An exploratory study of the patient experience of pharmacist supplementary prescribing in a secondary care mental health setting.

BACKGROUND: Management of chronic disease has become an increasing challenge to the National Health Service in the United Kingdom. The introduction of supplementary prescribing was seen as a possible mechanism to address the needs of this patient group. Individuals with mental illness were considered particularly suitable for management in this way.
OBJECTIVE: To explore the views and experiences of patients with mental illness on being managed by a pharmacist supplementary prescriber in a secondary care outpatient setting.
METHODS: A study of patient experiences utilising semi-structured interviews and self-completion diaries was adopted. Eleven patients participated in the study. Data were analysed utilising code and retrieve, and content analysis respectively.
RESULTS: Patients valued the increased accessibility to, and continuity of, their prescriber compared with their experience of other healthcare professionals. Patients reported they were able to trust the pharmacist's knowledge of medication, were provided with sufficient information regarding reasons for treatment and side effects, and felt that they had an active role in decisions concerning their healthcare.
CONCLUSIONS: This exploratory study showed that patients had positive views of being managed by a supplementary prescriber. However, it should be noted that the number of participants was small. It is therefore important that further, more wide ranging research is conducted to evaluate pharmacist prescribing within mental health settings.

INTRODUCTION

Management of chronic disease has become an increasing challenge to the National Health Service (NHS) in the United Kingdom (UK) with an estimated 17.5 million adults suffering from long-term conditions.1 It has been reported that these patients account for approximately 80% of general practitioner (GP) consultations and occupy 60% of hospital beds.1 The introduction of non-medical prescribing was seen as a possible mechanism to address the needs of this patient group by the Department of Health in the UK.1 Predicted benefits included enhanced access to healthcare, improved management of medication and improved patient safety.2 Non-medical prescribing by pharmacists has been implemented internationally (including in the USA, Australia and Canada); however, the models adopted within each country differ.3 Supplementary prescribing in the UK allows appropriately trained health professionals (such as pharmacists and nurses) to manage patients under the direction of a clinical management plan. A summary of the roles and responsibilities of a supplementary prescriber in the UK can be seen in Table 1. In the mental health setting, this development was supported by the document “New ways of working for psychiatrists” which raised the profile of mental health pharmacists and pharmacist non-medical prescribing by advocating appropriate delegation within the multidisciplinary team. The UK Psychiatric Pharmacists Group and College of Mental Health Pharmacists and the Department of Health identified that individuals with mental illness were considered particularly suitable for management by non-medical prescribers (NMP).5,6 The College of Mental Health Pharmacists indicated that only specialist mental health pharmacists would be suitable to undertake this role due to their qualifications and specific knowledge of this therapeutic area.6

Table 1.

Supplementary prescriber roles and responsibilities.

Supplementary prescriber works in partnership with an independent prescriber (doctor) to manage care of patient Diagnosis undertaken by independent prescriber (Doctor) Patient-specific clinical management plan is developed and utilised for each patient to set out in detail what the supplementary prescriber can prescribe and for which indications Partnership and shared responsibility for patient management Able to prescribe any medicine (listed on clinical management plan)

Supplementary prescribing is a partnership between a pharmacist supplementary prescriber, patient and independent prescriber.5 The manner in which this partnership works has been recognised as a crucial factor in determining the effectiveness of the service. However, few studies have focussed on the views of the service user.7,8 Importantly, the Department of Health indicated that the opinions of service users should be sought in order to improve care and facilitate a “patient led NHS”.9 Published studies in the UK have shown patients to be generally satisfied with pharmacist supplementary prescribing but these have not explored the views of those with mental illness.10,11,12,13 Previous research in secondary care with patients diagnosed with schizophrenia found that they were dissatisfied with the information provided to them about their medication and with their level of input into healthcare decisions.14 The extensive knowledge of the specialist pharmacist coupled with the extended role in the prescribing process may be a tool with which to address certain patient concerns and improve healthcare.

