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The Journey of a Prescribing Pharmacist and Leading Change
Paul Forsyth
Lead Pharmacist- Clinical Cardiology (Primary Care) / Heart Failure Specialist
NHS Greater Glasgow & Clyde
RPS Conference
Birmingham 3rd September 2017
ENT17-R137/August 2017
My Background
Registered as pharmacist in 2002
Community pharmacist 2002 – 2004
Heart failure specialist pharmacist 2004 – 2016
Lead pharmacist – Clinical Cardiology (Primary Care) 2016 – present
Supplementary prescriber 2006 – 2007
Independent prescriber 2007 – present
– Prescribe on daily basis since 2007 (primary care and outpatient heart failure clinics)
– Developed pharmacist-led Post-MI LVSD clinics which operate across seven local hospitals and adjoining primary care localities
– Still run two weekly ½ day outpatient clinics (approx 20 patients)
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Objectives
Discuss:
– Background to pharmacist prescribing
– Essential components for success
– Worked example: Post-MI LVSD pharmacist-led clinics
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Background to Pharmacist Prescribing
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Independent Prescribing
Regulations since 2006
Training programme typically run over 6 months
– Part-time
– Face-to-face teaching and self-directed study
– Minimum of 26 days of teaching
– Additional minimum 12 days of learning in a practice environment whilst being mentored by a medical practitioner
Reference https://www.pharmacyregulation.org/education/pharmacist-independent-prescriber
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Numerous Accredited Training Courses
Anglia Ruskin
Aston University
Bangor University
University of Bath
University of Birmingham
University of Bolton
University of Bradford
University of Brighton
Buckinghamshire New University
Cardiff University
University of Central Lancashire
University of Chester
Coventry University
University of Cumbria
De Montfort University*
University of Derby
University of East Anglia
Edge Hill University
Glyndwr University
University of Hertfordshire
University of Hull
Keele University
King's College London
University of Leeds*
University of Lincoln
Liverpool John Moores University
London South Bank University
University of Manchester
Medway School of Pharmacy
University of Portsmouth
Queen's University, Belfast
University of Reading*
Robert Gordon University
University of Salford
Sheffield Hallam University
University of South Wales
(formerly University of Glamorgan
and University of Wales)
University of Strathclyde*
University of Suffolk (formally
University Campus Suffolk)
University of Sunderland
Swansea University
University of the West of England
University of Wolverhampton
University of Worcester
University of York
Reference
https://www.pharmacyregulation.org/education/pharmacist-
independent-prescriber
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Mandatory Learning Outcomes
16 different mandatory learning outcomes, including:
– Applying clinical assessment skills to:
inform a working diagnosis
formulate a treatment plan
monitor response to therapy
review the working differential diagnosis
Reference https://www.pharmacyregulation.org/education/pharmacist-independent-prescriber
ENT17-R137/August 2017
Up-take of Pharmacist Prescribing in Scotland (1)
ENT17-R137/August 2017 Reference: NHS Education for Scotland, Pharmacist Prescribing workforce report for NHS Scotland 2016
Up-take of Pharmacist Prescribing in Scotland (2)
ENT17-R137/August 2017 Reference: NHS Education for Scotland, Pharmacist Prescribing workforce report for NHS Scotland 2016
Pharmacist prescribing:What are the essentials?
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Defining Need
Pharmacy interventions ? nebulous and poorly understood by others
NHS challenges: Multi-morbidity and aging population
Pharmacy need to work with the NHS to offer solutions to problems with a medication focus
ENT17-R137/August 2017 Reference: NATIONAL HEART FAILURE AUDIT, APRIL 2015 - MARCH 2016
http://www.ucl.ac.uk/nicor/audits/heartfailure/documents/annualreports/annual-report-2015-6-v8.pdf
MDT Working
21st Century healthcare is complex and multi-professional
MDT support is vital
– Governance links to senior medics
Reference: Ponikowski P., el al. 2016
ESC Guidelines for the diagnosis and
treatment of acute and chronic heart
failure. Eur. Heart J. 2016;37(27):2129-
2200m
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Strategic Planning
Equity and consistency of approach
– Population-level interventions
– ‘Every patient, every time’
Aligning to local and national priorities
– Quality clinical indicators / national clinical audits
– Service burdens / waiting times
– Treating patients closer to their home
Meeting with stakeholders
– Knitting with other services
– Not duplicating roles
– Ensuring good communication
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Beyond the rhetoric
What makes an expert?
