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New prescribing rights to come in 2005
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Independent prescribing is undoubtedly going to be one of the hot topics
for the profession in 2005. Less than a year after the first
pharmacist wrote a prescription as
a supplementary prescriber (PJ, 27 March 2004, p369), a consultation
on independent prescribing by pharmacists is about to be published.
Providing there are no unforeseen hurdles, independent prescribing will
be introduced later this year. According to a Department
of Health spokesman: “Subject to ministerial agreement and Parliamentary
approval, we expect the necessary statutory and regulatory changes to
be completed in 2005.”
But before then, a number of issues need to be considered. The first
step has already taken place: a scoping exercise in which the Government
privately consulted with key members of the profession. Next is the public
consultation. The DoH could not give a publication date, but it is thought
it might be as early as next week.
It is hard to predict what issues the consultation will consider. However,
by talking
to people who participated in the scoping
exercise, as well as some opinion leaders in the profession, a clear
picture emerges of how
independent prescribing might develop.
Two central themes have come up time and time again: the need for a clear
definition of “independent prescribing” and whether or not
pharmacists should be restricted to
prescribing within a formulary.
The benefits of extending independent prescribing to pharmacists are
far-reaching.
“Independent prescribing will allow pharmacists to achieve what
many have said is their true role — being the experts in medicine — and
have this role recognised by the health care service and public alike,” says
Nigel Simmons, non-medical prescribing lead, Cambridgeshire. He says
it is up to individual pharmacists to seize the opportunity. “All
pharmacists should review their work practices and consider where they
will be able to develop prescribing roles. The days of pick and stick
must become a thing of the past if pharmacists are to show themselves
as more than technicians or dispensing
assistants,” he comments.
David Pruce, director of practice and quality improvement at the Royal
Pharmaceutical Society, explains that independent prescribing is a tool
to enhance the services that pharmacists already provide. “For
example, pharmacists are already involved in admission clinics but need
a doctor to co-sign what they decide [to prescribe]. Similarly in chronic
disease areas, it would be a better use of pharmacists’ skills
if they could prescribe as well as advise. The result for patients would
be a smoother service with fewer delays and the most appropriate professional
making decisions.”
David Webb, director of clinical pharmacy, London, Eastern and South
East specialist pharmacy services, says: “The topline benefit is
improving the care given to patients. Independent prescribing by pharmacists
will lead to better access to medicines and a potential improvement in
safety of prescribing.” More controversially, he points out that
it will lead to the legalisation of current practices that are outwith
the Medicines Act.
The introduction of independent prescribing by pharmacists will undoubtedly
increase patient choice, something that is high on the political agenda. “Patients
choose to access services in different ways and pharmacist prescribing
will add another alternative,” explains Ash Soni, National Pharmaceutical
Association chairman. “So patients can choose who is best-placed
to treat them at a particular time. Sometimes it will be a pharmacist,
sometimes a nurse, sometimes a GP and sometimes another health professional
like a dentist.” A document
published by the NPA last month (PJ,
11 December 2004, p840) describes many of the benefits that independent
prescribing by pharmacists could bring. Alongside increased patient choice,
it highlights faster access to medicines, equity of
access, reduced pressure on GPs, an ability to supply P and GSL medicines
more widely
(ie, according to their POM licence), and
increased job satisfaction for pharmacists.
Independent prescribing model
What seems to be needed is a clear definition of “independent prescribing”.
Alison Strath, principal pharmaceutical officer at the Scottish Executive,
suggests that pharmacy needs a hybrid model of independent and supplementary
prescribing. “One of the questions pharmacists will face in discussions
over independent prescribing is ‘are you a diagnostician?’,” she
says. “And while pharmacists can diagnose minor conditions, this
is not necessarily the case in more complex areas of
disease. So although independent prescribing for minor conditions could
include diagnosis, I think that for complex conditions a diagnosis should
be obtained from a medical practitioner first. The pharmacist would then
be free to pick the most appropriate treatment.”
In other words, it comes down to maximising the skills of each profession.
Ms Strath points out: “Medics’ skills are in diagnosis. Pharmacists
should come in after diagnosis and use their skills to fit the treatment
to the individual patient.”