The aim of this study was to explore the views and experiences of patients with mental illness on being managed by a pharmacist supplementary prescriber in a secondary care outpatient setting.

METHODS

Approval for the study was obtained from Dyfed Powys Research Ethics Committee and the appropriate NHS Trust Research and Development Office. A case study of one pharmacist prescriber utilising two qualitative methodologies, namely semi-structured interviews and self-completion diaries was adopted. The use of multiple methods is a recognised feature of a case study approach in order to describe the phenomenon under investigation.15 The pharmacist was identified through a known contact of the researcher as being an actively practising supplementary prescriber, as such, convenience sampling was utilised. They were female, with approximately 10 years clinical experience within the field of psychiatry.

The supplementary prescriber worked in partnership with five independent prescribers, all of whom had given written informed consent for their patients to be approached as potential participants and had themselves been provided with a description of the study methodology. Reasons for referral to the pharmacist supplementary prescriber by the independent prescribers (psychiatrists) included management of dose titration or to provide more detailed guidance on medication issues. Patients were treated for bipolar disorder, psychosis or depression. All eligible patients were identified by the supplementary prescriber and independent prescriber and provided with written information about the study during a routine pharmacist supplementary prescriber consultation. Patients were identified and approached by the pharmacist over a discreet time period. Inclusion criteria for the study required patients to be over 18 years of age, have their care managed by the pharmacist supplementary prescriber for a minimum of two previous consultations, and deemed able to provide informed consent by their care team. Written informed consent was obtained prior to participation. Upon enrolment patient demographics were provided to the researcher by the pharmacist supplementary prescriber. The project consisted of three stages. All consenting patients were required to participate in stage 1, and were then able to choose whether or not to complete stages 2 or 3. A small financial remuneration was offered to thank participants for their time (GBP10 each for stages one and three, GBP5 for completion of stage two).

Stage 1: Semi-structured interview following supplementary prescriber consultation

Patients were interviewed by the researcher (RED) in private, immediately following a consultation with the pharmacist supplementary prescriber either within an out-patient clinic or hospital pharmacy department. The purpose of this stage was to encourage participants to reflect and discuss immediately post-consultation. A semi-structured interview schedule was developed (see Table 2 for the topic outlines), utilising open questions to allow patients to discuss their views freely. The interview schedule was piloted with the first patient and minor changes made. Interviews were audio-recorded with written consent and transcribed ad verbatim.

Table 2.

Stage 1: Post consultation topic guide.

Patient expectations of their appointment To what degree were the expectations met Patient agenda for the appointment Patient: pharmacist interaction Opportunity for patient to communicate their thoughts Opportunity to ask questions Length of appointment Future recommendations

Stage 2: Patient completion of diary

Immediately following the post-consultation interview participants were provided with a research diary and were invited to use it over the following six weeks to record events related to their care by the supplementary prescriber such as further appointments. Diaries were utilised to allow patients the opportunity to record events as they happened, therefore reducing the need to rely upon their memory to such a great extent during the interview in stage three.16 Patients were asked to prospectively record the date and description of events related to the care provided by the supplementary prescriber (for example, any telephone calls or appointments that may have been held during that time). Guidance was provided at the front of the diary and reinforced verbally upon distribution. Entries did not have to be made on a daily basis, only when relevant events occurred. Participants were contacted by their preferred method (email or telephone) after approximately three weeks to allow them the opportunity to ask questions and then again at the end of six weeks as a reminder to return the completed diary.17 Entries served as an aide-mémoire for the final interview in stage three.

Stage 3: Post-diary interview

Following the diary period, or after approximately six to eight weeks if no diary was completed, consenting participants attended a final face-to-face interview. A semi-structured interview was conducted; this is known as the diary: diary-interview method.18 The focus of this stage was to establish patient views of on-going management by the supplementary prescriber (this is in contrast to stage one where the focus was on the most recent interaction, see Table 3 for the topic outlines), with reference to the diary entries. Interviews were held following a further appointment with the supplementary prescriber in order to minimise inconvenience to the participants. If this was not possible, a mutually agreed time and place was arranged. Interviews were audio-recorded with written consent and transcribed ad verbatim.

