hypertension

� Only patients withuncontrolled BP would beinvited to the clinic

� Clinic administration wouldbe provided by the practice

As well as looking at BP, thepharmacist would address globalcardiovascular risk through formalrisk assessment and appropriateintervention — a concept which isnow built into the QOF for newlydiagnosed hypertensive patients.

The first clinic was established in2007, in a practice where only 56% ofpatients were achieving the QOF BPtarget of ≤150/90mmHg; more than200 patients on the practice registerhad uncontrolled hypertension.

The clinic ran once a week for asingle clinical session for six months,

listing 122 patients, with a “do notattend” rate of 21%. Accordingly, Iwas able to review 96 patients in atotal of 139 clinic appointments.

Most patients were seen onlyonce or twice, with eight patientsrequiring three visits and fourpatients attending for four visits inthe six-month period. At the end ofthat period, 57% of this difficult-to-manage group were controlled tothe QOF target of BP≤150/90mmHg.

The overall practice QOFachievement for BP control to≤150/90mmHg increased from 56%to 68% (target is 70%) over the sixmonths, increasing to 76% at theend of the first year.

Full cardiovascular riskassessment was carried out for allpatients and 39 of the 96 patients(42%) were newly identified as athigh risk of developingcardiovascular disease (≥20% riskover the next 10 years), indicatingstatins should be started.

Mentoring and supportFollowing the success of the initialclinic, the aim was to set up similar

services across the PCTs usingtrained pharmacist prescribers fromprimary care and the community.

A second clinic was run by acommunity pharmacist whom Isupported. This pharmacist hadexperience of running ahypertension clinic. I was usuallyon-site for advice during the clinics,but working in a separate consultingroom. Similar results were seen inthis clinic with 69% control of BPto ≤150/90mmHg at six months,although only 72 patients were seenwithin this time frame.

The low number of patients wasdue to a shorter clinic duration andongoing issues with practiceadministrators failing to listadequate numbers of patients forthe clinics. Despite this, the overallpractice QOF achievement for BPcontrol to ≤150/90mmHg increasedfrom 51% to 74% over the sixmonths.

In a third clinic, which I ledinitially but was recently taken overby a newly qualified independentprescriber funded by the GPpractice, BP control rose to 84%(88/105) of the clinic population

Box 1: Challenges facing pharmacist prescribers

Some of the challenges facing pharmacistprescribers in developing their prescribing roleinclude:

Infrastructure Lack of infrastructure,particularly IT connectivity and access to thepatient record, limits the sites at which clinicscan be offered to GP surgeries, polyclinics orPCT health centres. This disadvantagescommunity pharmacists who are seeking toextend their role since, despite the availabilityof consulting rooms on site, they cannotreadily access patients or their medicalrecords. Pharmacists wanting to take onprescribing roles should approach GPsurgeries initially to forge partnerships, with aview to offering services from their ownpremises in future when trust has been built.

Time Setting up new services takes time toengage the relevant parties, develop systemsand protocols, undertake audits and ensureappropriate governance arrangements are inplace. Individual pharmacists often struggle tofind the time for such service developmentalongside their other commitments and, as aresult, progress is thwarted.

Funding Prescribing budgets are allocated toGPs based on their registered patientpopulations. Identifying budgets for non-medical prescribers who do not sit withintraditional settings in primary care is difficultand, to date, most pharmacists rely onaccessing the GP prescribing budgets — againemphasising the importance of partnershipworking. Funding issues go beyond accessinga prescribing budget, because pharmacistsneed to secure payment for the services theyare to deliver. Pharmacists need to beempowered to develop business cases forsubmission, for example, to practice-basedcommissioning groups or individual practicesto secure such funding to allow these servicesto become embedded in primary care.

Vision Many pharmacists have been fundedthrough the prescribing courses only to find alack of vision and drive to make use of theirskills. As a result their skills start to atrophyand enthusiasm wanes. After investing inthem and to ensure equity, PCTs should besupporting prescribing pharmacists to developin the same way that GPs are currentlysupported in service development.

