In both primary and secondary health care, the use of medicines is the most common intervention. However, the use of medicines is not without risk. Selecting and prescribing drugs is increasingly complex and demanding, and it is undertaken as part of a multi-disciplinary process that involves pharmacists, some of whom are now prescribers in their own right, along with doctors, nurses and other members of the healthcare team. All must strive to promote safe, appropriate and cost-effective prescribing that respects patient choice and promotes adherence. This book was written to help the reader understand and address many of these issues. It is unashamedly written from a pharmacy  erspective, although we do hope those from other disciplines will also ind it of use. We have made considerable effort to update each chapter and ensure the content is relevant to current practice. Selected website addresses have been included to assist those who want to obtain further information, and many references are now available electronically. However, knowledge in therapeutics progresses rapidly, changes to dose regimens and licensed indications are frequent, safety issues emerge with established drugs and new medicines appear at regular intervals. Yesterday another landmark study may have been published that added to, or perhaps altered, the evidence base for a speciic treatment. Together with the ongoing publication of national and international guidelines and frameworks, the face of therapeutics is ever changing. It is therefore inevitable that some sections of this book will date more quickly than others.

In practice, many licensed drugs are used ‘off label’ or ‘near label’ when prescribed for a certain indication or used in a speciic patient group, such as children. To omit reference to these agents in the relevant chapter would leave an apparent gap in therapeutic management. As a consequence, we have encouraged our authors to present details of all key drugs used, along with details of the prescribed regimens, even if not licensed for that speciic indication.

There is, however, a downside to this approach. The reader must always use this text critically and with caution. If this is done, the book will serve as a valuable learning resource and help the reader understand some of the principles of therapeutics. We hope that, in some small way, this will also assist in achieving positive patient outcomes.

Clinical Pharmacy Practice

Clinical pharmacy encourages pharmacists and pharmacy support staff to shift their focus from product orientation to more direct engagement with patients, to maximise the beneits that individuals obtain from the medicines they take. Since the late 1980s the practice of clinical pharmacy has grown from a collection of patient-related functions to a process in which all actions are undertaken with the intention of achieving explicit outcomes for the patient. In doing so clinical pharmacy has moved forward to embrace the philosophy of pharmaceutical care (Hepler and Strand, 1990) and, more recently, the principles of medicines optimisation (Royal Pharmaceutical Society, 2013).

The aim of this chapter is to provide a practical framework within which knowledge of therapeutics and an understanding of clinical practice can best be utilised. This chapter describes a pragmatic approach to applying aspects of the pharmaceutical care process and the speciic skills of clinical pharmacy to support the optimal use of medicines in a manner that does not depend on the setting of the practitioner or patient.

Structured postgraduate education has served to improve the knowledge of clinical pharmacists, but fully achieving the goals of pharmaceutical care has proved more challenging. Part of the dificulty has been the requirement to place the patient at the heart of the system, rather than being a relatively passive recipient of drug therapy and associated information. To deliver pharmaceutical

care requires more than scientiic expertise. It mandates a system that describes irst the role and responsibilities of the pharmacist and provides the necessary infrastructure to support them in this role, and secondly a clear process by which the pharmacist can deliver his or her contribution to patient care. Pharmaceutical care is predicated on a patient-centred approach to identifying, preventing or resolving medicine-related problems. Central to this aim is the need to establish a therapeutic relationship. This relationship must be a partnership in which the pharmacist works with the patient to resolve medicationrelated issues in line with the patient’s wishes, expectations and priorities. Table 1.3 summarises the three key elements of the care process (Cipolle et al., 1998). Research in chronic diseases has shown that self-management is promoted when patients more fully participate in the goal-setting and planning aspects of their care (Sevick et al., 2007). These are important aspects to consider when pharmacists consult with patients. In community pharmacy in the UK, approaches to help patients use their medicines more effectively are the medicines use review (MUR) and the new medicines service (NMS). The MUR uses the skills of pharmacists to help patients understand how their medicines should be used, why they take them and to identify any problems patients have in relation to their medicines, providing feedback to the prescriber if necessary. Two goals of MUR are to improvethe adherence of patients to prescribed medicines and to reduce medicines wastage. The NMS has been introduced to allow pharmacists to support patients with long-term conditions who have been recently started on a medicine to target medicines adherence 

To prescribe is to authorise, by means of a written prescription, the supply of a medicine. Prescribing incorporates the processes involved in decision making undertaken by the prescriber before the act of writing a prescription. Historically prescribing has been the preserve of those professionals with medical, dental or veterinary training. As the role of other healthcare professionals, pharmacists, nurses, optometrists, physiotherapists, podiatrists and therapeutic radiographers have expanded, prescribing rights have in turn been extended to them. The premise for this development has been that it better utilises the training of these professional groups, is clinically appropriate and improves patient access to medicines.

Regardless of the professional background of the individual prescriber, the factors that motivate them to prescribe a particular medicine are a complex mix of evidence of effectiveness and harms, external inluences and cognitive biases. A rational approach to prescribing uses evidence, has outcome goals and evaluates alternatives in partnership with the patient. With the advent of new professional groups of prescribers (non-medical prescribers), there is a need for a systematic approach to prescribingand an understanding of the factors hat inluence the decision to prescribe a medicine. These issues will be covered in the following sections. Initially the fundamentals of rational and effective prescribing will be discussed followed by a brief outline of the acquisition of prescribing rights by pharmacists and the associated legal framework. The prescribing process and factors


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