Table 3.

Stage 3: Follow up topic guide.

Patient views on pharmacist prescribing and previous experiences Patient’s awareness of the pharmacist’s role Management of patient’s condition since seeing the pharmacist Patient expectations of a prescribing pharmacist Patient: pharmacist interaction Outside of organised appointments What constitutes a typical appointment

Data analysis

All data and patient information were anonymised. Following interview transcription, a code and retrieve analysis was carried out to allow the identification of and coding of common themes.19 Code and retrieve involves bringing together sections of text with common themes, they are then coded or labelled. This allows the commonalities, differences and patterns of the interviews to be identified. Themes were identified inductively from the data. Analysis was carried out in a cyclical process to ensure that no codes had been missed. Diary entries were analysed by thematic content analysis20 in order to categorise the type of entries provided. The Qualitative Data Analysis Software N6 was utilised to assist in data management and analysis. Each stage was analysed chronologically as the focus of each stage was different. All transcribing and data analysis was carried out by the main researcher.

RESULTS

Thirteen of 20 patients treated by the supplementary prescriber during the study period were provided with information about the study. The remaining seven did not meet all of the inclusion criteria or were too unwell to participate (as determined by the pharmacist and their independent prescriber). Twelve patients provided consent for each stage. One patient who gave consent did not participate due to deterioration in mental state; therefore 11 patients participated in the study. Patient demographics are shown in Table 4. The results of each stage are presented below:

Table 4.

Patient demographics (n=11).

	Number
Age (years)
18-29	3
30-39	3
40-49	3
50+	2
Gender
Male	3
Female	8
Diagnosis
Bipolar disorder	8
Psychosis and depression	1
Depression	2
Co-morbidities
Menopausal symptoms	1
Poly-cystic ovary syndrome	1
Eating disorder	1
Psoriasis	1
Hypertension	1

Stage 1: Semi-structured interview following supplementary prescriber consultation.

Eleven patients participated in this stage. Interviews lasted a mean of 18 minutes. The main themes generated from these interviews, and discussed below, were:

The pharmacist-patient relationship

Comparison to other HCPs

Time allowed for the consultation

All participants felt comfortable consulting with their pharmacist and had developed a trusting relationship with her. Patients stated that the pharmacist’s personality played a significant role in developing rapport, alongside her knowledge of their condition and treatment. The relationship was felt to be especially important for managing individuals with a mental illness:

PT1 …you’ve got to be a certain type of person who can make somebody with mental health issues and prescribing their drugs at ease and be able to express how you feel.

Participants believed that the pharmacist listened to what they had to say during their consultations. Patient 9 considered this to be a positive feature in comparison to their prior experiences:

PT9 … I would say …… I felt like I was listened to she didn’t sort of cos sometimes in the past when I’ve seen maybe not her but like a doctor I, some of the ideas have been like not listened to or dismissed that sort of thing so I feel she listens quite well.

As the pharmacist listened to the patients’ views and openly discussed treatment options, patients perceived any decisions to be made in partnership:

PT5 Whereas if you say how do you feel about this do you want to go up [dose] do you want to take them [medication] off you know it’s not the ’I’m the professional I’m telling you what to do’ …..you know it’s let’s discuss this this together so I I think that’s the best approach.

Throughout the interview participants compared the pharmacist’s approach to those experienced with GPs and psychiatrists. Positive views of the supplementary prescriber pharmacist were expressed by all. This was especially true with regards to the continuity of healthcare professional, the pharmacist’s knowledge, how they felt within the consultation and their involvement in any decisions concerning their care:

PT7 Something that used to be a pain was that the doctors changed for ever and I can’t remember how many doctors assured me no, they were going to be here and then they went they we’re all lovely people and um ….I eventually got to the point where I didn’t actually want to invest anything in them.