�FOLLOWING THESUCCESS OF THEINITIAL CLINIC, THEAIM WAS TO SET UPSIMILAR SERVICESACROSS THE PCTSUSING TRAINEDPHARMACISTPRESCRIBERSFROM PRIMARYCARE AND THECOMMUNITY

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during the first six months, with 35patients (33%) newly identified asbeing at high risk of cardiovascularevents. Over six months the practiceQOF for BP control improved from56% to 77%.

Clinics 4 and 5 are ongoing, ledby local prescribing advisers, and we expect a combined patientdatabase of over 500 patients in thecoming months.

My role in these clinics has been to train and support thepharmacist prescribers, help withdifficult clinical issues, audit theirservice and support them indemonstrating their effectiveness tothose who will ultimatelycommission the service.

I hope that these pharmacistprescribers will be commissioneddirectly by the GP practices onceour project monies run out. This hasalready happened for the third clinicwe established, which is now fundedby the GP practice in which it isbased.

Box 2: My role

My primary role as aconsultant pharmacist forcardiovascular disease is topromote the best possible carefor cardiac patients,particularly with regard tomedicines management.However, I cannot personallydeliver this to the wholepopulation of south Londonand, therefore, developing,supporting and mentoringothers — be they pharmacists,nurses or doctors — to enhancetheir roles and improve theirclinical skills is the mostefficient and effective way toachieve this goal.

Supporting non-medical prescribers is just one aspect ofhow I can have an impact; other elements of my work include:

� Development and implementation of sector-wideprescribing guidance for cardiovascular diseasethrough the local cardiac and stroke network

� Running a network of cardiac pharmacy leads in allprimary and secondary care organisations in southLondon

� Delivering education and training across all disciplines,informing the commissioning process for new services(such as pharmacy-based NHS health checks)

� Working at a national level with organisations such asthe National Institute for Health and Clinical Excellence

Helen Williams: “Supportingnon-medical prescribers isjust one aspect of how I canhave an impact”

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By Paul Forsyth, MRPharmS

Prognosis and death are topics thatpharmacists historically have not hadto broach with patients. Does

becoming a prescriber change this?After a first acute hospital admission for

heart failure, for example, a patient has aworse prognosis than for most common typesof cancer. Pharmacist prescribers are likely tobecome involved in the care of these patients

during an acute hospital admission or at a chronic managementclinic. During an initial admission patients in heart failure willbe prescribed many medicines — taken to reduce mortality aswell as to prevent hospital readmission and relieve symptoms.Therefore, if pharmacists are going to be involved inprescribing and up-titrating these medicines then it only seemsfair that these pharmacists should be available to discuss withthe patients the reasons why.

Patients should be monitored regularly for worsening ofsymptoms. Different medicines are indicated for heart failureas the patient progresses through his or her illness.Spironolactone is a good example of this,since it is typically considered when aperson becomes either breathless upon verylight “less than normal” activity orpotentially breathless even when at rest.

It stands to reason that if a pharmacistbecomes involved in a heart failure clinic andchooses to prescribe drugs like spironolactonethen he or she must be prepared to explainthis decision to the patient — and discuss thelong-term pros and cons of the therapy. This, by its very nature,involves the topics of prognosis and death. When I first qualifiedas a prescriber I was uncertain how to broach these with patients.In some ways I was scared about how the person might react. Icertainly felt that the course hadn’t prepared me for this. But Ialso felt that my patients had a right to be given all the informationthey needed about their condition. National guidelines, heathcarestandards and patient groups now all recommend as much.

Talking about long-term prognosis and death isn’t a skillthat can be learnt and perfected overnight. All patients reactdifferently to the subject and some patients don’t want todiscuss it at all. Since qualifying as a prescriber in 2007 I havedeveloped more confidence through shadowing colleagues andhearing how they managed the issue. This also meant simplytalking to patients and seeing what they knew about their heartfailure and, most importantly, what they wanted to know.

Premature death is an inevitable end to many patient journeys.If, as pharmacists, we want to get involved in prescribing forchronic conditions, we shouldn’t be afraid of this and, usingrespect, tact and compassion, should be happy to discuss it.

Paul Forsyth is a heart failure pharmacist working in primarycare for NHS Greater Glasgow and Clyde

Reflections of an independent prescriber

We should not beafraid to discuss death

�IN SOME WAYS IWAS SCARED ABOUTHOW THE PERSONMIGHT REACT

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