Clinical Pharmacy: Prescribing
Key Points
- Prescribing involves assessing benefits vs. harms of treatment
- Medication should be cost-effective, appropriate, and dosed correctly
- Patient autonomy, consent, and shared decision-making are fundamental
- Consultation requires interpersonal, reasoning, and practical skills
- Prescribing is influenced by evidence, external factors, and cognitive biases
Rational and Effective Prescribing
WHO Definition of Rational Medicine Use: Patients receive medications appropriate to clinical needs, in proper doses, for adequate time, at lowest cost.
Four Aims of Good Prescribing (Barber, 1995):
- Maximize effectiveness
- Minimize risks
- Minimize costs
- Respect patient's choices
STEPS Framework (Preskorn, 1994):
Inappropriate/Irrational Prescribing
- Poor medicine choice
- Polypharmacy with interacting medicines
- Prescribing for self-limiting conditions
- Continuing treatment longer than necessary
- Inadequate dosing
- Ignoring patient's wishes
Consequences: Increased morbidity/mortality, antimicrobial resistance, wasted resources, inappropriate patient demand.
Pharmacists as Prescribers
Evolution in UK
- 1986: Cumberlege Report - community nurses prescribed limited medicines
- 1992: Legislation passed for nurse prescribing
- 1999: Crown Report introduced supplementary prescribing
- 2003: Pharmacists & nurses as supplementary prescribers
- 2006: Pharmacist independent prescribing (except Controlled Drugs initially)
- 2010: Unlicensed medicines allowed
Types of Non-Medical Prescribing
Independent Prescribing: Responsible for assessment, diagnosis, and clinical management.
Supplementary Prescribing: Voluntary partnership with independent prescriber to implement Clinical Management Plan (CMP).
| Prescriber Type | Can Prescribe | Restrictions |
|---|---|---|
| Pharmacist Independent | Any licensed medicine | Within competence; Controlled Drugs restriction lifted later |
| Nurse Independent | Any licensed medicine + some Controlled Drugs | Within competence |
| Optometrist Independent | Eye conditions & surrounding tissue | No parenteral administration, no Controlled Drugs |
| Supplementary Prescribers | Per Clinical Management Plan | Includes Controlled Drugs, off-label, unlicensed |
Legal & Ethical Framework
Accountability
- Legal: Law of Tort (clinical negligence, confidentiality, battery)
- Professional: Statutory professional bodies
- Employer: Contractual obligations, vicarious liability
Ethical Principles (Beauchamp & Childress)
- Autonomy: Respect patient self-determination, confidentiality, informed consent
- Non-maleficence: Do no harm, consider double effect
- Beneficence: Do good, act in patient's benefit
- Justice & Veracity: Fair resource distribution, truth-telling
Consent Considerations
- Voluntariness: No pressure/coercion
- Information: Diagnosis, benefits, risks, alternatives
- Competency: Assessment of decision-making capacity
- Gillick Competence: Children under 16 with capacity
- Mental Capacity Act (2005): Presumption of capacity, best interests
Off-label & Unlicensed Prescribing
Unlicensed Medicine: No marketing authorization in the prescribing country.
Off-label: Licensed medicine used outside terms of marketing authorization.
Prescriber Responsibility
When prescribing off-label/unlicensed medicines, the prescriber assumes full professional, clinical, and legal responsibility for any harm caused.
The Consultation Process
Calgary-Cambridge Framework
- Initiating the session
- Gathering information
- Physical examination
- Explanation and planning
- Closing the session
Plus two ongoing tasks: Providing structure & Building relationship.
Communication Skills
- Non-verbal communication (eye contact, posture, proximity)
- Active listening without interruption
- Building rapport through acceptance
- Avoiding jargon, using simple explanations
Shared Decision Making
Incorporate patient's illness framework, beliefs, culture, and lifestyle. Discuss alternatives and negotiate mutually acceptable treatment plans.
Adherence
Definition: Extent to which patient's behavior matches agreed recommendations.
Types of Non-Adherence
Unintentional: Wants to follow but cannot (forgets, device difficulties).
Intentional: Decides not to follow (beliefs, perceptions, motivation).
Strategies: Reminder charts, multi-compartment devices, large print, administration aids, exploring beliefs/barriers.
35-50% of medicines for chronic conditions are not taken as recommended.
Medication Review
Definition: Structured critical examination of medicines to optimize impact, minimize problems, reduce waste.
| Review Type | Purpose | Patient Present | Notes Access |
|---|---|---|---|
| Prescription Review | Technical issues, cost-effectiveness | No | Possibly |
| Concordance Review | Medicine-taking behavior | Usually | Possibly |
| Clinical Review | Medicines in context of clinical condition | Yes | Yes |
NO TEARS Approach (Lewis, 2004)
- Need and indication
- Open questions
- Tests and monitoring
- Evidence and guidelines
- Adverse effects
- Risk reduction
- Simplification
Influences on Prescribing
Key Influences
- Patients: Expectations, cultural factors, beliefs
- Healthcare Policy: National guidelines, frameworks
- Colleagues: Trusted advice, opinion leaders
- Pharmaceutical Industry: Representatives, marketing, education sponsorship
- Cognitive Biases: Heuristics affecting decision-making
| Cognitive Bias | Description |
|---|---|
| Novelty Preference | Belief newer treatments are better |
| Over-optimism Bias | Overestimating positive outcomes |
| Confirmation Bias | Favoring confirming evidence |
| Mere Exposure Effect | Preferring familiar ideas |
| Loss Aversion | Avoiding loss > pursuing gain |
| Illusory Correlation | Seeing non-existent connections |
Strategies to Influence Prescribing
Managerial Approaches
- Formularies: Restricted lists for consistency and cost control
- Guidelines: Evidence-based standards (NICE, SIGN)
- Clinical Decision Support: Interactive computer programs
Educational & Supportive Approaches
- Incentives: Financial schemes for good prescribing
- Benchmarking: Comparative prescribing data
- Academic Detailing: Pharmacists as prescribing advisers
- AIDA Model: Awareness → Interest → Decision → Action
Clinical Governance
Definition: System for continuous quality improvement and safeguarding standards.
Seven Pillars
- Patient/public involvement
- Risk management
- Clinical audit
- Staffing and management
- Education & CPD
- Research & clinical effectiveness
- Use of information
Competency Framework
National Prescribing Centre Framework (3 areas, 9 competencies):
| Area | Competencies |
|---|---|
| Consultation | Clinical knowledge, Establishing options, Communication |
| Prescribing Effectively | Prescribing safely, professionally, Improving practice |
| Prescribing in Context | Information, NHS context, Team & individual |
Conclusion
Prescribing must balance potential benefits and harms through rational, patient-centered approaches. Prescribers must recognize influences and biases, work within ethical/legal frameworks, and utilize consultation skills for shared decision-making. Ongoing competence development and clinical governance are essential for safe, effective prescribing.