PT2 I trust what she has to say about um drugs more than I would a doctor ……..because I think she’s more knowledgeable……… in terms of drugs and what they do and how they work, I think she knows more than a doctor would.

Patients had increased involvement in the consultation, making it a more lengthy process. This was seen as an advantage not always experienced in other circumstances:

PT7 …one of the nice things about coming in with a change of problem and talking to [pharmacist] is that we have time to go through it properly whereas I have a feeling if I go to my GP he’s watching his watch.

Stage 2: Patient completion of diary

Seven of the 11 participants completed diaries over a six week period. There were no differences in terms of age, gender and diagnosis between those who did participate compared to those who did not. The number of entries ranged from four to 44 and were categorised into broad themes. Patients described a range of events or thoughts related to the care provided by the pharmacist. No significant incidents occurred throughout the study for any of the participants. However, entries included:

a brief description or an arrangement of a consultation with the pharmacist

PT2 Appointment with [pharmacist]. Checked rash, side effects and asked if I wanted to carry on. Had longer two month type appointment.

an occasion where both pharmacist and patient had made a joint decision regarding therapy

PT5 I had an appointment with my pharmacist – we chatted for 30 mins about my mood, sleep, eating etc. It was a really good session, she listened to what I had to say and we agreed to increase the dose of my meds.

the pharmacist’s availability outside of the consultation

PT2 [pharmacist] phoned me as she said she would. Explained what the doctor said and gave me the choice to proceed or not. Remembered I was at my parent’s house and made arrangements for tablets to be delivered to pharmacy nearer their house.

patients’ intentions to discuss particular issues with the pharmacist at the next available opportunity

PT8 Having a very down day, will discuss how I feel with pharmacist next time.

their general views of the service

PT8 Saw pharmacist today, all went well, meds have been really helping and we discussed all possible issues / complications and all is ok. Feel quite relaxed about meds ok to increase dosage of one of meds.

The entries provided an insight into the patient’s ongoing relationship with the pharmacist and their subsequent communications.

Stage 3: Post-diary interview

Eight patients participated in the final stage of the study. There were no differences in terms of age, gender and diagnosis between those who did participate compared to those who did not. Interviews lasted a mean of 32 minutes and focussed on the on-going management by the supplementary prescriber.

The main themes generated from these interviews, and discussed below, were:

Patient satisfaction

Consistency of care

Pharmacist accessibility

Pharmacist knowledge

The mental health patient

The interviews in this final stage raised very similar issues to those discussed in stage one, where patients compared the care from other healthcare professionals to that provided by the pharmacist supplementary prescriber. All patients expressed positive views of the manner in which they were engaged in the decision making process and were satisfied with the service. They also believed the amount and level of information provided by the supplementary prescriber was appropriate:

PT2 …like I have a lot of choices, [pharmacist] doesn’t tell me what to do, she kind of gives me choices about what I could do um its very kind of co-operative.

All of these views contrasted to patients’ previous experiences with GPs and psychiatrists. It was perceived that doctors did not take their views into account and did not provide as much information within the consultation:

PT8 It felt a little bit more interactive cos sometimes I did feel …. doctors they are a little bit more kind of you have to take it like this and you’re going to take it like this and then you’ll come back in a while and see if it’s all ok kind of thing whereas it was more progressive if you know what I mean.

PT4 … seems to be quite good actually cause she does give me a lot more information about the actual drugs themselves than the doctor ever did. So, she seems to know a greater variety and be a lot more up to date on all of them.

As established in stage one, participants appreciated consulting with the same healthcare professional on a regular basis. This continuity gave the opportunity for the pharmacist to monitor their condition more closely, to tailor the medication to the individual and to allow the patient to ask questions and discuss their condition.

PT9 …well one reason why I’ve stayed with the pharmacist for such a long time was because what I was finding with the psychiatrist, I was seeing him not very frequently.

