What challenges do independent prescribing pharmacists face day to day? How does the additional responsibility add to the complexity of their roles? These regular contributors to the "Reflections of an independent prescriber" series offer their thoughts
When guidance is only a guide
Valerie Sillito
May 2012
I first started writing prescriptions as a supplementary prescriber in 2005 and did the conversion course to become an independent prescriber in 2007 — “specialising” in respiratory care
New ways to improve the patient experience
Sue Robinson
April 2012To date, my non-medical prescribing practice has focused on the treatment of women with gynaecological cancers. Recently, an oncologist colleague offered me the opportunity to expand my skills and, being up for a challenge, I agreed to start seeing patients with breast cancer
Here's something new: talking to the patient
Emma Graham-Clarke
March 2012
Prescribing in critical care is different to that in most other areas. The most obvious variation is that patients do not have much input into the process — it is difficult when they are tubed, ventilated and sedated
How I can support depressed patients
Rachel Hall
February 2012
Half of patients with long-term conditions will suffer from depression. So it is no surprise that I come across patients on a daily basis who are suffering with the condition, whether or not it has been formally diagnosed
Groundbreaking? No. Good value? Indeed.
Nina Barnett
January 2012
Unlike many other independent prescribers, I do not have a ward or clinic that I cover routinely but work in various locations in intermediate and secondary care. Recently, I provided cover for our off-site intermediate care unit for older people, which provides step-up and step-down beds for prevention of hospital admission and early hospital discharge, respectively
What information should we use?
David Gibson
December 2011
At school I was a keen historian and I lament the fact the subject never really fitted in with the scientific career I chose. One important learning point I took from my history lessons at school was the use of sources of information, in particular the use of primary and secondary sources. As a pharmacist, this has become especially pertinent
The loose ends are sorted. Job done
Christine Dixon
November 2011Training as a pharmacist prescriber costs the taxpayer money. It also requires considerable personal commitment for the pharmacist concerned, as well as support from his or her colleagues. Once obtained, what difference does this qualification make?
New ways to tackle non-attendance
By Paul Forsyth
October 2011Prescribing is, in many cases, straightforward once you have done a full clinical review on a patient.
Always something new to learn
By Rachel Hall
September 2011I am sure patients are getting more complex, or is it because I know things now that I didn’t know five years ago when I first started prescribing?
Like riding a bike
By Sue Robinson
July/August 2011After 10 months’ maternity leave I have returned to work. This in itself is a huge challenge both mentally and physically and it has taken a few months to re-engage my idle brain. So it was with some apprehension that I returned to my prescribing role
Teaching: heads you win; tails I lose!
By Emma Graham-Clarke
June 2011I have worked in critical care for more years than I care to remember. Despite the heartbreak that you see, the patients who make it — seemingly against all odds — and the strength of the teamwork make it worthwhile
Often no right or wrong answer
By David Gibson
May 2011As a hospital admissions pharmacist many of the patients I see have some degree of renal impairment. When prescribing in acute care, the accurate estimation of kidney function is a frequent consideration
Prescribing of CDs? Not soon enough
By Christine Dixon
April 2011I work in an elective orthopaedic centre that admits 100 patients a week; these patients usually stay for no more than five days. A rota of consultants provides postoperative care
Managing your own reaction to an ADR
By Paul Forsyth
March 2011Through university we learn about the physiological effects of drugs on the body, desired or otherwise. As pharmacist prescribers, our decision-making is therefore influenced by both the potential benefit a medicine may offer to a patient and the likelihood that the same medicine may cause adverse drug reactions (ADRs)
When can switching drugs be justified?
By Rachel Hall
February 2011As a prescriber working in the cash-strapped NHS I give a great deal of thought to cost-effectiveness when prescribing
Someone’s looking over your shoulder…
By Emma Graham-Clarke
January 2011It’s been a funny old autumn. I seem to have had someone with me permanently — either being taught about critical care or doing one of several peer reviews that have been going on. I find that there’s nothing quite like having someone look over your shoulder as you prescribe to make you think twice about everything you write
Remain focused in unfamiliar territory
By David Gibson
December 2010Studies have shown that 5–10% of hospital admissions in the UK are due to adverse drug reactions. The problem for the acute hospital clinician is how to identify patients who are at risk of these events
One size does not fit all patients
By Suzanne Elvin
November 2010No matter the medical condition, no one drug regimen suits all patients — part of being a successful prescriber involves learning how to identify what regimen will suit each individual patient
Why I like to get to know my patients
By Rachel Hall
October 2010
I am passionate about getting to know my patients — I believe this continuity builds trust, gives me insight into their condition and helps with the shared decision-making process
Not such a simple request after all
By Christine Dixon
September 2010As an independent prescriber, I am often asked by nurses to prescribe laxatives and antacids. These requests, which often seem simple on the surface, can be complex, and prompt clinical intervention is sometimes required
We should not be afraid to discuss death
By Paul Forsyth
July 2010Prognosis and death are topics that pharmacists historically have not had to broach with patients. Does becoming a prescriber change this?
