The critical appraisal of a Non-medical ‘Diabetic Specialist’ Pharmacist Prescriber in a General Practice setting and how this role meets the Department of Health stated aims and outcomes.
Non-medical prescribing (NMP) has contributed to one of the most significant changes amongst healthcare professionals; a resultant modification from the roles that were traditionally fulfilled (Cooper et al, 2006). Based on an initial model of supplementary prescribing (SP) that was developed in the 1990’s which was solely in use by community nurses, the adaption of this legislation in 2003 permitted pharmacists to enter the field of prescribing, but only for long-term conditions such as diabetes that had been diagnosed by a doctor or those by a dentist then crowned in 2006 and this dependent model underwent transformation, formulating a platform for the proposal of the initiative that allowed non-medical allied healthcare professionals such as pharmacists to cross a new barrier in medical care; independently prescribing medicines in accordance with their competence and specialty. This application to extend the role of prescribing to pharmacists, nurses and other health care workers was postulated as part of the UK government effort to provide more rapid and readier accessibility of medicines for patients, introducing the Patient Group Directions system (Aronson, 2006).
The aims and objectives of NMP (DOH, 2006)
The focus of these aims, that were provided for NMP were presented with attention on maximising benefits to patients and the NHS and consisted of the following:
- Advantages of Independent Prescribing v’s Supplementary Prescribing
In 2006, the Department of Health provided a guide that delivered advice and information for non-medical prescribers; that permitted them to authorise prescriptions for patients. These were grouped under two different types; the independent prescribers who are able to prescribe medicines for medical conditions to patients within their specialty (Tinelli et al; 2013) and the supplementary prescribers (SP) who are also authorised to prescribe medication to the patients; on condition that it is done in partnership with a doctor or dentist. In the UK, SP signified an advancement in non-medical prescribing; comprising a multilateral agreement between the patient, the independent prescriber and the dependent prescriber; forming a voluntary partnership (Cooper et al., 2008). This method involves the doctor or the dentist providing the primary diagnosis and treatment; then in conjunction with the supplementary prescriber and with the agreement of the patient a plan is proposed for the care of the patient, known as the Clinical Management Plan (CMP).
This patient specific plan is evaluated and monitored accordingly, by the SP who proceeds to manage the provision of any further supplies required by the patient. The CMP forms the basis of SP and must mention the class and or description of all the medicines that shall be prescribed, inclusive of any limits related to the strength and dosage (Stewart et al., 2008). There are no legal restrictions present on the drugs that can be prescribed or the medical conditions that can be treated within this framework by the supplementary prescribers’ as the initial prescription is completed by the physician; SP’s usually encompass pharmacists, nurses, radiographers, physiotherapists and podiatrists.
- Improvements in patients access to medicines (DOH, 2006)
As opposed to one fulfilling out the role as a non-medical supplementary prescribing pharmacist, pursuing that of an independent non-medical prescribing pharmacist (INMPP) provides a wider platform allowing greater responsibility in attending patient care. This post allows pharmacists to evaluate, prescribe and manage patients without the formal involvement of the doctor; thus encompassing patients with both diagnosed and undiagnosed conditions, and is the most recent development in prescribing (Stewart et al., 2008). The INMPP prescribes within their specialty and competence, which includes the prescription of all licensed drugs except certain controlled medicines.
The practice of non-medical prescribing is highly prevalent in the North-West of England, in comparison to other regions and statistics have shown that almost 80% of non-medical prescribers tend to practice in the area where they obtained their initial qualification.
In 2006, the DOH put forward its aims for INMP’s and stated the following: “maximise benefit to patients and the NHS, through increased flexible use of workforce skills” (DoH, 2006); these aims were presented in order to meet the demands of patient care required.
Flexible team working across the NHS (DOH, 2006)
Flexibility is no doubt a vital component and in order to undertake such a role it is essential to ensure that an insight into the patient and inter-collegiate requirements have been assessed; awareness of the challenges that are accompanied with the role of a INMPP in the context of diabetes, which is an extensive field of medicine must be comprehended and approached holistically. Pursuing a position in a general surgery environment allows the pharmacist to accommodate for the demands of professional medical care, which requires attending to the complex needs of the patients. With designated time constrained slots per appointment the general practitioner faces a tough battle between adhering to statistics and providing the utmost quality of care. In 2009, the European Working Time Directive introduced a limit on the maximum number of hours that could be worked per week to 48 hours (EWTD, 2009); however this was accompanied with the scope that would permit the availability of opening times to be such that they run into the late evening or weekends. This act demonstrates how the demands of patient care can be addressed by other allied health professionals who could provide an adequate service for a multitude of patients, thus leaving the more complex clinical cases to be seen by the general practitioner.
