What is supplementary prescribing?
A partnership between an independent prescriber and a supplementary prescriber (nurse, midwife, pharmacist) to implement an agreed patient-specific clinical management plan.
Individuals are professionally accountable for their own actions and prescribing decisions. Employers remain vicariously liable for the actions and decisions of their staff.
What are the details of a CMP?
- Name of the patient
- Illnesses or conditions which may be treated by the SP
- Date of start of review
- Reference to medicinal product which may be prescribed
- Any restrictions or limitations of any product
- Relevant warnings about known sensitivities
The arrangements for notification of:
- adverse reactions to any medicinal product prescribed or not
- the circumstances in which the supplementary prescriber should refer to the IP
What are the 3 disadvantages of SP?
- Very time consuming
- Necessarily restrictive
- Only really suitable for stepwise management of chronic conditions
What is independent prescribing?
An IP is responsible for the clinical assessment and management of people without needing to consult another prescriber.
They must:
- Ensure they have all the necessary information to prescribe safely.
- Prescribe only within the limits of their knowledge, skills and area of competence.
- Provide appropriate follow-up.
What can be on a treatment plan?
- Process of differential diagnosis
- Assessment of severity or staging
- Diagnostic tests
- Stages of treatment
- Medicines intended to be prescribed and evidence
- Patient safety checks associated with this decision
- How response to treatment will be monitored
- Referral indicators and associated process
What are the 5 stages of the calgary-cambridge model of consultation?
- initiation
- gathering information
- physical exam
- explanation and planning
- closing session
What are the 7 benefits of the calgary-cambridge model?
- Actively determines and explores patient’s ICE
- Accepts legitimacy of patient views and shared thinking to encourage patient involvement
- Gives information in chunks and checks patient understanding
- Makes suggestions and choices, not directives
- Encourages patient to contribute their ideas, suggestions, preferences and beliefs
- Negotiates a mutually acceptable plan
- Next steps, safety netting, summarising
What are the 4 steps for initiation?
- Introduce yourself AND your role
- Check patient identity
- Clarify agenda for the consultation, both yours and patients
- Clarify plan for the consultation
Which three histories are needed for info gathering?
Medical history
- Current and previous diagnoses
- Current medication /adherence
- Any allergies or ADR
Family history
Social history
- Smoking
- Alcohol - units a week
- Exercise
- Diet
Current understanding of conditions and their management
What are the 5 benefits of an accurate medical history?
- Builds rapport
- Determines the effects of the condition on the patient and their family
- Explores the patients’ ICE
- Eliminates serious problems
- Determines more accurately what is wrong with the patient
What are the 6 common red flags for respiratory?
- SOB
- Wheeze
- Chest pain
- Haemoptysis
- Stridor
- Hoarse voice
What are the 8 common red flags for GI?
- Weight changes
- Dysphagia
- Nausea/vomiting
- Haematemesis
- Abdominal pain
- Jaundice
- Swellings
- Change in bowel habit/stool type
What are the 5 common red flags for CNS?
- Fits/faints/loss of consciousness
- Vision changes
- Hearing changes
- Numbness/tingling/weakness
- Loss of memory/personality change
What is the acronym for symptom assessment?
S - site
O - onset
C - character
R - radiation
A - associations
T – time course
E – exacerbation/relieving
S - severity
Why is it important to involve patients in decisions?
Most patients (~70%) WANT to be involved in decisions about their healthcare
If patients are involved in the decision, then they are more likely to be adherent
Patients involved in decisions about their care are more likely to:
- Be satisfied with their prescriber
- Be better informed
- Perceive that they have increased control over their condition
- Have better health outcomes
How is the human rights act 1998 relevant to HCPs?
- TheHuman Rights Actis relevant to health care providers since it regulates the relationship between individuals and public authorities
- It is unlawful for public authorities to act in a way which is incompatible with a convention right. Decisions should be focused on patients’ wishes and interests
What is the mental capacity act 2005?
