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Flexibility to prescribe from the whole BNF will be extended to pharmacists
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From next spring, suitably trained pharmacists will be able to prescribe
any licensed medicine for any medical condition, with the exception of
Controlled Drugs, the Department of Health announced last week.
Prescribing for any condition from a full formulary is the most radical
of the proposals on which the Government
consulted earlier this year
(PJ, 5 March, p257). News of the announcement has been welcomed widely
by the pharmacy profession. However, leading members of the medical profession
have not been so positive. Hamish Meldrum, chairman of the British Medical
Association’s GP Committee, last week commented: “While we
support the ability of suitably trained nurses and pharmacists to prescribe
from a limited range of medicines for specific conditions, we believe
only doctors have the necessary diagnostic and prescribing training that
justifies access to the full range of medicines for all conditions. This
announcement raises patient safety issues and we are extremely concerned
that the training provided is not remotely equivalent to the five or
six years’ training every doctor has undertaken.” Paul Miller,
chairman of the BMA’s consultants’ committee, was less measured
in his response, saying: “This is an irresponsible and dangerous
move. Patients will suffer.”
The BMA’s concerns seem to lie with non-medical prescribers’ ability
to diagnose. But is that how independent prescribing by pharmacists will
work in practice?
What is an “independent prescriber”?
David Pruce, director of practice and quality improvement at the Royal
Pharmaceutical Society, points out that the term “independent
prescriber” was redefined in the Government’s consultation
on proposals to introduce independent prescribing by pharmacists. “We
were pleased to see the change of definition of independent prescribing
that was in the consultation. It made it clear that independent prescribing
doesn’t necessarily mean that you make the diagnosis.” The
new definition is: “A practitioner (eg, doctor, nurse, pharmacist)
responsible for the assessment of patients with undiagnosed or diagnosed
conditions and for decisions about the clinical management required,
including
prescribing.”
Mr Pruce says that he imagines that most pharmacists will prescribe following
a diagnosis by a doctor, although there are those who already use their
diagnostic skills. “In the same way that GPs know their limits
and refer more complex cases on to secondary care, I would expect pharmacists
to do the same,” he adds.
Gul Root, principal pharmaceutical officer at the Department of Health,
explains: “It is likely that, in the main, pharmacist prescribing
will follow a primary diagnosis by a doctor. However, pharmacists who
diagnose minor ailments could, of course, prescribe independently without
a diagnosis being made by a doctor. There may be situations when a pharmacist
could be trained to make a diagnosis and prescribe independently.” She
predicts that as time progresses and more pharmacists become experienced
the situation may change.
Mrs Root expects that, in the first instance, independent prescribing
will be carried out by pharmacists who have been proactively influencing
prescribing decisions within multidisciplinary teams in specialised areas. “These
pharmacists will, under normal circumstances, have contemporaneous access
to the relevant patient record. Community pharmacists who have undertaken
the prescribing course, and who have access to the patient record as
well as access to a prescribing budget, should be able to prescribe independently,” she
says.
She explains that it will be up to workforce development directorates,
in conjunction with primary care organisations, to determine locally
the most appropriate pharmacists who will undertake training based on
local NHS need and the clinical skills of the pharmacist.
Helen Williams, pharmacy team leader, cardiac services, at King’s
College Hospital, London, is a supplementary prescriber in a heart failure
clinic. “I wouldn’t want to diagnose heart failure for these
patients but once the diagnosis has been made I am quite happy to manage
that and a number of other co-morbidities that have been prespecified,” she
comments. “Within our clinic, I think that our independent prescriber
will be happy that we are able to have more autonomy to determine treatment,” she
adds.
She believes that part of the strength of having nurses and pharmacists
working together with doctors in the heart failure clinic is that each
professional deals with aspects of patients’ management that is
within their own area of expertise.
She adds that the experiences of supplementary prescribing have served
to improve teamwork. “There is no reason to think that extending
prescribing powers is going to fragment it any more. It will just mean
that each individual will be able to work to their own strengths.”
