Consultant and the type of medication that will mainly be prescribed by the pharmacist.
There is also a well-established pharmacist-led oral chemotherapy clinic for patients with solid tumours running in the Trust, which is similar to pharmacist clinics in other centres in UK.6
In this model, the pharmacist manages a case load of patients, who are seen in a weekly ward-based clinic. The pharmacist completes the patient review and toxicity assessment at each cycle of chemotherapy, allowing them to consider any dose adjustment as necessary. Supportive medicines are prescribed and supplied with counselling and the pharmacist prescribes the next cycle of chemotherapy, usually capecitabine for breast or colorectal cancer or a tyrosine kinase inhibitor, for example, erlotinib for lung cancer
Benefits to patient care and outcomes
There is a limited amount of data regarding patient views on non-medical prescribers; however there is some evidence that many patients find being managed by an allied healthcare professional acceptable and they are supportive of this.7
Because the pharmacist is often reviewing a smaller number of patients, it means they have more dedicated time to spend directly with patients in their clinic visit, improving patient experience. This can be further improved by the consideration of pre-prescribing and dispensing of oral chemotherapy for stable patients established on treatment, meaning there is a one-stop appointment
demonstrate that they are the expert on medicines. Often with the medication available, a judgement has to be made regarding the benefit the patient may obtain from the treatment compared with the toxicity they may experience. This can be a particularly difficult consideration for this cohort of patients, where the toxicities of complex medication regimes and agents can be significant. Providing appropriate counselling in the clinic setting allows the patient to make a fully informed decision during the consent process. In addition, it is important to consider polypharmacy in this setting, particularly for a group of patients who often have a high pill burden. The rationalisation of medicines can have a significant impact upon quality of life and provide more adequate treatment management and symptom control.8,9
Pharmacists working within this advanced role must be aware of their limitations and when it is appropriate to seek advice of a more senior colleague. It is imperative that any pharmacist working in this setting receives appropriate training and supervision to ensure they are acting appropriately. Pharmacists will not be seeking to replace medical consultants, and one of the key distinctions is that pharmacists do not diagnose patients but provide treatments from within approved treatment algorithms and clinical guidelines after a diagnosis and treatment plan has been agreed.
There are frameworks available that can provide a tool for assessment clinical
“Pharmacists are ideally placed to answer queries and have input into more complex cases to manage a patient’s treatment as part of a multidisciplinary team”
and enabling patients to leave clinic with their medication without having to wait for out-patient pharmacy dispensing, unless they require dose modification. The ever-increasing availability of more complex drug therapies for the management of oncology and haematology conditions means that specialist advice is needed before considering and initiating any treatment, allowing the pharmacist to truly
knowledge in the specialised area and review of competency.3
may also identify the need for further training, as reviewing patients in a clinic setting requires the development of consultation skills and may also require in depth training of clinical examination processes depending on the type of patient being reviewed.
A barrier to the development of such roles may be the capacity of the pharmacy
department to release pharmacist time if a specific role is unable to be created, and to provide support to verify the pharmacist- generated prescriptions. In addition, the driver to create clinic capacity and skill mix may not be present if there is a plentiful supply of medical colleagues or resistance to non-medical prescribing.5
Future developments There are many opportunities for pharmacists to take on their own case-load of patients and manage them in pharmacist-led clinics. Experience in the UK has shown that working alongside medical colleagues who prescribe while the pharmacist focuses on reviewing patients’ tolerance to medication and/or monitoring clinical parameters is a potential model to be utilised. However for pharmacists to truly ‘lead’ in clinics, working as an independent prescriber is crucial. Pharmacist prescribers are starting to develop the level of specialism seen in their medical colleagues and as such provide a valuable addition resource for healthcare providers to use when managing increasing demand and limited medical resources. l
References 1. Department of Health. Nurse and pharmacist prescribing powers extended. http://webarchive. nationalarchives.gov.uk/
publicationsandstatistics/pressreleases/ dh_4122999 (accessed 12 March 2015)
2. Jubraj B. A new diploma. Tomorrow’s Pharmacist. 2008. www.pharmaceutical-journal.com/career/
ticle (accessed 12 March 2015).
3. Royal Pharmaceutical Society, Professional Curriculum for Cancer Care, 2014. www.rpharms. com/faculty-resources/expert-practice-curricula. asp (accessed 16 March 2015).
4. Colquhoun A. Prescribing pharmacists in Ayrshire and Arran are as busy as ever. Pharm J 2010;284:610.
5. Williams H. How independent prescribing can be nurtured in primary care. Clin Pharmacist 2010;2:264.
6. Purcell S. Pharmacists can help to manage tyrosine kinase inhibitor toxicities. Clinical Pharmacist 2012;4:297
7. Hobson R, Scott J, Sutton J. Pharmacists and nurses as independent prescribers: exploring the patient’s perspective. Family Pract 2010;27:110.
8. Lennan E. Non-medical prescribing of chemotherapy: engaging stakeholders to maximise success? Ecancer 2014;8:417
9. Todd A et al. Patients with advanced lung cancer: is there scope to discontinue inappropriate medication? Int J Clin Pharm 2013;35(2):181–4.
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