Supplementary prescribing: Patient, Louise Stuart mbe podiatrist and professor perspectives

Martin Fox

ver the past 20 years, the healthcare Background work force has been transformed. For The vast majority of podiatrists access O eligible allied healthcare professions, medicines for their patients via statutory non-medical prescribing has been introduced. exemptions, Patient Group Directions or This move has given fast and safe access to rely on prescriptions written by medical appropriate medicines for a range of patients. colleagues. Those who have successfully Supplementary prescribing rights were undertaken the supplementary prescriber Alan Borthwick extended to include the podiatry profession course can prescribe medicines for an in 2005, but few podiatrists have taken on individual within an agreed clinical this role. At present, around just 120 UK management plan between reviews by the podiatrists are qualified supplementary independent prescriber – most often a prescribers (Health Professions Council, physician. Podiatrists are not yet able to 2010). With so few practising supplementary prescribe independently, unlike appropriately prescribers in podiatry, it is perhaps qualified nurses and pharmacists unsurprising that their impact – on the health (Department of Health, 2006). service, patient care and, ultimately, outcomes – may be considered minimal. The patient’s perspective Umberto Saoncella So what are the benefits of non-medical Umberto Saoncello has been receiving care prescribing, and what value does it add to the for active Charcot foot disease and foot health service? More specifically, how does ulceration for the past 3 years in Manchester. supplementary prescribing improve outcomes During this time he has regularly attended in the management of people with long-term the hospital-based multidisciplinary diabetic conditions, such as diabetes and diabetes- foot team, which includes a podiatrist related complications of the foot? supplementary prescriber. When asked to Here, the authors offer various perspectives comment on his experiences he said: – that of the patient (Umberto Saoncella), the “The diabetic foot clinic has been a beacon professor and physician (Philip Wiles) and of hope for me over the past 3 years. Before Philip Wiles the podiatrists (Louise Stuart, Martin Fox) being managed in the clinic, I struggled to – on the benefits of supplementary prescribing. obtain specialist care for my foot problems. In conclusion, Alan Borthwick looks at the In the past 2 years I have swiftly received possibilities of independent prescribing for antibiotics, prescribed by my podiatrist, as Author details can be found podiatrists and projects currently under way to well as my diabetologist, when they have on the last page of this article. determine the best path forward. been needed.

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“As a patient ... I “It seems logical to me as a patient that a “Personally, I have benefited from the case fail to understand podiatrist prescriber offers joined-up care. I discussions and the need to explain prescribing why, at the most fail to understand why, at the most important decisions. Supplementary prescribing has also important juncture juncture of my care, the pen could be taken released some of my time to spend on other of my care, the pen from the hand of the person who knows me aspects of patients’ general care and diabetes could be taken from best and thrust into the hand of another management. professional who, in some cases, may know “Podiatrists cannot, as yet, prescribe the hand of the little about my condition. independently. Supplementary prescribing person who knows me “I was dealt with competently, kept informed is fine within a clinic environment, but the best and thrust into of all aspects of my care and had full confidence lack of independence is a hindrance when the hand of another in the podiatrist prescribing for me. There trying to manage foot ulceration in the professional who was a totality of care given, not fragmented community. Neither my podiatry colleagues, ... may know little management. My GP was kept fully informed nor our patients, have the luxury of time to about my condition.” of my treatment and continued to prescribe in waste. I look forward to the extension of full the community in line with advice given by the independent prescriber status to appropriately podiatrist and my diabetologist. trained podiatrists.” “I would argue that people with diabetes- related foot problems need more specialists The prescribing able to prescribe medicines appropriately podiatrists’ perspective in all locations, not just hospitals. At times, my Louise Stuart mbe and Martin Fox describe care – particularly outside of the hospital – has not the supplementary prescribing course for been provided by those sufficiently knowledgeable podiatrists as the most useful one they have or skilled to manage my foot problems.” undertaken since qualifying. If readers think that writing a prescription is the only benefit, The professor’s perspective they urge them to think again: Philip Wiles is Honorary Professor, University “Penning the prescription is the tip of the of Salford and a jobbing general diabetes iceberg; we review medicines in every patient consultant working in a large district general we see. This allows us to provide a safer, hospital diabetes centre. Having mentored more informed and holistic service for people and worked with both independent and with diabetes-related foot complications. supplementary prescribers, Philip had this to But apart from our anecdotal experiences, say on his experiences: what evidence is there that supplementary “By far the greatest impact made by the podiatrist prescribers add value to the health introduction of supplementary prescribing at our service and improve patient experience and hospital has been on the diabetic foot service. In outcomes? that environment clinical problems are dynamic “In 2009, the North-West Allied Healthcare and the pace frequently frenetic, making non- Professions Non-Medical Prescribing Network medical prescribing completely practical. As (AHP NMP) undertook an audit of allied a result, clinics run more smoothly and the healthcare professional prescribing practices. patients leave for home more quickly. To the best of our knowledge, it is the largest “Supplementary prescribing is underpinned audit of its kind. The aim was to assess the by a robust governance process that applies impact of supplementary prescribing on structure and scrutiny to prescribing. Best patient care. practice has extended into the community, “The AHP NMP audit revealed the where I have seen a more rational approach immediate access to medicines provided by to antibiotic prescribing in primary care non-medical prescribing, with a prescription settings as a consequence of contact with a being drawn in 80% of all emergency prescribing podiatrist. appointments. The follow-on effect of this

