The Pharmaceutical Journal
Vol 270 No 7245 p544
19 April 2003

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Is pharmacist prescribing our golden future — or is it a blind alley?

By Stephen Axon

Unless a more generic accreditation system is adopted, allowing the health professionals involved more flexibility, pharmacist prescribing as an effective "new role" is in danger of being stillborn.

Community pharmacists see pharmacist prescribing as a fundamental part of their long-term future as for many years they have safely and competently prescribed medicines in response to symptoms. Recently, however, there has been a clear swing away from independent prescribing in the community pharmacy towards the secondary (now supplementary) prescribing role for the hospital and practice-based pharmacist culminating in the recently published guide for implementation ("Supplementary prescribing by nurses and pharmacists within the NHS in England"). Is this really the best approach?

At the British Pharmaceutical Conference in 2002 the Royal Pharmaceutical Society's prescribing group chairman, Dr June Crown, pointed out that pharmacists already act as independent prescribers as part of the everyday service in the community pharmacy (PJ, 28 September 2002, p450). This counter-prescribing is initiated in the pharmacy by the pharmacist and performed effectively without any need for additional training. It was this prescribing role that the profession initially pressed for inclusion within the NHS and, but for the Government's change of mind and Minister, seemed to be on its way until it was quietly dropped from the prescribing agenda in favour of the supplementary role. In view of the excellent track record of pharmacists in this useful, cost-effective and patient-oriented service, and not forgetting the increasing deregulation of more potent medicines, why is the Government no longer pursuing the natural development of the pharmacist's counter-prescribing as a primary NHS function? Why is it focusing instead upon prescribing as a supplementary role for a small number of illnesses to be performed by limited number of pharmacists where, in the words of the chief pharmacist for England, there is a "local need"?

Training

The training requirements set out at the Government's website and in an annex to the guidelines make it clear that that supplementary prescribing pharmacist will be permitted to prescribe only within the bounds of a clinical management plan agreed by the doctor, pharmacist and patient. The pharmacist will be required to be trained generically in prescribing and specifically for the prescribing role identified at the start of training. If the pharmacist subsequently takes on supplementary prescribing for additional conditions, this would need to be by agreement with the medical practitioner and probably the trust. Responsibility for the associated continuing professional development would rest with the pharmacist and is likely to be monitored by the Royal Pharmaceutical Society and involve documentation related to each management plan. This is the same Society that has difficulty with annual membership cards and the concept of practising certificates. One might cynically ask where the pharmaceutical gurus will be found to carry out the monitoring process. Will they be "inactive" pharmacists, and, indeed, who will monitor the monitors?

Little reward

Supplementary prescribing, requiring a great deal of training and ongoing revalidation for (probably) little reward and limited patient benefit, should be contrasted with a generic prescribing role within the NHS that would not require additional training, would both relieve pressure on GP surgeries and provide a convenient service to the public. The Government's proposals are certainly a far cry from the increased opportunities for independent prescribing by pharmacists heralded at last year's BPC.

Given the restrictions on supplementary prescribing, the potential for financial return for the pharmacist will be limited when viewed in the light of time that will need to be spent by pharmacists in training and CPD updating. From the contractor's standpoint, pharmacist training and cover while training is undertaken will be costly. In all probability, therefore, those who take part in supplementary prescribing will not be drawn from the community sector, where the majority of the profession is employed and where we are constantly being told that the pharmacist's expertise is underused.

The pharmacy approach contrasts markedly with that adopted by nurses. Here, as a first stage, duly qualified nurses were permitted to prescribe from a limited formulary. The second stage was to extend the formulary to include all pharmacy and GSL medicines together with 140 specified POMs for treating minor illness, minor injury, health promotion and palliative care. The only proviso was that nurses prescribe within the professional constraint of what they consider to be their areas of expertise. Now, as a third stage following a training period of a similar length to that for pharmacists, they may, in addition, act as supplementary prescribers in surgeries. All things considered, it seems therefore that a four-year university degree course and preregistration training counts for little if pharmacists are not to be trusted to have assimilated sufficient expertise to recognise the limits of their own professional competency in generic fields where the profession has always counter-prescribed. The biggest nonsense of this lies in that fact that the restriction applies only in the NHS setting as pharmacists are free to prescribe — and when it suits Government are encouraged to do so — provided, of course, that the Treasury does not have to pick up the bill.

This is all a far cry from pharmacist prescribing as first envisaged in 2000, where lists of common illnesses and of appropriate medicines were drawn up by the previous Secretary of State for Health in consultation with, among others, the (then) president of the Society and chairmen of the National Pharmaceutical Association and the Pharmaceutical Services Negotiating Committee as the basis for pharmacist prescribing.

As far as community pharmacy is concerned, it is likely to be confined to a small number of pharmacists with time and inclination to study a relatively small number of specific conditions to a level of competence to enable them to duplicate the work already being done by others. Sadly this would mean that pharmacist prescribing remains at GP surgeries with no real benefit to patients. Even if the prescribing is in the community pharmacy, the system, based upon personal accreditation, means that in the accredited pharmacist's absence there could be no supplementary prescribing. Any additional prescribing pharmacist, such as a locum, would need to be trained for the role in the same way, recognised locally and listed on the clinical management plan. Of course an appointment system where pharmacy prescribing would be fitted in around the availability of the accredited prescribing pharmacist could be arranged but that would be of no benefit to the patient.

Different perceptions

Perhaps the problem boils down to the different perceptions of the prescribing role of the pharmacist. On the one hand there are those who see it as an extension of the counter-prescribing role to enable the pharmacist to shoulder some of the burden of the GP where symptomatic treatment of illness is called for. On the other, there are those who consider the pharmacist's prescribing role should be steered more in the therapeutic direction, where the role would be supportive and supplementary.

However, there is no reason why, as in the case of the nurses, both approaches could be pursued leaving both the patient and the profession winners and the Government to realise its often stated intention to make more effective use of the skills of pharmacists in all the sectors of practice.

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