Paying for overindulgence
By Rachel Hall
June 2010Type 2 diabetes is certainly on the rise. At the moment I seem to be diagnosing at least one patient a week
Not a routine visit
By Sue Marsh
May 2010A woman attended the outpatient clinic the other week as an emergency appointment. She had been seen three weeks previously with no outstanding problems and her next cycle of chemotherapy had been arranged.
I pause, think… then stop the drug
By Emma Graham-Clarke
April 2010Another day, another ward round, but many of the patients remain the same. Critical care is a mixture of fast turnover patients, in and out in about 24 hours, and long-stay patients, some of whom remain on the unit for several weeks. However, the medicines all need reviewing regardless of the patient.
Practise what you preach?
By David Gibson
March 2010NICE and the DH recommend that all patients who are at risk of VTE should be offered thromboprophylaxis. In light of these new guidelines the acute trust I work for is in the process of improving its VTE policies. This has got me thinking about my role as a prescribing pharmacist for medical patients.
Listening to those who cannot talk
By Margaret Hook
February 2010There is an old Yiddish proverb: “A wise man hears one word and understands two.” But what do we know when a patient cannot speak any words and how can we help?
Out of my comfort zone
By Rachel Hall
January 2010As an independent prescriber, the need to offer holistic care to my patients sometimes takes me outside my comfort zone.
But do I add value?
By Sue Marsh
December 2009I often wonder if I add value to the oncology clinic. Is there an added benefit to patients from seeing me, as a pharmacist, rather than the consultant oncologist? Certainly my reviews take longer than the doctors’ — and I used to worry about this. Perhaps my “conversation-halting skills” are not up to scratch! I realise now that the patients tell me about problems they don’t bother the doctor with.
Side effects: are they friend or foe?
By David Gibson
November 2009How do the specialist knowledge and skills of a prescribing pharmacist differ from those of a doctor? When justifying pharmacist prescribing, the impact on patients’ quality of care needs to be demonstrated. This is not always easy, but it can be done.
Whose pain is it anyway?
By Margaret Hook
October 2009Understanding the emotional elements of a patient’s “problem” is a necessary skill when deciding what to prescribe. With this insight I believe I can help to empower patients to respond to changes in their condition in a positive way. But, particularly in palliative care, it is not always easy.
The one thing that strikes me…
By Rachel Hall
September 2009The one thing that strikes me as a pharmacist prescriber is the number of people who don’t take their medicines either correctly or at all. Over the past three years, since I have worked full time at the GP surgery, there have been many occasions where patients have admitted their poor adherence.
Having your face and name known: priceless
By Paul Forsyth
July/August 2009Prescribers will, at some point, run into difficulties and have to ask others for support and help.
Stimulus for change
By David Gibson
June 2009I was recently discussing with a friend, who is a GP, how doctors start prescribing new medicines. I am always a bit nervous about prescribing a drug for the first time. She referred me to an article published in the BMJ a few years ago (1996;312:949), which described the reasons for changing prescribing behaviour in a group of GPs. They described three models of change that influenced prescribing decisions.
At the edge of licence
By Margaret Hook
May 2009Pharmacists working in palliative care are accustomed to seeing medicines prescribed for unusual reasons, as well as the use of unlicensed medicines. My perspective certainly changed when I became a prescriber. Suddenly I was no longer comforted by shared responsibility — backed up by the Palliative Care Formulary.
When I learnt not to make assumptions
By Rachel Hall
April 2009Some consultations stick in your mind forever. For me, one such consultation with a 45-year-old man with type I diabetes really stands out. He had not visited his GP for over 18 months — despite numerous requests. He attended my clinic because the insulin treatment he was prescribed was about to be discontinued.
A special set of skills
By David Gibson
March 2009I have been practising as an independent prescriber in the medical assessment unit at Darlington Memorial Hospital for the past 18 months. A recent restructuring of the ward allowed me the opportunity to collect some information about my prescribing.
About more than just the prescription
By Margaret Hook
February 2009Independent prescribing in a hospice is not all about writing the prescription. It involves teamwork and, often, lengthy consultations.
Career-changing and life-saving!
By Rachel Hall
January 2009I remember clearly the day I wrote my first prescription. It was for ramipril 2.5mg capsules. It felt strange signing it and I double checked it several times before giving it to the patient.