We need to value continuing development of professional expertise
Aspects of prescribing clinics which might change with level of experience and expertise, including
– Duties
– Level of autonomy / supervision
– Type of patient reviewed
Developing Pharmacists: Becoming an Expert
Reference: Royal Pharmaceutical Society, https://www.rpharms.com/resources/frameworks/advanced-pharmacy-framework-apf
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Pharmacists with a Different Level of Clinical Understanding
We need pharmacists that understand both sides of
the risk
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Risk: Population vs. Individual
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Supervision & Support
Prescribing can be difficult !!
– Complex decision making Multiple treatment options
Patients that don’t conform to guidelines
Plausibility / confidence / problem solving
‘Suck it and see’
– Dealing with treatment failures
– Dealing with ADRs
– Dealing with patient mortality / morbidity
Pharmacists are taught to be risk adverse
Preceptorships & mentoring are extremely valuable
– Do we have enough prescribing mentors?
Long-term peer support
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Performance Management / Evaluation
Performance management
– Pharmacists are an expensive resource!
– Need to be efficient Patients per clinic
Time per patient (pre / during / post clinic)
Admin time
Evaluation
– Medication changes
– Service burdens
– Clinical outcomes
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Leading Change:
Post-MI LVSD ‘Teach & Treat’
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Left ventricular systolic dysfunction (LVSD) post
myocardial infarction (MI) independently predicts
mortality1
Appropriate use of angiotensin converting enzyme
inhibitors (ACEIs), beta-blockers (βBs), and
mineralocorticoid receptor antagonists (MRAs)
significantly improves outcomes2
Background to Post-MI LVSD
1) . Velazquez E.J., et al. An international perspective on heart failure and left ventricular systolic dysfunction complicating myocardial infarction:
The VALIANT registry. Eur. Heart J. 2004 25(21):1911-1919
2) Ponikowski P., el al. 2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure. Eur. Heart J. 2016;37(27):2129-
2200m
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Royal Alexandra Hospital, Audit 09/12 to 09/13
Low achievement in optimisation of secondary prevention in
Post-MI patients with significant LVSD
– Mean ACEI dose = 43.8% of target
– Mean BB dose = 30.9% of target
Pharmacy approached by consultant cardiologist to see if they
could help
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Pilot Results
Pharmacist reviewed patients a mean 4.6 times.
Significantly more patients were treated with
– Beta-blocker compared to 'usual care’; 96.1% vs 82.5% (p=0.025)
– MRA compared to 'usual care'; 49.0% vs 24.6% (p=0.008)
More patients were treated with ACEI compared to 'usual care’, this was not statistically significant;
– 94.1% vs 89.5% (p=0.383).
Mean doses of medication compared to ‘usual care’ (expressed as a % of ESC guideline target dose) were significantly higher:
– ACEI; 71.7% vs 43.8% (p<0.001)
– Beta-blocker; 55.9% vs 30.9% (p<0.001)
– MRA; 35.3% vs 15.8% (p=0.006)
ENT17-R137/August 2017 Reference: European Journal of Heart Failure (2015) 17 (Suppl. 1), 341 doi:10.1002/ejhf.277
From Pilot to ‘Teach & Treat’
Dovetail with new Scottish Government Pharmacy Vision-
‘Prescription for Excellence’ 1
– ‘……in the management of long term conditions pharmacy will
work in partnership with the medical profession so that post
diagnosis caseloads can be allocated to these pharmacists…..’
