The Pharmaceutical Journal
Vol 270 No 7230 p27
4 January 2003

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Pharmacist prescribing summary

Is the Government committed to pharmacist prescribing in N Ireland?

Terry Maguire, FPSNI, a community pharmacist in Belfast, discusses the diverse issues affecting the implementation of pharmacist prescribing in Northern Ireland

Pharmacists in Northern Ireland, in common with colleagues in the rest of the United Kingdom, have welcomed the proposals for the introduction of pharmacist prescribing. The Pharmaceutical Society of Northern Ireland in its strategy, "Vision 2020" (1997), identified both independent and supplementary prescribing as key objectives for modernisation of the profession and, therefore, not surprisingly, was strongly in favour of the content of MLX 284 which outlined the Government's ideas on the introduction of supplementary prescribing for pharmacists. Two of the three key objectives of Vision 2020 referred specifically to prescribing by pharmacists:

• Objective 2 — "prescribing and supply of GSL and P medicines and certain POMs within protocols for registered patients"

• Objective 3 — "medication management and outcomes monitoring including the ability to alter doses and change medicines within agreed protocols"

Prescribing rights for pharmacists, for both independent prescribing (objective 1) and supplementary prescribing (objective 2) is clearly attractive to the PSNI, since pharmacy prescribing as envisaged in the Crown review would clearly realise most of "Vision 2020".

Legislative change will allow this to happen. Normally such change needs the approval of the health minister at Stormont and it will be interesting to see if wider political problems here will impact on the introduction of pharmacy prescribing. In spite of PSNI's enthusiasm, pharmacy prescribing, at this time, seems to be a secondary care issue only.

Lack of local government

With the suspension of the N Ireland Assembly and the standing down of the locally elected health Minister, there could be a hold on plans for change. Under direct rule from Westminister, ministerial responsibility for health falls to a Labour minister at the N Ireland Office, currently Des Brown. There is a real fear among health care professionals generally that the modernisation agenda agreed and supported by the Assembly will now slow down, if not halt altogether, causing N Ireland to fall further behind the other UK regions. It might surprise colleagues in Britain to know that fundholding here has only recently been done away with.

Primary care organisations and local health and social care groups (LHSCGs) have only been put in place in the past few months. However, they do not have the support of general practitioners and as a result are not really having any impact in the delivery of primary care services. GPs have reservations about their long-term effectiveness. Until GPs can be assured on this, they will not be participating and the LHSCGs will have no real power. This is important since these are the organisations that are likely to commission pharmacy services that will involve community pharmacy prescribing.

So modernisation of health care in N Ireland might be slowed and with it pharmacy prescribing. However, Des Brown seems to be refusing to let this happen.

A strategy for pharmacy

A "Pharmacy strategy" is currently being drafted and will be sent out for consultation in early 2003. This document will identify the priorities for, and perhaps timescale of, pharmacist prescribing. Supplementary prescribing is included and will be initially targeted at secondary care. Hospital pharmacists, particularly those with specialist remits — in cardiology and cancer, for example — will be trained and will set and evaluate patient care plans and in this context prescribe. It is likely the timescale for this will be common with the rest of the UK.

Independent prescribing is not a large issue in hospital pharmacy practice. Community pharmacy would appear to be ideally positioned to take on independent prescribing. This should be in the N Ireland Pharmacy Plan but seems to have less priority than other developments. There is a feeling that DHSSPS is perhaps less eager to see community pharmacists prescribing independently. Perhaps it fears this might lead to additional costs. But increased costs have not been demonstrated in pilots on pharmacy supply in Greater Glasgow and in Croydon. At least one "pharmacist supply" pilot is running locally and involves pharmacists assessing patients with coughs and colds and, where appropriate, prescribing (supplying) remedies from a limited formulary.

Does the Government want community pharmacist prescribing?

So this is the context for pharmacy prescribing in N Ireland currently. There is no doubting the commitment of hospital and community pharmacists generally to their potential role in prescribing either by direct supply or by supplementary prescribing.

Being personally one of the strongest supporters of prescribing for community pharmacy I have recently become more aware of the wider issues affecting its implementation. Discussions on the topic with colleagues and officials from government has brought me to a somewhat cautious, if not slightly cynical, view of developments. Sadly, I have been forced to consider that perhaps Government never intended supplementary prescribing for community pharmacists and may have no intention of going in this direction in the long-term. Why might this be?

Crown reassessed

I had the honour of working on one of the subgroups of the Crown review. Politics were a key aspect of the way that the process moved forward. Those from the professional groupings that worked on the subgroups did an excellent job dealing with the many responses. However, I have always had a feeling that we ended up where we were supposed to end up and an invisible hand was leading us.

I had cause to reflect on this again recently. I was struck by a comment from a well-known hospital pharmacist who stated that "supplementary prescribing will make my warfarin clinics legal". Is this the rub? Is this what it has been all about?

Let us not forget this was the core reason for Crown. Unison, the union representing a sizable chunk of the nursing profession, was concerned that custom and practice in hospitals exposed their members daily to the possibility of legal action. Nur-ses were making prescribing decisions, technically illegal for them. Crown was about solving this problem and it has done this admirably.

Sadly, those of us community pharmacists who believed that, by default, we would also benefit, might have been led slightly astray. Notwithstanding the seismic changes that are happening there still remain many barriers to community pharmacy prescribing. We need to work diligently to identify and resolve these barriers.

First and foremost there is the probity issue. How can the prescriber also be the dispenser? Concerns about dispensing doctors come to mind and systems to control them might provide answers. Perhaps the skills-mix debate will also help.

Pharmacist prescribing, which represents the next vital step for our profession, is close. It cannot be lost and we must ensure that it is delivered. The goal is not yet achieved.