Mr Webb agrees: “What would really help is a less tightly controlled
form of supplementary prescribing. So pharmacists work with medical colleagues
who make the diagnosis but they have more freedom because a clinical
management plan is not required.”
This view is echoed by Mr Pruce. He
suggests that a different term to “independent prescribing” is
needed. “The classical definition of independent prescribing includes
making a diagnosis but the diagnosis may
already have been made before the pharmacist independently prescribes.” Formulary or not?
Pharmacy practice differs between sectors so it is likely that independent
prescribing will develop in a number of ways.
“What suits one practice setting may not meet the needs of another,” Mr
Webb explains. “For example, whereas a formulary approach might
be useful in community pharmacy
because of the parallels with nurse prescribing, this would not necessarily
translate well into an acute care setting or for pharmacists working
with GPs.”
Others disagree. “All pharmacists need to have access to the whole
BNF and then they should work within their competencies,” Ms Strath
says. “Restrictions would reduce the impact pharmacists could have
on improving care.” Mr Simmons agrees that a fixed formulary would
be too restrictive. “Once a formulary is established, it is a lengthy
process to make changes. The best option is for an almost unlimited formulary,
but with a requirement that prescribing only occurs within a framework
of expertise and experience,” he says.
Perhaps lessons should be learnt from nurses who already have independent
prescribing rights but who can only prescribe from a formulary. “Nurses
are seeking to achieve prescribing powers for the full BNF,” says
Mr Simmons. “If pharmacists accept a limited formulary, they will
continue to be the ‘poor relation’ and only partial members
of the patient care team.”
Mr Pruce suggests a balance. “We need to tailor what a pharmacist
can prescribe to the service. So for areas such as discharge clinics
or medication reviews, it would be difficult to see how the pharmacist
could function properly with a restricted formulary. But in others, such
as a minor ailments service, then a restricted formulary would work well.”
However, Mr Soni says: “The prescribing role should depend on the
competency of the individual pharmacist and nothing else. We must be
careful not to have separate formularies for community pharmacy, hospital
pharmacy and primary care pharmacy because pharmacists move between sectors.” He
adds that separate formularies could create problems for cross-sector
working, something that is becoming increasingly common. Using independent prescribing
How might independent prescribing be used? In hospitals, Mr Simmons
suggests that pharmacists could become responsible for discharge and
admission
prescribing. Mr Webb suggests additional roles in prescribing drugs
with narrow therapeutic indices and therapeutic substitution. He highlights
subtractive prescribing (ie, crossing off items that are not appropriate
or no longer needed) as an example of something that some pharmacists
already do but, it could be argued, that by altering therapy in this
way the pharmacist is acting as a prescriber. Independent prescribing
rights would solve this problem.
In the community, independent prescribing would allow the pharmacist
to become the first port of call for patients with acute illness, says
Mr Simmons. “Prescribing would build on the existing advisory role
for over-the-counter medicines but provide a much greater and more effective
range of choices.”
Turning to the new pharmacy contract, Mr Pruce suggests that independent
prescribing will be used within enhanced services. “One of the
biggest barriers to implementing the outcomes of full medication reviews
carried out by pharmacists is getting changes made on the GP computer
systems. So we might see pharmacists doing reviews and then making changes
to patients’ prescriptions.”
Other areas in which independent
prescribing could be used are out-of-hours services and residential and
nursing homes.
One issue that is certain to come up during the consultation is whether
or not dispensing and prescribing need to be separated. And someone is
likely to point out that dispensing doctors are responsible for both
prescribing and dispensing so why place additional restrictions on pharmacists?
However, few could
disagree that, regardless of anything else, separating the functions
is of clinical value.
Mr Simmons highlights skill mix as a
solution. “With the moves towards registered technicians and the
review of working practice from the skill mix consultation, it should
be possible to create a safe working environment where prescribing and
dispensing can take place in the same premises with a clear division
of responsibilities as a governance and safety check,” he says.
Mr Soni comments that when a community pharmacist is prescribing in a
consultation, it is most likely that a second pharmacist will be working
in the dispensary. Therefore, it is unlikely that a pharmacist would
prescribe and dispense.
