When I first starting prescribing in 2005 the emphasis was very much on choosing a subject, doing an appropriate “module” provided by the training university and concentrating future activities within a well defined area of expertise. Because the surgery I was working with wanted someone to look after patients with chronic obstructive and pulmonary disease and perform spirometry with them there was complete agreement within the practice about what I was going to be doing. This made life easy for all involved and I ended up with my own group of patients whom I reviewed on a yearly basis.
However, the aim of pharmacist prescriber seems to have shifted somewhat and I now find myself dealing with a whole new scenario and I am not at all sure I am as prepared for this as I ( and others?) might like. The publication of “Prescription for excellence” in Scotland promises a move to all pharmacists being able to prescribe by 2023 and I get the impression that a majority think that “polypharmacy” reviews are the way to go.
The current GP contract requires any patient on four or more repeat medicines to have an annual review of their medicines. How this is carried out tends to vary. It could be done face to face or via the computer. A lot of this activity is ruled over by time and opportunity, staffing levels and the approaching “end of the year and how many more quality and outcomes framework points do we need”? Pharmacists are after all the ideal profession to carry out these reviews with patients and subsequently I have recently changed my hypertension clinic to a polypharmacy review one. Of course I thought this would be easy, just sit down with the patient and have an informal chat about their medicines, suitably armed with my trusty British National Formulary, the patient medication record and a patient summary provided by the practice.
Well little did I know what a can of worms I was opening! So there I am, trapped in a room with a patient who, it turns out, is only too willing to discuss her problems with me, most of which bear little relation to the medicine she is taking. Did I want to know about the neighbours and their marital problems, the lack of a local bus service needed to get to the shop or, heaven forbid, the weather? Having managed to negotiate through this minefield of minutiae we finally get down to it (i.e. are you taking your pills at all, is it the correct dose, are you taking it at the right time and so on).
Of course not only do I discover all sorts of little quirky habits of pill taking (e.g. I only take my antihypertensives when I feel I need them) but also some more serious issues about long-term treatment for diseases for which I only have a superficial knowledge. I have discovered quickly it is not enough to know what the medicine is for, how to take it appropriately, side effects, possible interactions and what flavours they come in but also what the latest national guidelines suggest, the preferred drug option on the local formulary and any regular monitoring required.
To say that I suddenly felt rather out of my depth is putting it mildly and these patients want answers now, not next week, and what was I going to do to solve their problems.
I suspect the issues are further compounded because, as a prescriber, I am accustomed to making decisions about treatment for my patients on an immediate basis, not on a “I will discuss it with the GP and get back to you” one. Of course patients are generally happy with this scenario but I am left feeling somewhat inadequate in my role as a prescriber. Certainly one good thing that has happened is that my clinical knowledge is improving by leaps and bounds (hopefully) and the GP and I are fast becoming best buddies while discussing various patient issues.
There is no doubt in my mind that pharmacists will be able to do these reviews, given suitable information and backup from medical colleagues but the question of access to medical records is becoming ever more urgent if we are to do this work in a meaningful and appropriate way.