Short term funding secured from NHS Education for
Scotland (NES)
Long-term NHS Greater Glasgow & Clyde ‘buy in’
– City-wide coverage
– Widen service to include all grades of LVSD (not just moderate to
severe as in pilot)
ENT17-R137//August 2017 1.Prescription for Excellence: A Vision and Action Plan for the right pharmaceutical care through integrated partnerships
and innovation. September 2013. Scottish Government. Crown Copyright. Available from URL: http://www.gov.scot/resource/0043/00434053.pdf
New Vision: Mixed Pharmacist Model
‘Simple’ Patients: General Practice Based Pharmacists (e.g. Health Centres etc)
– ACEI (or ARB)
– Beta-blocker
– DAPT
– Lipid lowering medication
– BP lowering medication
‘Complex’ Patients: Secondary care based pharmacist clinic, under governance of consultant
– MRA
– Diuretics
– Anti-anginals
– Ivabradine
– Devices (e.g. CRT / ICD)
– ARNI
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‘Teach’
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‘Treat’
ENT17-R137/August 2017 Reference: NHS Greater Glasgow & Clyde, Pharmacy Post-MI LVSD Service Flowchart
Example: Royal Alexandra Hospital Area Clinics
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Example: Clinic Template on Trakcare
15 minute appointment slots
– History
– Clinical examination, including manual BP/pulse, chest auscultation
– Venepuncture
– Hand written prescription
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Simple Patient: Transfer into Primary Care Clinic
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Complex Patient: Retained at Specialist Clinic
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Results vs Historic Audits: ACEI(01.09.2013 to end 08.2017)
Critical mass needed to evaluate clinical outcomes
Achievement of ACEI Dosing in Baseline Hospital Audits vs Pharmacist-led Clinics for Post-MI
LVSD Patients Fit Enough to Return to Cardiac Rehab
0
10
20
30
40
50
60
70
0 1-24 25-49 50-74 75-99 100
% of ACEI Target Dose
% o
f P
ati
en
ts Historic Royal Alexandra Hospital (n=133)
Historic Glasgow Royal Infirmary (n=58)
Historic New Victoria Hospital (n=76)
Historic Southern General Hospital (n=64)
Pharmacist-led Clinic (n=849)
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Status Quo
Current weekly specialist pharmacist clinics at:
– RAH (Paul Forsyth- Tue pm)
– VOL (Stewart Cusick- Thur am)
– GRI (Steve McGlynn- Thur am)
– Yorkhill (Iain Spierits- Mon am)
– VIC (Lynsey Moir- Wed am)
– QEUH (Pernille Sorenson- Wed pm)
– Inverclyde (Joanne Berrich- Fri pm)
Current primary care pharmacists trained and accredited to accept referrals from following hospitals:
– RAH (Elizabeth Russell, Louise Connolly)
– VOL (Stewart Cusick)
– GRI (Lynsey Foot)
– Yorkhill (Adrienne Fraser, Clodagh Clarke, Sandra Cahill)
– QEUH / VIC (Laura Laing)
– Inverclyde (Allison Atkinson)
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Next steps: Scotland-wide roll-out
Funding (start up costs for one year) secured from NHS NES for national roll-out
– Plan supported by Scottish Government National Advisory Committee for Heart Disease
– Plan to roll-out to two Board areas per year
NHS Highland
– Clinics starting Sept 2017
NHS Tayside
– Clinics starting late 2017
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UKCPA Heart Failure Group set up
– Chairs- myself & Alison Warren (Brighton)
– Secretary- Janine Beezer (Sunderland)
Meet ~3 times per year
– Share practice models
– Represent pharmacy British Society for Heart Failure Board
NICE appraisals
etc
– Run training days / events
– Future R&D collaboration
In collaboration with RPS, Advanced Practice Competency Framework for pharmacists specialising in heart failure developed and recently submitted for publication
UK wide collaboration
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Summary
ENT17-R137/August 2017
We now have a host of trained independent prescribing
pharmacists around the UK
Essentials for success:
– Defined need
– MDT working & strategic planning
– Pharmacists can continue to develop into true experts
– Peer support beyond the qualification
Supervision of early practice
Long term support networks
– Proper evaluation
Summary
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Thank You!
Questions
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