Supplementary PrescribingSupplementary Prescribingin Practicein Practice

26 September 200526 September 2005

Mr. Mahesh Sodha, M.Sc. Mr. Mahesh Sodha, M.Sc. F.R.Pharm.S.F.R.Pharm.S.

Community Pharmacist and Community Pharmacist and Member of Professional Executive Member of Professional Executive committee and Board Chelmsford committee and Board Chelmsford

PCTPCT

Mahesh SodhaMahesh Sodha

Community Pharmacist with an extensive Community Pharmacist with an extensive experience of both secondary and primary experience of both secondary and primary care. A generalist with a special interest in care. A generalist with a special interest in Oncology, Palliative Care, Urology and Oncology, Palliative Care, Urology and Diabetes. Worked as a Practice Research Diabetes. Worked as a Practice Research Pharmacist and as a Primary Care Cancer Pharmacist and as a Primary Care Cancer Lead for Harlow and Epping Forest PCTsLead for Harlow and Epping Forest PCTs

Member of the Executive Committee and Member of the Executive Committee and Board of Chelmsford PCT and works as a Board of Chelmsford PCT and works as a GP Practice PharmacistGP Practice Pharmacist

SettingSetting

6 partner GP Practice – 2 branches in 6 partner GP Practice – 2 branches in Chelmsford - 2 sessions per weekChelmsford - 2 sessions per week

Qualified Summer 2004Qualified Summer 2004 Started 1Started 1stst surgery in September 04 and surgery in September 04 and

currently manage some 70 to 80 currently manage some 70 to 80 patientspatients

One generic CMP agreed by all GPsOne generic CMP agreed by all GPs Electronic CMP on IT system – approvalElectronic CMP on IT system – approval IT link in Pharmacy with GP systemIT link in Pharmacy with GP system

Supplementary Prescribing Supplementary Prescribing

In theory – Implementation of a Clinical In theory – Implementation of a Clinical Management PlanManagement Plan

In Practice – Doctors do not warm up to In Practice – Doctors do not warm up to CMPs – Hence one generic CMPCMPs – Hence one generic CMP

My CMP:My CMP:

Conditions: Conditions: BNF Class: BNF Class:

Type ll diabetesType ll diabetes 6.16.1

HypertensionHypertension2.2,2.4,2.5,2.6,2.2,2.4,2.5,2.6,

DyslipidaemiaDyslipidaemia 2.11 and 2.122.11 and 2.12

Case Study 1Case Study 1stst Patient Patient

My Initial Action

My Subsequent Action

Outcomes

53-year-old male type II diabetes. HBA1C = 8.71% (previous value 11.3%). On gliclazide 40mg recently changed to 80mg. BP = 146/86 and cholesterol = 4.32 mmol/litPatient NEVER treated for hypertension

Initiate Metformin 500mg od increasing to bd. To t.d.s.Initiate Ramipril 1.25 mg. and titrate upwards.

Increase Ramipril to 2.5mg . Can only tolerate metformin bd NOT tds.

16.11.04 BP = 132/84 and HBA1c = 6.3%Ramipril now 5mg od to aim for BP under 130/80

EvaluationEvaluation

Patient Satisfaction Patient Satisfaction QuestionnaireQuestionnaire

28 out of 32 returned28 out of 32 returned PACT data to look at PACT data to look at

prescribing trendsprescribing trends Evaluation and feed back from Evaluation and feed back from

a consultant diabetologista consultant diabetologist

What do the patients think?What do the patients think?

My overall satisfaction with this visit to the My overall satisfaction with this visit to the pharmacistpharmacist

Overall satisfaction with this consultation

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What did the patients thinkWhat did the patients think

My confidence in the ability of this pharmacistMy confidence in the ability of this pharmacist

Patients confidence in the pharmacist

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What did the patients thinkWhat did the patients think

The recommendation I would give to my friends about The recommendation I would give to my friends about this pharmacist would be…this pharmacist would be…

Recommendation to friends

01020304050607080

Poor Fair Good VeryGood

Excelent

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Excellent

What do the GPs think?What do the GPs think?

My Mentor and other GP Comments:My Mentor and other GP Comments: Increased patient access and choiceIncreased patient access and choice Efficient use of skill mix in Primary Efficient use of skill mix in Primary

carecare Significant contribution to high QOF Significant contribution to high QOF

practice achievementpractice achievement This successful model can be This successful model can be

disseminated to other practices and disseminated to other practices and other areas of clinical management.other areas of clinical management.

Hurdles/ChallengesHurdles/Challenges

Selling the idea to the PCT and Selling the idea to the PCT and obtain some funding for trainingobtain some funding for training

Locum expenses to get protected Locum expenses to get protected time for study was not possibletime for study was not possible

Personal effort to study a course that Personal effort to study a course that is non-scientific (cf to Pharmacy)is non-scientific (cf to Pharmacy)

The biggest obstacle even today is The biggest obstacle even today is the funding to run the actual clinical the funding to run the actual clinical sessions – who pays?sessions – who pays?

Worth It – WHY?Worth It – WHY? Patient benefitsPatient benefits1.1. Longer unrushed appointmentsLonger unrushed appointments2.2. Thorough counsellingThorough counselling3.3. Full monitoringFull monitoring4.4. Holistic treatmentHolistic treatment5.5. Satisfaction survey Satisfaction survey GP work load – can concentrate on GP work load – can concentrate on

tackling complex cases requiring high tackling complex cases requiring high clinical skills and for which they are clinical skills and for which they are trainedtrained

Good use of skill mixGood use of skill mix

Some Minor ProblemsSome Minor Problems

Computer generated prescriptions Computer generated prescriptions and Signing repeatsand Signing repeats

Prescribing for minor ailments – Prescribing for minor ailments – independent prescribing? independent prescribing?

Where should the funding for the Where should the funding for the pharmacists come from? They are pharmacists come from? They are independent contractors like GPsindependent contractors like GPs

Next StepsNext Steps Develop further skills and initiate Develop further skills and initiate

type II diabetes patients on type II diabetes patients on insulin and monitor theminsulin and monitor them

Provision of services to other GPsProvision of services to other GPs Development of CMPs in other Development of CMPs in other

areas of care e.g. Chronic Painareas of care e.g. Chronic Pain Extend to independent Extend to independent

prescribing particularly in the prescribing particularly in the area of minor ailments.area of minor ailments.

Successful PrescriberSuccessful Prescriber A clear focus on exactly how, when and where A clear focus on exactly how, when and where

you want to practice.you want to practice. Have good clinical practice skills. Have good clinical practice skills. Have the support of the key people in your local Have the support of the key people in your local

Primary Care Trust Primary Care Trust Have the respect and support of clinicians whom Have the respect and support of clinicians whom

you want to work with (independent prescribers)you want to work with (independent prescribers) Above all, enthusiasm and motivation to pursue Above all, enthusiasm and motivation to pursue

this ambition to manage patients in a clinical this ambition to manage patients in a clinical practice. NEEDS: not only good therapeutic skills practice. NEEDS: not only good therapeutic skills but also excellent consultation skills, which focus but also excellent consultation skills, which focus on psycho- social aspects of disease on psycho- social aspects of disease management.management.

NOT ROCKET SCIENCENOT ROCKET SCIENCE

Thank YouThank You