The prescribing process and evidence-based medicine

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The prescribing process and evidence-based medicine




Study Points



image Good prescribing ensures maximum benefit for the patient and value for money


image The stages involved in the prescribing process


image Evidence-based medicine



Introduction


The prescribing of medicines is the most common medical intervention in patient care and drug costs are a major component of NHS expenditure. Ensuring optimum benefits for patients and value for money for taxpayers and other individuals and organizations paying for health care are priorities and a model of ‘good prescribing’ has been proposed that has four aims. These aims are to:



Maximizing effectiveness is about selecting a drug therapy that will achieve its therapeutic objective in a suitable timescale.


Minimizing risks is recognizing that all drug treatments carry an element of risk of causing harm to the patient and that selection of the drug should be about managing these benefits and risks.


The cost of therapy should also be taken into account by the prescriber although such consideration should go beyond a simple review of the drug costs but also consider any costs of monitoring treatment such as blood tests, length of treatment and any additional items that could be required such as prescribing an additional drug to protect the gastrointestinal tract from adverse effects caused by the first.


Establishing the views of the patient is a vital part of the process of assessing the relative importance of the first three aims in this model. Patients may differ in their views regarding managing the symptoms of a condition, living with the consequences of a condition, exposing themselves to risks of harmful effects and the amount of money they would be willing or able to pay for treatment. In addition, patients may wish product selection to take their lifestyle into account such that the frequency and route of administration of the selected product fits in with their daily routine.


It is accepted that ‘good prescribing’ involves trade-offs between these four aims and that this often involves delicate balancing between each of the aims.



The prescribing process


The prescribing process will be considered under five headings although there is some overlap between these and their sequence may not be the same in all cases. The first is concerned with all the things that must be in place before a prescriber can start to prescribe; the second with collecting information; the third with analysing the information and making the prescribing decision and the fourth with making appropriate records and plans for monitoring the patients progress and the last with auditing and evaluating prescribing practice.



Prerequisites


Prescribing can only be carried out by healthcare professionals that have the appropriate prescribing qualifications and these will vary depending on the type of prescribing to be carried out. To prescribe prescription only medicines on the NHS or privately the prescriber, if not a medical prescriber, must have successfully completed the training to allow them to act as a supplementary or an independent prescriber. The training course consists of a taught element (around 26 days) and learning in practice (around 12 days), which includes prescribing under the supervision of a medical prescriber. To participate in a minor ailment scheme and prescribe pharmacy only medicines at NHS expense the pharmacist will likely have had to complete appropriate accreditation set by the local primary care organization.


Patients that are to receive their prescriptions from a supplementary prescriber must give informed consent. Patients do not need to sign this informed consent but is good practice to make a note in the patient’s medical notes when informed consent was given. The exact nature of informed consent is difficult to define and it is likely that the input from the healthcare professional will vary between patients when obtaining consent. Observation of disputes between patients and physicians regarding whether informed consent was given show that simply handing the patient a leaflet does not discharge the physician from their obligation to obtain informed consent. In any legal dispute it is up to the courts to decide which party they believe but the disputes that found in favour of the physician tended to be those where the physician was able to demonstrate that they had given the information to the patient because they had documented the advice they gave in the patient’s medical records.


Prior to the patient consultation, the prescriber should ensure that they are suitably prepared. Part of this preparation includes ensuring they have sufficient indemnity insurance that covers their prescribing and that their job description clearly shows that prescribing is part of their role. Another part of the preparation is acquiring the appropriate knowledge and skills (see Table 20.1).