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“There are is the prompt treatment for the patient, the As was the case in nursing, pharmacy and multiple benefits prevention of referrals and a cost saving to optometry, a range of prescribing activity to prescribing, not hospital-based emergency care that would options are being considered for podiatrists. only in improved otherwise have been engaged. Would limited prescribing within a set patient care but also “The audit also revealed that a review of formulary be sufficient, or would freedom to in terms of ensuring patients’ medicines took place in 97% of prescribe where relevant be preferable? Might cases. The impact of the medicines review it be effective to prescribe within a limited the appropriate led to the recognition of sub-therapeutic range of conditions, or would this create more use of scarce doses and inappropriate regimens, which problems for patients than even the current NHS resources.” were subsequently red-flagged to independent system allows? prescribers. In one in ten cases the non- Answers to these, and related, questions medical prescriber identified inappropriate will determine the case for independent repeat prescriptions, the correction of which prescribing status for the podiatry profession. would result in cost savings and a reduction As evidence grows that supplementary in medicines waste. prescribing benefits patients, makes services “Few studies have critically examined the more responsive and reduces the burden on impact of non-medical prescribing and, in GPs and hospital physicians, the case for the absence of evidence, the effectiveness independent prescribing for the podiatry of prescribing is assessed by the surrogate, profession will strengthen. n and less than ideal, measure of number of prescriptions issued. The assumption that the success of non-medical prescribing lies in the number of prescriptions written was refuted by the AHP NMP audit. There are multiple Louise Stuart mbe is a Consultant Podiatrist benefits to prescribing, not only in improved and Martin Fox is a Vascular Podiatrist, patient care but also in terms of ensuring the both are based at Manchester Community appropriate use of scarce NHS resources.” Health, Manchester; Alan Borthwick is a Senior Lecturer, Southampton University, Independent prescribing: Southampton; Umberto Saoncella is a person The way forward? with diabetes, Manchester; Philip Wiles is a Consultant Physician, North Manchester In its report of July 2009, the Department of General Hospital Diabetes Centre, Manchester, Health’s Allied Health Professions Prescribing and Honorary Professor, University of Salford, and Medicines Supply Mechanisms Scoping Greater Manchester. Project recommended two additional implementation phases designed to enhance access to, and up-take of, non-medical prescribing across a range of allied healthcare Department of Health (2006) Improving Patients’ Access to Medicines: A Guide to Implementing Nurse and professions. In February 2010, the Allied Pharmacist Independent Prescribing within the NHS in Healthcare Professions Medicines Project England. DH, London was established with a view to enacting the Department of Health (2009) Allied Health Professions first of the two recommended phases and is Prescribing and Medicines Supply Mechanisms Scoping presently preparing for public consultation Project Report. DH, London on extending independent prescriber status to Health Professional Council (2010) Health Professional the podiatry and physiotherapy professions. Council Podiatrist Register Data. HPC, London. Available at: www.hpc-uk.org (password protected) Although there has been unavoidable uncertainty around the policy priorities of the North West Allied Health Professional Network (2009) North West Allied Health Professional Non-Medical new coalition Government, the work of the Prescribing Audit. AHPN, Salford. Available at: www. project continues apace. ahpnw.nhs.uk (password protected)

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