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Medicines Management Adviser
The Greater Glasgow Primary Care NHS Trust Medicines Management Team (MMT) is a multidisciplinary department providing advice and prescribing support. Roles include prescribing data analysis, bulletin production, coordinating pharmaceutical input to practices, setting and monitoring prescribing budgets, developing and delivering educational sessions and acting as an information resource for healthcare professionals. The job is varied and challenging and provides excellent opportunities for professional and personal development. It also allows interaction with many different professionals in the wider NHS (the UK National Health Service).
It is only 10 years since the first medical and pharmaceutical prescribing advisers were appointed by Scottish Health Boards to work with GPs. Anecdotally, GPs were initially suspicious that prescribing advisers planned to cut costs and impose Health Board priorities. There has since been a substantial increase in the provision of prescribing advice and support to practices and primary care organisations. This demonstrates that initial fears have been allayed, and the input is valuable to members of the primary healthcare team, Health Boards and Primary Care Trusts (PCTs).
Greater Glasgow is the largest PCT in Scotland. There are 218 GP practices, 630 GPs and 215 community pharmacies covering a population of approximately 900,000.
The department’s multidisciplinary nature is vital to effective working, as the skills and experience of each profession are complementary. The head of department is Dr Andrew Power, a GP with an interest in pharmacology and therapeutics. Some PCTs no longer have dedicated medical prescribing advice. This is unfortunate as medical staff provide a valuable insight into GPs’ priorities, problems and concerns.
The Medicines Management Advisers, Margaret Mackie, Audrey Thompson and Jenny Carroll, are all pharmacists. Richard Lowrie and Alister MacLaren, the Primary Care Lead Clinical Pharmacists, lead the practice pharmacist programme. The MMT pharmacists have a broad range of backgrounds and experience.
The department receives dietetic input from Vicki Welch, Nutritional Adviser to Primary Care. She reviews prescribing of nutritional products, aids guideline development and provides education on nutritional issues. The smooth running of the department is ensured by administrative assistance from Jackie Richardson and Karen Bowers.
Analysis of prescribing data
Scottish Prescribing Analysis (SPA) data and the electronic database “Prescribing Information System for Scotland” (PRISMS) are scrutinised to provide data for selected practices. A detailed report is prepared before team members visit the practice to present findings and discuss relevant issues. Common themes include generic and therapeutic substitution, formulary development, local policies and rational prescribing. Meetings with Local Health Care Cooperatives cover a variety of topics from formulary development to prescribing indicators, budget setting and prescribing information.
The MMT monitors a number of prescribing indicators and reports these to practices and the PCT. These indicators are generally taken from the Accounts Commission for Scotland report Supporting Prescribing in General Practice.(1)
Budget setting and monitoring
Allocation of budgets to medical practices was usually based primarily on historical spend, although the budget setting mechanism now incorporates weighted capitation. Performance against budget is routinely monitored, and the development of large overspends or underspends highlights the fact that detailed review of prescribing is necessary. Many factors affect prescribing costs, such as demography, deprivation and nursing homes, and it is important to recognise that budget performance in isolation does not indicate good or bad prescribing.
The detailed information on prescribing costs and volume provided by PRISMS allows forecasting of likely prescribing patterns. This, coupled with horizon scanning for drugs not yet marketed, allows prediction of drug spend in forthcoming years, thus aiding the PCT in forward planning.
Area Drugs and Therapeutics Committee (ADTC)
The ADTC’s main role is development and maintenance of the Glasgow Formulary – an advisory document, now in its eighth edition, used in all Glasgow NHS care settings. The MMT acts as a conduit between primary care and the ADTC. Information on GP prescribing complements the work of medicines use evaluation pharmacists who provide data on hospital prescribing patterns; ADTC discussions and decisions are disseminated to primary care practitioners. Primary/secondary care interface issues remain a priority, and the ADTC, its subgroups and the hospital drugs and therapeutics committees help resolve any problems.
A number of sessional pharmacists provide services to GP practices. Their work focuses on medication review clinics where patients are invited to the surgery to discuss their medicines. Care issues are passed to the patient’s GP with recommendations for action. This may be to commence, alter or stop therapy, instigate monitoring or refer for investigations. Once the GP has agreed to the planned actions, the pharmacist makes any alterations and notifies the patient. GP acceptance is high, evidenced by a steady acceptance of 95% of recommendations. This is an important method of implementing and monitoring changes in prescribing practice.
The MMT encourages enquiries from all health professionals within Glasgow on any aspect of prescribing. It is vital that the team has current knowledge of developments in the medical and pharmaceutical literature and is aware of relevant national guidelines and policies.
The Glasgow Prescriber is a monthly bulletin covering a variety of topical issues whose target audience includes GPs and community pharmacists. It is posted on the ADTC website and an electronic mailing list has been developed to facilitate wider distribution. The department has significant involvement in the ADTC quarterly newsletter PostScript.
The MMT has extensive involvement in developing and delivering education and training for GPs, GP registrars, postregistration house officers, nurse prescribers and pharmacists at all levels, from undergraduate to postgraduate.
This is a varied, interesting and rewarding area of practice. It provides the opportunity to work with many different professions in primary and secondary care and the clinical environment. Some people may find the lack of direct patient contact frustrating (or appealing!), but the work helps other healthcare professionals to improve patient care. Membership of the Scottish Prescribing Advisers Association provides an invaluable opportunity to share information and ideas and develop practice across Scotland.
The greatest challenge remains implementation of decisions and policies. This is aided by the hands-on role of the practice pharmacists.