- Improvements in Patient Care (DOH, 2006)
As an INMPP, one can contribute to the reduction of such strains, enabling the provision of a patient care orientated service, which is able to deal with patient needs more efficiently. A major advantage of pursuing this role in a general practice is that it permits INMPP to employ a hands-on approach to providing care for diabetic patients, contributing to the enhancement of the existing service. Being at the forefront in delivering care to a specialist group of patients with diabetes enables me to obtain in-depth, first-hand experiences; allowing me to understand the complexity of care that is involved and educating me about how to deal with any complications that may arise, and the appropriate manner in which these should be addressed. Diet, exercise, culture, religion, treatment regimes, co-morbidities and poor control of diabetes are just some of the extensive factors which all have to be taken into account, when considering management and treatment. Another crucial aspect that one must always bear in mind, is to treat each patient as an individual case. Many factors like mental capacity, depression, anxiety, stress, employment, social background, family, support, literacy, language, mobility are all non-medication related contributors which play a vital part of the comprehensive treatment of such a condition and must not be overlooked or underestimated when considering therapy.
Being able to recognise signs, symptoms, and request bio-medical analyses accordingly, require intricate detailed examinations and interpretations, which are honed and developed through years of experience. It is therefore imperative that the surrounding supportive network within the practice, both locally and nationally, are receptive and pro-active in aiding such a budding role through intra/inter-working. The INMPP needs also to be able to recognise their own limitations and to become acquainted with an in-house signposting to joint members of the team where complex issues may arise; the use of peer prescriber support to help facilitate their role and assist in gaining confidence, shall contribute to keeping the welfare of the patient the priority.
Pursuing the role of a INMPP, allows one to contribute to ‘bridging the gap’, in the delivery of healthcare services; acting as a means to refining and honing the care that is already being provided to patients, predominantly when demand exceeds the available resources (Stennar et al., 2009). The current legislations have permitted the evolution of prescribing for INMPPs’, thus expanding their existing role in the management of medicines for patients, for example, those with diabetes (Courtaney & Carey, 2007).The DOH highlighted in 2003, the need for a new measure to be put in place to address the increase in the prevalence of diabetes (Stennar et al., 2009). This has instigated the promotion of partnerships, amongst various healthcare professionals both medical and non-medical, with clear aims and outcomes which comprise of supporting the patients and assisting them in managing their diabetes better. This has led to the generation of some of the key elements of the NHS policy which emphasises the importance of patient involvement and of patient choice, in the delivery of care (DOH, 2005).
- Improvements in patient’s safety (DOH, 2006)
As a non-medical prescriber one must always be aware of what the patient needs and requirements are; it’s imperative that an agreement has been made between the patients before any of the prescribing of medicine from a non-medical prescriber takes place. Obtaining the trust and the confidence of the patient forms a vital component of the role of a NMP, and patients may be hesitant to receive their prescriptions from a non-medically qualified prescriber or have underlying doubts regarding medicine safety. One must not underestimate the challenges that accompany prescribing, which usually requires an amalgamation of interventions (Hacking & Taylor 2010); it entails an in-depth understanding and knowledge about the physiology and the pathophysiology of the disease or diseases concerned. Pharmacological interventions should be employed with a rigorous awareness of the pharmacokinetics and pharmacodynamics of the relevant drugs being prescribed (Hacking & Taylor 2010).
- Management of Long term Conditions (DOH, 2006)
Working with patients with diabetes is a complex situation, as this metabolic disease involves many other inter-related disorders such as liver disease, kidney disease, obesity , and cardiovascular disease to name a few. Thus, working as an independent prescriber (IP) allows one to bypass the need to generate the CMP, thus saving time and reducing the number of practical problems associated with the administration of the CMP within the legal frameworks (Stennar et al., 2009). Some of the crucial aspects that form the foundation for working as a successful INMPP involve excellent communication and consultation skills, building rapport within the practice and gaining high acceptances from the patients (Stewart et al; 2008). The DOH extension of pharmacist and nurse prescribing rights has no doubt had a profound effect on the treatment and control of diabetes (DOH, 2006). A study carried out by Carey and Courtenay in 2008, demonstrated how IP was the preferred method of prescribing rather than SP for both nurses and pharmacists, when managing complicated medical conditions such as diabetes. The patient feedback reinstated that the pharmacists desire to provide a good service was evident, and that the patients appreciated the quicker access to treatment and longer appointments that were available; consequently decreasing the doctor waiting times (Derek et al., 2009). Patient comments confirmed that they were pleased with the service being provided and the flexibility of being able to walk directly in and liaise with a healthcare professional made a significant positive difference to them. They not only felt that they had better control over their conditions, but valued the in-depth knowledge that was provided to them about their medications. They felt reassured and these benefits were further reaffirmed by the doctors who commended the improvements observed in patient care, with the assistant of the INMPP (Stennar et al., 2009).