Participants found the supplementary prescriber more accessible than a psychiatrist and were regularly given the option of contacting the supplementary prescriber beyond the immediate face-to-face consultation, either via email or telephone:

PT5 …mmm and I think also I can get hold of her ….. and I will be able to speak to her directly whereas with a psychiatrist you would struggle to do that or they’d probably leave a message and they might ring you in three days time.

Participants recognised the pharmacist’s high level of knowledge regarding their medication. This awareness contributed to patients’ confidence in the pharmacist’s role:

PT1 And I said I’m more than happy for her to do that because I trust her and her knowledge, she’s a pharmacist.

Finally, some participants believed that the approach of healthcare professionals to patients with mental illness should be different to those with physical illness. A suggested reason for this was the sensitive nature of the conditions and that medication is often approached on a ’trial and error’ or ’guinea pig’ basis. Importantly, patients cannot take a ’magic bullet’ (Patient 8) to cure their condition and medication therefore needs to be tailored to the individual:

PT5 … in terms of say the GP doing it like I would prefer to come here and see [pharmacist] than do it with the GP because [pharmacist] understands all the mental health stuff and some GP’s they don’t really get it or they don’t believe in it or whatever.

All patients in this exploratory study expressed positive views on the service. The only negative comments related to the delay in collecting their medication from the pharmacy on a few occasions. However, this was associated with the procedures of dispensing and supplying the medication rather than the supplementary prescriber more specifically.

DISCUSSION

This exploratory study elicited the opinions of patients with mental illness on their management by a pharmacist supplementary prescriber. Within this particular setting the pharmacist received referrals from all five of the independent prescribers who agreed to their patients being included in the study. Reasons for referral included initiation of medication requiring close monitoring and treatment of patients with complex pharmaceutical needs. The differing independent prescribers and varied reasons for referral allowed a range of subjects to be included. There was a degree of attrition as not all patients participated in all stages. However, there were no differences in terms of age, gender and diagnosis between those who did participate compared to those who did not. The views were positive, consistent with findings from other small scale studies conducted within the UK.11,21,22 Perceived patient benefits of pharmacist prescribing have also been reported by supplementary prescribers themselves and other stakeholders.12,23,24,25,26

Patients felt that they had developed a meaningful and trusting relationship with their supplementary prescriber over time. The importance of having such a close association has been highlighted by the National Institute for Health and Clinical Excellence (NICE) in their guidelines to treat bipolar disorder. It is recommended that healthcare professionals “establish and maintain collaborative relationships with patients …… be respectful of the patient’s knowledge and experience of the illness”.27 A similar view was expressed by one of the participants who felt that managing patients with mental illness required a different approach compared to those with physical illness. It was perceived that the pharmacist created a ’friendly and relaxed’ atmosphere within the consultation and that they were easier to talk to than the psychiatrist. The importance of positive relationships between mental health patients and community pharmacy staff was highlighted by Knox and colleagues.28 Similarly, participants in other studies believed their pharmacist prescriber displayed an interest in them as a ’person’ rather than as an illness and provided more time to discuss their health-related issues.11,22 This research was largely conducted in the general practice or community pharmacy; therefore the prescribing role may have been somewhat different to the current study where the prescribing role was carried out in a secondary care out-patient setting. However, this study does provide further evidence of a patient focused interaction. In addition to the approach of the supplementary prescriber, other factors contributed to the development of this rapport, namely the time allowed for the consultation and continuity of care.

In contrast to their prior experiences with other healthcare professionals, patients in this study valued the increased accessibility to their prescriber. This included an ability to contact the supplementary prescriber more easily than they would a doctor.11,12 Furthermore, it was highlighted by one patient that when attending appointments with rotational junior medical staff it was necessary to repeat their “story” on each occasion. The continuity achieved through management by the same supplementary prescriber allowed for discussion of issues that were important to the patient and relevant to their current treatment. All of these benefits were identified at the inception of supplementary prescribing alongside the main focus to improve patient safety.2,5 The pharmacist supplementary prescriber allocated 30 minutes for each appointment, although in practice this was frequently extended according to the patients’ individual requirements. This was in contrast to the strict ten minute appointments patients experienced with their GP or 20-30 minutes with their independent prescriber. Having more time available for appointments meant that areas outside the illness could be discussed increasing understanding between patient and healthcare professional.

