Borthwick, Alan

Fox, Martin

Saoncella, Umberto

Stuart, Louise

Wiles, Philip

English

Southampton (e-Prints Soton)

XX	 The	Diabetic	Foot	Journal	Vol	13	No	3	2010Supplementary prescribing: Patient, podiatrist and professor perspectivesOver the past 20 years, the healthcare work force has been transformed. For eligible allied healthcare professions, non-medical prescribing has been introduced. This  move  has  given  fast  and  safe  access  to appropriate medicines for a range of patients.Supplementary  prescribing  rights  were extended  to  include  the  podiatry  profession in  2005,  but  few  podiatrists  have  taken  on this  role.  At  present,  around  just  120  UK podiatrists  are  qualified  supplementary prescribers  (Health  Professions  Council, 2010). With so few practising supplementary prescribers  in  podiatry,  it  is  perhaps unsurprising that their impact – on the health service, patient care and, ultimately, outcomes – may be considered minimal. So  what  are  the  benefits  of  non-medical prescribing, and what value does it add to the health  service?  More  specifically,  how  does supplementary  prescribing  improve  outcomes in the management of people with long-term conditions,  such  as  diabetes  and  diabetes-related complications of the foot?Here, the authors offer various perspectives – that of the patient (Umberto Saoncella), the physician  (Philip  Wiles)  and  the  podiatrists (Louise Stuart, Martin Fox) – on the benefits of  supplementary  prescribing.  In  conclusion, Alan  Borthwick  looks  at  the  possibilities  of independent prescribing for podiatrists and at the  projects  that  are  currently  under  way  to determine the best path forward.BackgroundThe  vast  majority  of  podiatrists  access medicines  for  their  patients  via  statutory exemptions,  Patient  Group  Directions  or rely  on  prescriptions  written  by  medical colleagues.  Those  who  have  successfully undertaken  the  supplementary  prescriber course can prescribe medicines for a patient within  an  agreed  clinical  management plan  between  reviews  by  the  independent prescriber  –  most  often  a  physician. Podiatrists  are  not  yet  able  to  prescribe independently, unlike appropriately qualified nurses  and  pharmacists  (Department  of Health, 2006).The	patient’s	perspectiveUmberto Saoncello has been receiving care for  active  Charcot  foot  disease  and  foot ulceration for the past 3 years in Manchester. During this time he has regularly attended the hospital-based multidisciplinary diabetic foot  team,  which  includes  a  podiatrist supplementary  prescriber.  When  asked  to comment on his experiences he said:“The diabetic foot clinic has been a beacon of hope for me over the past 3 years. Before being managed in the clinic, I struggled to obtain specialist care for my foot problems. In  the  past  2  years  I  have  swiftly  received antibiotics,  prescribed  by  my  podiatrist,  as well  as  my  diabetologist,  when  they  have been needed.Author details can be found on the last page of this article.Alan BorthwickPhilip WilesUmberto SaoncellaMartin FoxLouise Stuart mbeXX	 The	Diabetic	Foot	Journal	Vol	13	No	3	2010“It seems logical to me as a patient that a podiatrist  prescriber  offers  joined-up  care.  I fail to understand why, at the most important juncture of my care, the pen could be taken from the hand of the person who knows me best  and  thrust  into  the  hand  of  another professional  who,  in  some  cases,  may  know little about my condition.“I was dealt with competently, kept informed of all aspects of my care and had full confidence in  the  podiatrist  prescribing  for  me.  There was  a  totality  of  care  given,  not  fragmented management. My GP was kept fully informed of my treatment and continued to prescribe in the community in line with advice given by the podiatrist and my diabetologist.“I  would  argue  that  people  with  diabetes-related  foot  problems  need  more  specialists able  to  prescribe  medicines  appropriately   in  all  locations,  not  just  hospitals.  At times,  my  care  –  particularly  outside  of  the   hospital  –  has  not  been  provided  by  those sufficiently knowledgeable or skilled to manage my foot problems.”The	professor’s	perspectivePhilip Wiles is Honorary Professor, University of  Salford  and  a  jobbing  general  diabetes consultant working in a large district general hospital  diabetes  centre.  Having  mentored and  worked  with  both  independent  and supplementary prescribers, Philip had this to say on his experiences: “By  far  the  greatest  impact  made  by  the introduction of supplementary prescribing at our hospital has been on the diabetic foot service. In that environment clinical problems are dynamic and the pace frequently frenetic, making non-medical  prescribing  completely  practical.  As a  result,  clinics  run  more  smoothly  and  the patients leave for home more quickly. “Supplementary prescribing is underpinned by a robust governance process that applies structure and  scrutiny  to  prescribing.  Best  practice  has extended into the community, and I have seen a more rational approach to antibiotic prescribing in  primary  care  settings  as  a  consequence  of contact with a prescribing podiatrist.“Personally,  I  have  benefited  from  the  case discussions and the need to explain prescribing decisions.  Supplementary  prescribing  has  also released  some  of  my  time  to  spend  on  other aspects  of  patients’  general  care  and  diabetes management.“Podiatrists  cannot,  as  yet,  prescribe independently.  Supplementary  prescribing is  fine  within  a  clinic  environment,  but  the lack  of  independence  is  a  hindrance  when trying  to  manage  foot  ulceration  in  the community.  