The Pharmaceutical Journal
Vol 270 No 7230 p22-23
4 January 2003

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Pharmacist prescribing summary

Implementing supplementary prescribing — a baseline survey by The National Prescribing Centre

Some 71 per cent of primary care trusts across England expect some pharmacists, working in their area, to be prescribers by 2005. Clive Jackson, MRPharmS, chief executive of the National Prescribing Centre, describes how it might be implemented

On 21 November 2002, the Health Minister (Lord Hunt) unveiled new powers allowing pharmacists and nurses to prescribe medicines. This much-heralded announcement means that, from summer 2003, appropriately trained pharmacists should be beginning to take up the prescription pad and developing new professional roles that improve patient care and convenience.

To make this concept a reality requires a shift of emphasis from the policy development phase towards practical delivery at local level. The process of implementation will include a series of significant challenges for the National Health Service, for education providers and for the profession. Each will be relying on the others to deliver their contribution to ensure implementation is achieved in a timely and pragmatic way.

So what are some of the key steps that need to be taken and decisions that need to be made in order to allow pharmacists to become active supplementary prescribers?

• There needs to be an assessment of local health and service needs involving prescribing, in line with the emerging service delivery plans for commissioning organisations (ie, primary care trusts or NHS trusts)

• A decision needs to be made, if a supplementary prescribing service is deemed appropriate, whether it should be undertaken by nurses or pharmacists (or both)

• If pharmacy is the preferred option, it would need to be decided whether pharmacists from the community, the hospital, or GP practices would be best placed to deliver the service(s)

• There needs to be an evaluation of the willingness, capacity and capability, within the relevant local pharmacist pool, to take on this new responsibility

• Appropriately experienced doctors, who would be capable and willing to provide formal supervised practice sessions for pharmacists during their preparatory training, need to be identified

• Specific pharmacists for training in the new role need to be selected and the choice confirmed by the relevant PCT or NHS trust

• The implications of day-release for training on existing service delivery need to be considered, as does the pharmacists' personal workload commitment (up to 26 days of formal training over three to six months, plus 12 days of supervised practice with a suitable, previously identified doctor is required)

• The workload and delivery implications on existing services once the pharmacist is trained and undertaking the new prescribing responsibilities required needs to be considered

• A Royal Pharmaceutical Society accredited, supplementary prescriber training course needs to be identified and the pharmacist enrolled on it

• It needs to be confirmed that the pharmacist's registration with the Society is appropriately annotated to indicate their supplementary prescriber status on satisfactory completion of the accredited training course

Only at first base

In principle, pharmacists reaching this point in the process would be eligible to prescribe. However, in practice, further issues will need to be addressed before any pen can be placed on a prescription pad. These issues will include:

• Confirmation of the independent prescriber(s) who will be partnering the pharmacist, when working as a supplementary prescriber, to deliver the services required

• Joint development of clinical management plans (CMPs) for each patient who will be receiving the new service (with their agreement)

• Inclusion of the new service within the relevant corporate and clinical governance frameworks of the commissioning or host organisations

• Agreement on which budget the supplementary pharmacist prescriber will be working within (and held to account against) when prescribing

• Confirmation on how and where the pharmacist will obtain supplies of, and store securely, appropriate, personally identifiable prescription pads

• Agreement on how the pharmacist's clinical activity will be effectively communicated and recorded in the patients' health record. This agreement must include provision of timely access, whenever necessary, to appropriate patient information

• Confirmation of the methods to be used to monitor the pharmacist's supplementary prescribing practice (eg, Prescription Pricing Authority data, PRIMIS information), as with independent prescribers

• Consideration of the pharmacist's CPD requirements and how they will be delivered and funded

A complex but achievable opportunity

The path to pharmacist prescribing is not going to be simple. However, with careful forethought and planning each of the issues and decisions outlined above should be deliverable. This assumes that the profession gets together (in a corporate way) with relevant education providers and NHS organisations, as soon as possible, to develop a process to deliver necessary supplementary prescribing services locally.

PCTs have already started to consider where and how they might use the opportunity offered by supplementary prescribing to improve the effectiveness and efficiency of health care delivery for their patients and population.

National baseline survey

To help identify such early NHS thinking on new prescribing routes, the National Prescribing Centre (NPC) carried out a preliminary baseline survey, during September and October 2002, of all PCTs in England. Set out below are some of the key findings from this survey.

Every PCT in England (n=302) received a questionnaire during September. By the closing date, 197 completed forms had been returned (a 65 per cent PCT response rate).

Question 11 in the survey asked: "Can you provide a preliminary 'guesstimate' of how many pharmacists and nurses in your PCT locality might be put forward for initial training on supplementary prescribing in the first 18 months of the initiative?"

The responses can be seen in Panel 1. In aggregate, the 140 PCTs expecting the inclusion of pharmacists in their early plans for initial training reported that up to 770 pharmacist places would be required in the first 18 months. Additionally, the 153 PCTs expecting the inclusion of nurses in their early plans reported that up to 2,407 nurse training places would be required over the same period. This implies that PCTs, at this stage in consideration, believe the ratio of nurses to pharmacists, moving into supplementary prescribing, will be approximately 3:1.

It is interesting to note that the most common numbers of pharmacists reported, per PCT for initial training, were two, three, four, five and 10. These five most common numbers together accounted for 482 (62.6 per cent) out of the total of 770 pharmacist places.

Pharmacists Question 10 in the survey asked: "What types of pharmacist do you consider might be most effectively utilised to deliver supplementary prescribing-based services?"

The responses from the 191 PCTs responding positively to this question, can be seen in Panel 2. Some PCTs reported that they would be considering several types of pharmacist for training. Also some PCTs were considering introducing pharmacist prescribers, but not in the first 18 months.

Nurses Question 9 in the survey asked: "What types of nurses do you consider might be most effectively utilised to deliver supplementary prescribing-based services?"

The responses from the 183 PCTs responding positively to this question, can be seen in Panel 3. Some PCTs reported that they would be considering several types of nurse for training. Also some PCTs were considering introducing nurse prescribers, but not in the first 18 months.

What do these findings suggest?

These findings suggest that much has yet to be done to ensure that pharmacists are able to take up, in a timely way, the opportunities now offered by the introduction of supplementary prescribing into the NHS.

Not least among the rate limiting steps to achieving this will be the development and delivery of suitable initial training programmes for potential pharmacist prescribers accredited by the Royal Pharmaceutical Society.

These courses will need to be located conveniently for pharmacists who might be put forward for training, and have sufficient capacity to handle the expected level of uptake, especially in the first couple of years. PCTs, working together with their local Workforce Development Confederations, will need to be proactive in the early months of 2003 to help ensure suitable capacity is forthcoming.

It is encouraging to see that many PCTs have already given preliminary consideration to including supplementary prescribing-based activities into their service delivery plans. Equally encouraging is the significant proportion of PCTs that expect pharmacists, from a range of backgrounds, to play an important and early part in such services.

It is probably not surprising that PCTs expect more nurses than pharmacists to become supplementary prescribers (at least during the first couple of years), since there is already some experience of, and an infrastructure in place for, nurses who can prescribe. In addition, there are many more nurses working with the NHS than there are pharmacists.

However, the profession cannot, and must not, become complacent about the inevitability of pharmacists being recruited by the NHS to prescribe, purely because of a belief that we have the best blend of skills and expertise to do so.

In the reforming NHS, who ultimately prescribes will be a decision taken locally based on pragmatic assessments of service need and quality, patient convenience, available professional resources and cost effectiveness.

It is now up to pharmacy to make the case effectively!