Research conducted in Australia has shown that mental health patients value good quality services within pharmacy, including respecting their privacy.29,30 However, patients with mental illness have previously expressed views that they receive insufficient information about medication and do not feel involved in healthcare decisions to the extent they would wish.14,31 It has been previously reported that patients took antipsychotic medication because they ’were told to’ despite experiencing side effects.14 However, in the context of the present study patients were able to trust the pharmacist’s knowledge of medication, and were provided with sufficient information. This is consistent with the initial reasons for referral to the supplementary prescriber, as a pharmacist might be considered the most suitable healthcare professional to manage these aspects of patient care. Similarly, patients in general healthcare settings believed that pharmacist supplementary prescribers provided more medication information than their previous prescribers.10 All patients in the current study reported being actively involved with the supplementary prescriber in treatment decisions which was considered positive compared to their previous experiences with other healthcare professionals. On all occasions their current care programme was perceived to be more patient focussed. Importantly, whether a consultation is ’patient-centred’32 can impact on patient outcomes and medication adherence.33

Limitations

In this exploratory study the views of eleven patients managed by a pharmacist supplementary prescriber working within general adult psychiatry were investigated using a case study approach. The single pharmacist and small number of patients are limitations of the study. As seen from stage one (interview) data, patients identified the personality of the pharmacist to be a key factor in determining their satisfaction with the service. The manner in which other pharmacists would therefore interact with the participants could be significantly different and therefore limits the generalisability of the results. In addition, the patients were largely female with bipolar disorder. Furthermore, the results are only valid for this particular setting and cannot be extrapolated to other areas either within mental health, such as old-age or addiction psychiatry, or to other healthcare fields. The aim of this study however, was not to generalise. The manner in which patients were identified and the requirement for each patient to have seen the supplementary prescriber for a minimum of two consultations may have introduced an element of selection bias. Patients with positive views or those considered to be especially motivated could have been identified for inclusion by the supplementary or independent prescriber, whilst dissatisfied patients may have withdrawn from the supplementary prescriber service after the first consultation. These limitations may have been compounded by the small sample size. However, other studies exploring patient views on non-medical prescribing have been on a similar small scale.10,12 Prior to participation in the study, the supplementary prescriber was aware that stage one involved an in-depth discussion of the most recent pharmacist-patient consultation. This may have influenced the way in which the pharmacist approached that specific interaction. It was also noted that although the foci of stages one and three were different (immediate response to the supplementary prescriber consultation versus longer term views of management respectively) patients’ responses during the interviews generated similar themes. Lastly, the data analysis was conducted by only one researcher which could have introduced some bias into the study. However, the identified themes were confirmed by the other researchers. Nevertheless, the methods employed in this exploratory study were effective in obtaining data from this patient group.

CONCLUSIONS

In conclusion, this study has utilised both interviews and diaries in a novel way to explore the views of patients with mental illness who are being treated by a pharmacist supplementary prescriber. All participants expressed positive views of the service provided by their supplementary prescriber which highlights the ongoing importance of this ever evolving role of the pharmacist within a mental health setting. Aspects found to be of benefit included increased access to and continuity of healthcare professional and a more active role for patients in decisions concerning their healthcare. All of these positive attributes of non-medical prescribing were anticipated at the inception of this relatively recent initiative by the Department of Health2 and it is encouraging to see that they have been realised albeit in this small scale study. It is important, however, that further, research is carried out to evaluate pharmacist prescribing within the mental health setting such as exploring the views of both supplementary and independent prescribers on the service and recruiting larger numbers of patients who are treated by a variety of prescribers.