Campbell Shimmins, a community pharmacist and supplementary prescriber
in Doune, Perthshire, agrees. “What we can’t do is diagnose,
and no one is suggesting that we do that,” he argues. He believes
that it makes good sense for pharmacists to work in partnership with
GPs. “Pharmacists are naturally pedantic and I can’t see
us going off prescribing willy-nilly. We are far more likely to prescribe
by numbers and follow a formulary than a doctor, I suspect.”
Mahesh Sodha, a community pharmacist and supplementary prescriber in
Chelmsford, Essex, recognises that diagnostic skills are an area of weakness
for pharmacists, but says that in a multidisciplinary team, these skills
are not always necessary. A lack of diagnostic skills is compensated
for by pharmacists’ strengths in therapeutics, he says. “It
is great news indeed that at last pharmacists are recognised as clinicians
and given the responsibility to treat and manage patients holistically,” he
says.
“
However, I strongly believe that this should not be simply seen as a
right to prescribe but seen as an authority which is accompanied by the
responsibility to ensure that pharmacists only prescribe within their
competency,” he says. He adds that the key to success will be good
partnerships with GPs. “My own success is entirely due to good
working relationships with GPs, where there is mutual respect for each
other’s skills. These need to be developed nationally for independent
prescribing,” he argues. Training
The Society will be responsible for developing the curriculum and the
accreditation criteria for the education and training programmes that
will be developed by higher education institutions. “The Society
is working closely with the DoH looking at how best to serve the training
needs of pharmacists wishing to prescribe independently. In particular,
conversion courses will need to be developed for those supplementary
prescribers wishing to extend their prescribing powers,” said
Mr Pruce. Details of the training are still to be finalised. Mr Pruce
added that the undergraduate curriculum is about to be reviewed and
he imagines that this will take into account the extension to pharmacists’ prescribing
powers.
Once qualified, independent prescribers will be regulated by the Society
in the same way as supplementary prescribers. They will be expected to
submit records of continuing professional development that include activities
around prescribing, says Mr Pruce. Independent prescribers will then
have the right to prescribe throughout the UK although the NHS will not
necessarily permit them to do so. “People will be able to move
around the country with their qualification, but they will have to meet
a health need and be commissioned by the local primary care organisation,” he
explains. Flexibility
Ms Williams sets out some reasons why it is important that pharmacists
are able to prescribe from a full formulary. She explains that, since
pharmacists are involved in caring for patients with a range of medical
conditions, it would have been difficult to specify a formulary that
allowed pharmacists to practise freely and which also suited the best
needs of patients. “For example, a limited formulary that is
suitable for community pharmacists would look incredibly different
to a limited formulary that is suitable for use by specialist hospital
pharmacists,” she argues.
Ms Williams says that, having worked as a supplementary prescriber
for a year, while the process allows some degree of flexibility, it
soon
became apparent that most patients do not have a single disease or condition
that needs managing. “These co-morbidities impinge on the primary
condition that you are treating.” If we can manage all the patients’ medicines
it will stop them from having to bounce between different specialties,
she says.
She welcomes the fact that pharmacists will no longer be constrained
by clinical management plans (CMPs). Independent prescribing will allow
pharmacists more freedom in terms of flexibility around drug choice and
frequency to tailor drug therapy to the patient, she explains. “We
have 150 CMPs. If, tomorrow, something new happens in cardiology, either
we review 150 CMPs, or those patients need to go back to the independent
prescriber because it is not part of our practice,” she says. Independent
prescribing will allow her to evaluate any new data and apply it to her
practice. Minor ailment
Mr Shimmins predicts that minor ailments will be one of the first areas
in which community pharmacists will be exercising their independent
prescribing powers. He says that another obvious area, particularly
in Scotland, is the chronic medication service. “If, as a pharmacist,
you can make changes legally and conveniently for the patient, then
that is good for all concerned. It frees up time at the GP practice
and it is convenient and accessible for patients.” He points
out that access to patient records is fundamental to patient prescribing
and it is important that the communication links and IT are in place.