Neither  my  podiatry  colleagues nor  our  patients  have  the  luxury  of  time  to waste. I look forward to the extension of full independent prescriber status to appropriately trained podiatrists.”The	prescribing		podiatrists’	perspectiveLouise  Stuart  and  Martin  Fox  describe the  supplementary  prescribing  course  for podiatrists as the most useful one they have undertaken since qualifying. If readers think that writing a prescription is the only benefit, they urge them to think again:“Penning the prescription is the tip of the iceberg; we review medicines in every patient we see. This allows us to provide a safer and more informed and holistic service for people with  diabetes-related  foot  complications. But  apart  from  our  anecdotal  experiences, what  evidence  is  there  that  supplementary podiatrist prescribers add value to the health service  and  improve  patient  experience  and outcomes?“In 2009, the North-West Allied Healthcare Professions Non-Medical Prescribing Network (AHP  NMP)  undertook  an  audit  of  allied healthcare  professional  prescribing  practices. To the best of our knowledge, it is the largest audit of its kind. The aim was to assess the impact  of  supplementary  prescribing  on patient care.“The  AHP  NMP  audit  revealed  the immediate  access  to  medicines  provided  by non-medical prescribing, with a prescription being  drawn  in  80%  of  all  emergency appointments.  The  follow-on  effect  of  this “As a patient ... I fail to understand why, at the most important juncture of my care, the pen could be taken from the hand of the person who knows me best and thrust into the hand of another professional who ... may know little about my condition.”Supplementary	prescribing:	Patient,	podiatrist	and	professor	perspectivesXX	 The	Diabetic	Foot	Journal	Vol	13	No	3	2010is the prompt treatment for the patient, the prevention  of  referrals  and  a  cost  saving  to hospital-based  emergency  care  that  would otherwise have been engaged.“The  audit  also  revealed  that  a  review  of patients’  medicines  took  place  in  97%  of cases.  The  impact  of  the  medicines  review led  to  the  recognition  of  sub-therapeutic doses  and  inappropriate  regimens,  which were subsequently red-flagged to independent prescribers.  In  one  in  ten  cases  the  non-medical  prescriber  identified  inappropriate repeat prescriptions, the correction of which would result in cost saving and a reduction in medicines waste.“Few  studies  have  critically  examined  the impact  of  non-medical  prescribing  and  in the  absence  of  evidence,  the  effectiveness of  prescribing  is  assessed  by  the  surrogate, 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 benefits to prescribing, not only in improved patient care but also in terms of ensuring the appropriate use of scarce NHS resources.”Independent	prescribing:	The	way	forward?In its report of July 2009, the Department of Health’s Allied Health Professions Prescribing and  Medicines  Supply  Mechanisms  Scoping Project  recommended  two  additional implementation  phases  designed  to  enhance access  to  and  up-take  of  non-medical prescribing across a range of allied healthcare professions.  In  February  2010,  the  Allied Healthcare  Professions  Medicines  Project was established with a view to enacting the first of the two recommended phases and is presently preparing for public consultation on extending  the  independent  prescriber  status to the podiatry and physiotherapy professions. Although  there  has  been  unavoidable uncertainty around the policy priorities of the new Coalition Government, the work of the project continues apace.As was the case in nursing, pharmacy and optometry,  a  range  of  prescribing  activity options are being considered for podiatrists. Would  limited  prescribing  within  a  set formulary be sufficient, or would freedom to prescribe where relevant be preferable? Might it  be  effective  to  prescribe  within  a  limited range of conditions, or would this create more problems for patients than even the current system allows?Answers  to  these,  and  related,  questions will  determine  the  case  for  independent prescribing status for the podiatry profession. As  evidence  grows  that  supplementary prescribing  benefits  patients,  makes  services more  responsive  and  reduces  the  burden on  GPs  and  hospital  physicians,  the  case for  independent  prescribing  status  for  the podiatry profession will strengthen.  nLouise Stuart mbe is a Consultant Podiatrist and Martin Fox is a Vascular Podiatrist, both are based at Manchester Community Health, Manchester; Alan Borthwick is a Senior Lecturer, Southampton University, Southampton; Umberto Saoncella is a person with diabetes, Manchester; Philip Wiles is a Consultant Physician, North Manchester General Hospital Diabetes Centre, Manchester and Honorary Professor, University of Salford.Department of Health (2006) Improving Patients’ Access to  Medicines:  A  Guide  to  Implementing  Nurse  and Pharmacist Independent Prescribing within the NHS in England. DH, LondonDepartment  of  Health  (2009)  Allied  Health  Professions Prescribing  and  Medicines  Supply  Mechanisms  Scoping Project Report. DH, London. Available from: tinyurl.com/27dr6ob (accessed 02.08.10) Health  Professional  Council  (2010)  Health  Professional Council  Podiatrist  Register  Data.  Available  from:   www.hpc-uk.org (password protected)North West Allied Health Professional Network (2009) North  West  Allied  Health  Professional  Non-Medical Prescribing  Audit.  AHPN,  Salford.  Available  from: www.ahpnw.nhs.uk (password protected)“There are multiple benefits to prescribing, not only in improved patient care but also in terms of ensuring the appropriate use of scarce NHS resources.”Supplementary	prescribing:	Patient,	podiatrist	and	professor	perspectives

Supplementary prescribing: patient, podiatrist and professor perspectives

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