Supplementary Prescribing in Practice 26 September 2005 Mr. Mahesh Sodha, M.Sc. F.R.Pharm.S. Community Pharmacist and Member of Professional Executive committee and Board Chelmsford PCT

Mahesh Sodha Community Pharmacist with an extensive experience of both secondary and primary care. A generalist with a special interest in Oncology, Palliative Care, Urology and Diabetes. Worked as a Practice Research Pharmacist and as a Primary Care Cancer Lead for Harlow and Epping Forest PCTs Community Pharmacist with an extensive experience of both secondary and primary care. A generalist with a special interest in Oncology, Palliative Care, Urology and Diabetes. Worked as a Practice Research Pharmacist and as a Primary Care Cancer Lead for Harlow and Epping Forest PCTs Member of the Executive Committee and Board of Chelmsford PCT and works as a GP Practice Pharmacist Member of the Executive Committee and Board of Chelmsford PCT and works as a GP Practice Pharmacist

Setting 6 partner GP Practice – 2 branches in Chelmsford - 2 sessions per week 6 partner GP Practice – 2 branches in Chelmsford - 2 sessions per week Qualified Summer 2004 Qualified Summer 2004 Started 1 st surgery in September 04 and currently manage some 70 to 80 patients Started 1 st surgery in September 04 and currently manage some 70 to 80 patients One generic CMP agreed by all GPs One generic CMP agreed by all GPs Electronic CMP on IT system – approval Electronic CMP on IT system – approval IT link in Pharmacy with GP system IT link in Pharmacy with GP system

Supplementary Prescribing In theory – Implementation of a Clinical Management Plan In theory – Implementation of a Clinical Management Plan In Practice – Doctors do not warm up to CMPs – Hence one generic CMP In Practice – Doctors do not warm up to CMPs – Hence one generic CMP My CMP: My CMP: Conditions: BNF Class: Type ll diabetes6.1 Type ll diabetes6.1 Hypertension2.2,2.4,2.5,2.6, Hypertension2.2,2.4,2.5,2.6, Dyslipidaemia2.11 and 2.12 Dyslipidaemia2.11 and 2.12

Case Study 1 st 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/lit Patient 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 BP = 132/84 and HBA1c = 6.3% Ramipril now 5mg od to aim for BP under 130/80

Evaluation Patient Satisfaction Questionnaire Patient Satisfaction Questionnaire 28 out of 32 returned 28 out of 32 returned PACT data to look at prescribing trends PACT data to look at prescribing trends Evaluation and feed back from a consultant diabetologist Evaluation and feed back from a consultant diabetologist

What do the patients think? My overall satisfaction with this visit to the pharmacist

What did the patients think My confidence in the ability of this pharmacist

What did the patients think The recommendation I would give to my friends about this pharmacist would be… Excellent

What do the GPs think? My Mentor and other GP Comments: Increased patient access and choice Increased patient access and choice Efficient use of skill mix in Primary care Efficient use of skill mix in Primary care Significant contribution to high QOF practice achievement Significant contribution to high QOF practice achievement This successful model can be disseminated to other practices and other areas of clinical management. This successful model can be disseminated to other practices and other areas of clinical management.

Hurdles/Challenges Selling the idea to the PCT and obtain some funding for training Selling the idea to the PCT and obtain some funding for training Locum expenses to get protected time for study was not possible Locum expenses to get protected time for study was not possible Personal effort to study a course that is non-scientific (cf to Pharmacy) Personal effort to study a course that is non-scientific (cf to Pharmacy) The biggest obstacle even today is the funding to run the actual clinical sessions – who pays? The biggest obstacle even today is the funding to run the actual clinical sessions – who pays?

Worth It – WHY? Patient benefits Patient benefits 1. Longer unrushed appointments 2. Thorough counselling 3. Full monitoring 4. Holistic treatment 5. Satisfaction survey GP work load – can concentrate on tackling complex cases requiring high clinical skills and for which they are trained GP work load – can concentrate on tackling complex cases requiring high clinical skills and for which they are trained Good use of skill mix Good use of skill mix

Some Minor Problems Computer generated prescriptions and Signing repeats Computer generated prescriptions and Signing repeats Prescribing for minor ailments – independent prescribing? Prescribing for minor ailments – independent prescribing? Where should the funding for the pharmacists come from? They are independent contractors like GPs Where should the funding for the pharmacists come from? They are independent contractors like GPs

Next Steps Develop further skills and initiate type II diabetes patients on insulin and monitor them Develop further skills and initiate type II diabetes patients on insulin and monitor them Provision of services to other GPs Provision of services to other GPs Development of CMPs in other areas of care e.g. Chronic Pain Development of CMPs in other areas of care e.g. Chronic Pain Extend to independent prescribing particularly in the area of minor ailments. Extend to independent prescribing particularly in the area of minor ailments.

Successful Prescriber A clear focus on exactly how, when and where you want to practice. A clear focus on exactly how, when and where you want to practice. Have good clinical practice skills. Have good clinical practice skills. Have the support of the key people in your local Primary Care Trust Have the support of the key people in your local Primary Care Trust Have the respect and support of clinicians whom you want to work with (independent prescribers) Have the respect and support of clinicians whom you want to work with (independent prescribers) Above all, enthusiasm and motivation to pursue this ambition to manage patients in a clinical practice. NEEDS: not only good therapeutic skills but also excellent consultation skills, which focus on psycho- social aspects of disease management. Above all, enthusiasm and motivation to pursue this ambition to manage patients in a clinical practice. NEEDS: not only good therapeutic skills but also excellent consultation skills, which focus on psycho- social aspects of disease management. NOT ROCKET SCIENCE NOT ROCKET SCIENCE

Thank You