He believes that improvements in IT will also help to forge closer
links between health care professionals.
As a core part of the new contract in Scotland (see p637),
pharmacists will be providing direct access to repeat prescriptions
via a chronic
medication service. “In the past six years we have had model schemes
in place, which are like little chunks of chronic medication services.
Patients love it and it has been fairly successful and shown to have
benefits in a number of different areas of patient care,” says
Mr Shimmins. However, the difficulty for pharmacists has been getting
some of the changes actioned, he says. Independent prescribing will address
this.
More flexibility in dealing with minor ailments is something that Mr
Sodha also welcomes. “In my own practice as a supplementary prescriber,
I have flexibility to prescribe any drug from the BNF chapters relevant
to my area but I do not have the flexibility to prescribe for many minor
ailments.” However, he highlights that financial issues may be
a potential barrier to developments in this area. “I cannot see
the Government letting the prescribing bill rise exponentially by allowing
us to prescribe for minor ailments when patients would have otherwise
bought medicines over the counter.”
Mrs Root predicts that, over time, independent prescribing may replace
pharmacist-led minor ailment schemes. However, she says that in the short
term it is unlikely to do so since pharmacists who wish to become independent
prescribers will need to undertake further training similar to that for
supplementary prescribing. “PCOs will need to determine locally
whether they wish to continue with the current pharmacist-led minor ailment
schemes, where most of the ‘prescribing’ or supply is for
general sale list and pharmacy-only medicines, or whether they wish to
include more medicines including POMs, or whether only independent prescribers
can get involved in minor ailment schemes,” she says. She believes
that access to patient records will be one of the factors that will determine
whether, and how fast, PCOs move from minor ailment schemes to independent
prescribing programmes. Timescale
When supplementary prescribing was first announced in November 2002,
the Government hoped that there would be up to 1,000 pharmacists trained
and prescribing by the end of 2004. However, to date only 700 pharmacists
have qualified. Mr Sodha believes that one reason for this is that there
is no funding to provide protected time for pharmacists to undertake
training. “It will be interesting to see where the extra funding
for this comes from,” he says.
Mrs Root says that the DoH expects the Society to develop a curriculum
for independent prescribing by pharmacists while work on changing regulations
is being taken forward. Progress would then depend on how quickly higher
education institutes can develop a training programme and be accredited
by the Society. “We would expect to see the first pharmacist [independent]
prescribers working in 2007,” she says.
Once pharmacists are trained, Mr Pruce expects that independent prescribing
should be quicker to get off the ground than supplementary prescribing. “I
suspect that independent prescribing will be up and running more quickly
because it will be less bureaucratic than supplementary prescribing,
which requires the design of a clinical management plan.” He adds
that speed of uptake may also be influenced by the wider applications
of independent prescribing. “Hospital admission and discharge,
total parenteral nutrition, minor ailments and medicines use reviews
will all be much easier to carry out as independent prescribers.” Funding
Although funding for independent prescribing has not yet been agreed,
Alastair Buxton, head of NHS services at the Pharmaceutical Services
Negotiating Committee, expects that in England it will be funded locally
as an enhanced service, in the same way as supplementary prescribing.
Mrs Root confirms that PCTs will determine funding arrangements for
prescribing by community pharmacists. “Guidance will be issued to strategic
health authorities, which will identify funding support for non-medical
prescribing training for 2006–07,” she adds. Delivering the goods
Ms Williams is clear about what pharmacists need to do to make a success
of their new prescribing rights. “It will be down to pharmacists
and nurses with these new powers to demonstrate that they can do it
safely, that they recognise their limitations, and that they know when
to manage a patient independently and when to refer for additional
support.”
Mr Shimmins says: “I still believe that the GP should have absolute
control over a patient’s health but I do believe that pharmacists
have a valuable, and currently undervalued, role to play in that. We
meet a lot of political imperatives — certainly we have set ourselves
up to do that — so we had better deliver.” |
The
Pharmaceutical Journal