Table 20.1


Checklist for knowledge and skills required by pharmacist prescribers



























Legal restrictions effecting which medicines can be prescribed Independent pharmacist prescribers can prescribe any licensed or unlicensed medicine except diamorphine, dipipanone or cocaine for treating addiction but may prescribe those drugs when treating organic disease or injury.
Supplementary prescribers can prescribe any licensed or unlicensed medicine including controlled drugs provided it has been specified in the clinical management plan.
Professional restrictions effecting which medicines can be prescribed It is vital that each prescriber only prescribes within their own area of competence. Knowing one’s own limitations is a key skill for a prescriber. In addition, they must also have an appropriate level of experience dealing with the condition and it might be appropriate to refer a patient presenting with a condition rarely experienced to another prescriber for assessment and any prescribing if required.
Administrative arrangements regarding payments for the service The administrative arrangements regarding the prescribing process must be fully understood. In the case of minor ailments schemes these arrangements could include a description of records that should be kept and how payment for the service is to be made. For NHS prescribing the prescriber should be aware of the categories of patient that are exempt from NHS charges and what payments should be made by those that are not exempt.
Patient confidentiality Pharmacist prescribers must maintain patient confidentiality and take steps to ensure that no unauthorized personnel can gain access to patient medication records by securely storing the data either via lock and key or via appropriate electronic security measures such as passwords for data stored electronically.
Ethics Prescribers should be aware of the good practice guidance from the DH and the GPhC before they start to prescribe. The DH guidance addresses prescribers not prescribing for themselves, not normally prescribing for members of their family and also covers accepting gifts and hospitality for suppliers. Pharmacist prescribers must also comply with the GPhC Standards of conduct, ethics and performance.
Security Prescribers must be aware of security issues surrounding prescribing and take steps to minimize the risks. Blank prescription forms could be used by drug misusers to try and obtain supplies of prescription medicines for abuse or to sell to others. Care must be taken to ensure that the forms are securely stored. Personal security must also be considered if the prescriber is visiting patients in their own homes or other locations in the community.
Therapeutic management of conditions A pharmacist’s knowledge and skills required for the management of a therapeutic area must be up to date and based upon the best evidence available at the time. The knowledge should extend to non-drug approaches to treatment as sometimes these could be the most appropriate intervention.
Other members of the healthcare team Prescribers should be aware of other professionals they could refer patients to, e.g. general practitioner, the accident and emergency department in the hospital, dentists, the community nursing service (district nurses and health visitors) social services and self help groups.


Consulting with the patient


Where possible, prescribers should also familiarize themselves with the patient’s medical history prior to the consultation. This however, would not be possible in minor ailment schemes, as patients are likely to arrive without an appointment and their medical notes will not usually be available to the community pharmacist.


During the consultation, prescribers must take a full history of the presenting condition and any other factors such as other conditions the patient have or any other medications including OTC medicines and complementary medicines that the patient may be taking. It may be necessary to carry out further investigations such as measuring the patient’s blood pressure. This information must be recorded in the patient’s medical notes.


Before any prescribing can take place a diagnosis must be made. If the pharmacist is acting as a supplementary prescriber the diagnosis will have been made by an independent prescriber but the pharmacist should interpret the information obtained before and during the consultation to check that patient’s diagnosis remains valid. Independent prescribers must establish a working diagnosis based upon the information they have gathered on the patient. At this stage, it may be necessary to request laboratory tests such as urea and electrolytes, red blood cell count and haemoglobin tests to help confirm the working diagnosis.


With increasing complexity of health care and increasing specialization of the roles of healthcare professionals, there is a growing need for different professions to work together and pharmacists must ensure that they are aware of the different professions they could call on for support or to refer to patients (see Table 20.1).


Where patient care is shared between healthcare professionals there is an obvious need for clear communication links, especially around monitoring and reviewing the patient’s therapy. Clear communication links are particularly crucial in supplementary prescribing where two different professionals can prescribe for a patient. There must be a clear description of the criteria that would require the supplementary prescriber having to refer the patient back to the independent prescriber. Examples of such referrals could be failure of the patient’s condition to respond to the therapy outlined in the clinical management plan or suffering an adverse reaction to the prescribed medication. Both independent and supplementary prescribers must have access to a common medical record.

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Jun 24, 2016 | Posted by in PHARMACY | Comments Off on The prescribing process and evidence-based medicine

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