In terms of financial incentives, Mr Soni suggests: “The solution
is to give the patient a prescription and tell them they can take it
to any pharmacy they choose.”
In Scotland, such incentives may be removed through the proposed new
pharmacy contract. The contract (which is still subject to contractors’ approval)
looks set to move away from payment by prescription volume to capitation
fees for two of the four core services.“Pharmacist prescribing,
both supplementary and independent, will, in future, provide significant
support for the new chronic medication service (CMS) which is due to
be funded through capitation,” explains Frank Owens, Scottish Pharmaceutical
General Council chairman. “If contractors are to be given prescribing
rights, and if we are
to maximise the opportunities presented by these new rights, then we
need to remove any perverse incentives to prescribe. Moving away from
volume-based payments means that
remuneration will not depend on the number of prescriptions a pharmacist
writes. Instead, CMS fees will be based on the size of the
patient population that pharmacy serves.”
Will new rights be the end of supplementary prescribing?
Few would disagree that supplementary prescribing has been essential
in the road to introducing independent prescribing. Pharmacists
had to demonstrate the contribution they could make by becoming
prescribers. But the introduction of independent prescribing
is certainly not the death knell for supplementary prescribing.
Without
doubt, supplementary prescribing has and is delivering improved
patient care.
Supplementary prescribing enables pharmacists to manage long-term
conditions within a clinical management plan. While some would
say that the management plan is constraining, others argue that
this
is exactly what is needed to allow pharmacists to extend their
practice in a way that they feel comfortable, and in a way in
which doctors
are confident.
David Webb, director of clinical pharmacy, London, Eastern and
South East specialist pharmacy services, suggests that there is
a role
for both in the future. “Independent prescribing could be used
for complete episodes of acute care but supplementary prescribing,
used within a clinical management plan, is an important tool for
longer-term care. It has an obvious place in the management of chronic
conditions,” he explains. But he adds that the ongoing clinical
management plan does not fit well with things like discharge prescribing
and this is why there is a need for independent prescribing, too.
For the time being, pharmacists should continue to develop supplementary
prescribing roles. At the same time, they can look forward to the
end of 2005 when independent prescribing may become a reality. |
Plenty of other issues
exist. One is whether or not pharmacists should be able to prescribe
antibiotics. Ms Strath believes that they should: “Pharmacists
are thoughtful around antibiotic use, and are often at the fore of taking
forward antibiotic prescribing policies,” she says. Citing the
example of a patient with an infected bite from a pet seeking a pharmacist’s
advice on a Saturday afternoon, she comments that preventing pharmacists
from prescribing antibiotics in these situations and, instead, having
to refer patients to accident and emergency does not make sense.
For prescribing in chronic disease to be successful, pharmacists need
to have good, long-term relationships with patients. They need to see
patients on a regular basis, giving them the opportunity to monitor and
adjust medicines as appropriate. Many patients
return to the same pharmacy time and time again, so perhaps now the time
has come to consider introducing compulsory patient registration at community
pharmacies. Mr Pruce says that the need for registration will depend
on the specific service offered.
Then there is implementation. Beth Taylor, specialist principal pharmacist,
London and South East regions, believes that implementation will be the
biggest issue for community pharmacist prescribers. She points out that
there is so much happening in primary care at the moment that primary
care trusts are overloaded. In addition, she says: “There is an
expectation that PCTs will fund chronic disease management services
offered by pharmacists. But because chronic disease management is part
of the essential service in the new GP contract, any activity that pharmacy
can provide to support it could be funded through practice monies.”
Funding of independent prescribing services will certainly be an issue.
Not only funding of the pharmacist’s role, but also the costs of
prescribed drugs. There is also the possibility of private practice:
preventing pharmacists from prescribing privately might hinder travel
health services since most antimalarials are privately rather than NHS-prescribed.
And then there are workforce and training issues. Not all pharmacists
will want to train as prescribers. This means that although one pharmacy
might offer prescribing services, another down the road might not. This
could confuse patients. Furthermore, if a prescribing pharmacist is on
holiday, what happens to the service if the locum cannot prescribe?
There are many issues to consider. The consultation document and the
debate that will follow should open a new chapter in pharmacist prescribing. |
The
Pharmaceutical Journal