- Better use of health professional skills (DOH, 2006)
The INMPPs’ have emphasised how the on take of their new responsibilities associated with prescribing has boosted their job satisfaction. Working alongside the GP’s and the nurses more frequently has made the pharmacists feel more involved and part of the healthcare team (Hacking & Taylor, 2010). However, the views of some doctors and pharmacists have differed; whilst the pharmacists have been eager to undertake the role of independent prescribing, some doctors have had hesitations and have thus been less supportive, mentioning issues around the insufficient clinical skill set of the pharmacist (Derek et al., 2009).The successful outcome of prescribing is dependent on the acceptance of the stakeholders, these include the doctors, other healthcare professionals and most of all the patients (Stennar et al; 2009). A mixture of concerns has been raised over the years in regards to the level of clinical expertise and knowledge that is possessed by the INMPP, and the parameters in which prescriptions are made (Ranna et al., 2009; Stenner et al; 2009). However, in comparison of the independent nurse prescriber and the INMPP, the apprehensions that have usually been raised have concerned the adequacy of the pharmacological knowledge of nurses (Bradley et al., 2007).
- Adherence of the NMP to standard policies and procedures (DOH, 2006)
In order to ensure that the challenges faced by the pharmacists’ are not impeding the deliverance of optimal care, it is important that continued professional training remains ongoing and the existence of a good professional support network for the INMPP is thus essential, and this plays a vital part in pharmacist prescribing (Otway 2002, Bradley & Nolan 2007). Some of the potential challenges encountered by the pharmacists as described by the doctors’ include managing the demand of patient needs, whilst working within their restricted levels of competence in certain specialties’ (Derek et al., 2009). No key trepidations have been voiced by patients in general, and the few reservations that have been put forward by the patients are usually linked with the initial consultations that have taken place with the prescribing pharmacist, however post consultation reassurance, in most cases eliminates these anxieties (Derek et al., 2009).
- Recognising the benefits to patients of NMP (DOH, 2006)
Over the recent years a few studies have been carried out, which have aimed to collate the views of patients and their experiences in relation to NMP. The awareness of patient perspectives forms a crucial component and one must be educated about them, in order to provide the optimum patient care (Tinelli et al; 2013). Factors such as quality of care, accessibility to medicines, control of their condition, knowledge of the disease, and the patient-professional relationship are vital constituents of the deliverance of quality care. In Tineeli et al’s study (2013), findings confirmed that in the majority of cases the INMP’s were adhering to the national guidelines and demonstrated the key characteristics that are expected. These entailed building a rapport with the patient, educating them as necessary about their medicines and understanding the patients’ perspective of care (NICE guidelines, 2009).
Patients emphasised how they valued the opportunity of being involved in decision making about their medicines and that they felt reassured and confident with the NMP (Courtenay et al., 2011). The evidence available regarding the success of non-medical prescribing is still in its early stages; and some studies that have been carried out in various outpatient clinics have shown that the general consensus of patient views is that in support of SP and that the patients were happy with care received (Smalley, 2006). Tinelli et al, 2013 also found that patients reported positively in regards to their experiences; areas of improvements included longer consultations and opportunities for the patients to discuss the area of disease/illness more in depth addressing any of their concerns and questions more thoroughly (Latter et al., 2004; Watterson et al., 2010). These findings also demonstrated that overall INMP was highly appreciated by the patients with the majority proclaiming very little difference in care between the NMP and their usual doctor (Tinelli et al., 2013). Only a selected few stated a preference to be seen by their usual GP.
The DOH legislation that has provided pharmacists with the right to authorise prescriptions was based on maximising the use of the pharmacist’s healthcare skills in a more clinical setting (Avery & Pringle, 2005). A vital component that formed the driving force of this proposal was that related to establishing an efficient accessible method of delivery of medicines to patients (Hacking & Taylor, 2010).
The employment of NMP has provided a platform for the development of healthcare in the UK. It has allowed the better use of the skills that are available amongst allied healthcare professionals and provided an open playing field by removing the traditional territorial boundaries initially associated with doctors, dentist prescribing while pharmacists dispense and nurses administer treatment. The implementation of the NMP initiative was driven with the objectives and aims in mind that would provide better healthcare for patients with on-going care, with ease of accessibility to medicines, thus reducing the patient waiting time and ensuring a continuous delivery of care (Emmerton et al, 2005); whilst maintaining and managing the logistical imperative factors in healthcare such as economics and human resources.
INMPP has been well acknowledged by patients, who have supported the likes of pharmacists adopting greater responsibilities in order to provide better long-term continuing care. Thus, the acceptance of NMP to support those individuals with long term medical conditions has proven to be beneficial to both the healthcare professionals and the patients. The recruitment of these new responsibilities provides a catalyst for certain issues such as the delivery and accessibility of medicine to be addressed.
Although, more thorough investigation is required in regards to how the on take of this new prescribing role has affected those health professionals that have taken on these additional responsibilities and how it has affected their collegiate relations (Hacking and Taylor, 2010); in conclusion one can quite confidently state that this initiative has set a positive pathway for improvement in the healthcare system in the UK. A supportive culture is also necessary; the promotion of inter-professional relations are no doubt a crucial component that shall help with the acceptance of the INMPP role in the surgery setting even more so in the future; alongside ongoing training and support from the fellow physicians (Bradley & Nolan 2007; Orway 2002)