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Prescribing in community pharmacy – we need to start somewhere

 

Johnathan Laird
Johnathan Laird

INSPECTION (looking), palpation (feeling) and auscultation (listening) are clinical examination skills that generally don’t come naturally to pharmacists. Pharmacists don’t normally touch patients.

But, in Scotland that is changing.

Pharmacy in Scotland is moving forward rapidly. Like many others, I am a qualified independent prescriber and as such have been looking for training opportunities to support my new role. NHS Education for Scotland (NES) Pharmacy has provided superb training for prescribers in the last few years and I have been lucky enough to have had the opportunity to attend. This time last year I completed the core clinical skills course and more recently I completed the common clinical conditions course.

I have been reflecting on my own practice recently and also on the content of both these courses. As I distilled the content quietly after the event I wondered how my practice might alter as a result of the training. The theme that ran through both these courses, and actually the independent prescribing course, was the fact that prescribing is a complex activity and throughout the prescriber must ‘safety net’ the patient at all times. The bottom line as ever is that anything we do as pharmacy professionals has to be safe and must sit within our own personal sphere of competence.

Prescribing decisions are based on many factors. The more information the prescriber can gather the more informed the decision will be. A thorough history and core clinical assessment like inspection, palpation or auscultation are vital. Traditionally community pharmacists have done a little bit of this type of activity but generally there has been no requirement to carry this out as a matter of course.

I feel this has to change especially in community pharmacy practice.

The reason it has to change is simple. The opportunity in community practice lies in the prescribing role. These history taking and clinical assessment skills are essential. Their purpose is to gather good quality decisions and make more informed, accurate prescribing decisions.

I think this evolution should be seen as a steady direction of travel. The Scottish Government paper Prescription for Excellence has helped move things in the right direction. There are a number of fundamental changes that have to happen for us to use these skills effectively as part of the multidisciplinary team.

One such change is the need for the pharmacist to take a detailed history, record it in the patient record and perhaps follow that history up with some physical examination of the patient. The concept of pharmaceutical care requires a cyclical process, so follow-up and review of the patient should come naturally to pharmacists.

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So where do these skills fit in community pharmacy?

Rolling out an innovative service is tricky, but of course the most difficult aspect of any service is scaling it up. Creating a concept that works at scale and fits with the agendas of stakeholders is usually fraught with difficulty. That said we have made a start and progress has been made. For me the opportunity for community pharmacists to use these skills lies in playing to our strengths and using the community pharmacy setting to our advantage.

I have written previously about the vast footfall that enters community pharmacy on a daily basis. In fact community pharmacists are the most accessed health professional daily in the UK. Many patients present and seek advice or reassurance on any given ailment. The traditional approach of the community pharmacist has been to do a brief history, listen out for alarm symptoms and then either treat or refer. We don’t have access to the records and the pharmacist does not routinely carry out physical assessment based on this history. The quality of the decision to treat or refer in my view is impaired by the simple lack of information at the pharmacist’s disposal.

I would suggest one of the key functions of the modern community pharmacist is to triage patients efficiently and accurately. This role should be carried out in the context that most people who come to the pharmacy for advice are generally well. There has been a professional aversion to pharmacists diagnosing conditions but in triage the pharmacist must only establish whether the patient is well, unwell enough to prescribe for or unwell enough to refer on to another healthcare professional.

It seems logical to make this basic concept to become the building block upon which community pharmacist prescribers may extend their areas of competence and skills further.

As I have experienced first hand, this new way of working is a step into the unknown and requires careful contemplation to keep patients safe along the way, while allowing pharmacist prescribers to reach their potential.

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