- Every adult has the right to make his or her own decisions and must be assumed to have capacity to do so unless proven otherwise
- People must be given all appropriate help before anyone concludes that they are incapable
- Individuals must retain the right to make what might be seen as eccentric or unwise decisions;
- Best interests: anything done for or on behalf of people without capacity must be in their best interests, and
- Least restrictive intervention: anything done for or on behalf of people without capacity should be the least restrictive of their basic rights and freedoms.
What is the mental health act 2007?
- Designed to give health professionals the powers to detain, assess and treat people with mental disorders in the interests of their health and/or public safety.
- If you’re held under the Mental Health Act, you can be treated against your will
- This because the individual is judged not have sufficient capacity to make an informed decision about treatment at the time
What are the 4 ethical considerations when prescribing?
- Beneficence: benfits vs risks/costs always with patient at centre
- Nonmaleficence: do no harm, and any harm associated with treatment, it should not be disproportional to the benefits of treatment
- Respect for autonomy: to make a reasoned and informed choice by respecting the decision-making capabilities of an autonomous individual
- Justice: all patients in similar situations should be treated in a similar manner, and that benefits, risks and costs should be distributed fairly
Competency framework for all prescribers
Generic framework for any prescriber
Must be contextualised to reflect different areas of practice and levels of expertise
Reflect key competencies needed by all prescribers : should not be viewed as a curriculum but rather the basis on which one can be built
Applies equally to supplementary prescribing as to independent prescribing (although needs to fit within the framework and legalities of supplementary prescribing)
Domain 1 - the consultation: competencies that the prescriber should demonstrate during the consultation
Domain 2 - prescribing governance: competencies that the prescriber should demonstrate with respect to prescribing governance
Within the two domains are ten competencies
Each competency contains several supporting statements related to the prescriber role
What are the competencies in the framework?
- Assess the patient
- Identify evidence-based treatment options available for clinical decision making
- Present options and reach a shared decision
- Prescribe
- Provide information
- Monitor and review
- Prescribe safely
- Prescribe professionally
- Improve prescribing practice
- Prescribe as part of a team
Remote prescribing: specific challenges & guidance
- Make patient safety the first priority and raise concerns if necessary
- Understand how to identify vulnerable patients and take appropriate steps to protect them.
- Tell patients their name, role and (if online) professional registration details, establish a dialogue and make sure the patient understands how the remote consultation is going to work.
Explain that:
- They can only prescribe if it is safe to do so.
It’s not safe if they don’t have sufficient information about the patient’s health or if remote care is unsuitable to meet their needs.
- It may be unsafe if relevant information is not shared with other healthcare providers involved in their care.
- If they can’t prescribe because it’s unsafe they will signpost to other appropriate services.
- Obtain informed consent and follow relevant mental capacity law and codes of practice.
- Undertake an adequate clinical assessment and access medical records or verify important information by examination or testing where necessary.
- Give patients information about all the options available to them, including declining treatment, in a way they can understand.
- Make appropriate arrangements for after care and, unless the patient objects, share all relevant information with colleagues and other health and social care providers involved in their care to support ongoing monitoring and treatment.
- Keep notes that fully explain and justify the decisions they make
- Stay up to date with relevant training, support and guidance for providing healthcare in a remote context.
Remote prescribing and FtP investigations
- More than 30% of open Fitness to Practice cases at the GPhC relate to online pharmacy – a disproportionate amount compared to other pharmacy service providers.
- Fitness to Practice Committees considering these cases are taking a firm line, with pharmacists being suspended for significant periods of time from practice.
- Following earlier cases where patients have died following overdoses of opiate medication, the GPhC issued In Practice: Guidance for Pharmacist Prescribers in November 2019. At that time, they included the following guidance:
- Some categories of medicines are not suitable to be prescribed or supplied at a distance unless further safeguards have been put in place to make sure that they are clinically appropriate.
- The categories include medicines liable to abuse, overuse or misuse, or when there is a risk of addiction, and ongoing monitoring is important. For example: opioids, sedatives, laxatives, and gabapentinoids.
Which 3 medicines are on the Pregnancy Prevention Programme?
Topiramate
Valproate
Isotretinoin
