The Pharmaceutical Journal
Vol 276 No 7387 p165
11 February 2006

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Moving into independent prescribing is a risk worth taking for pharmacists

By Tony Schofield

I read Roger Cotton’s article “Could independent pharmacist prescribing be a risk to our reputation?” (PJ, 14 January, p38) with interest. The answer to his question is, of course, a resounding “yes”.

Independent pharmacist prescribing is a risk; however, I believe it a risk well worth taking.

Any development carries with it a risk but doing nothing would have serious consequences for our reputation. We are faced, as any health service manager will tell you, with exploding demand for health care. That is why numbers of prescriptions have increased significantly year on year and, of course, one of the reasons people are living longer is because the NHS has managed its resources and the skills of its staff in such an effective manner. Professionals with the existing training and skills to manage this demand are struggling to cope so the more appropriately trained professionals who can be recruited to put their shoulders to the wheel the better.

We used to believe that doctors’ surgeries were clogged up with people wanting minor ailments to be treated. That is not now the case. Many patients are waiting to have long-term illnesses managed and yet these patients do not need to see a doctor each time they visit a surgery. Yes, they can see a practice nurse, but nurses, too, are becoming overloaded.

In addition, many of these patients are busy with demanding careers, and having to keep appointments at their surgery is not always convenient, resulting in missed appointments and consequently more waste of resources.

Pharmacies are well placed

We have always shouted that pharmacies are well placed for patients in high streets, housing estates, town centres and out-of-town centres: in short, where there are people. Pharmacists with appropriate training could easily manage asthma, diabetes, hypertension etc. Provided a diagnosis has already been made by a doctor, a pharmacist can manage the medication.

It is true that supplementary prescribing was seen as a means of achieving this but, in practice, the restrictions of the clinical management plan have resulted in few community pharmacists seeing the worth of gaining the qualification.

Managing a patient’s asthma is fine but if the patient requires analgesia or a laxative, for example, he or she has to go back to see their doctor.

Mr Cotton raises four issues, which I shall respond to:

1. “GPs are subject to patient expectations that a consultation is almost invariably followed by a prescription. If pharmacists are subject to such pressures will they react similarly?” Possibly. However pharmacists are already aware of this expectation. Training involved in acquiring the qualification and governance procedures should mitigate against this. Pharmacist prescribers will have to justify their choices.

2. “GPs have sometimes been accused of over-prescribing, particularly for antibiotics and antidepressants, resulting in resistant strains and drug dependency. With little or no experience of prescribing such an array of medicines, how do we ensure pharmacists avoid the same accusations?” Many pharmacists have “prescribed” for many years from the entire British National Formulary. They may not have put their signatures on a prescription but they have advised doctors on prescribing. Many pharmacists have worked in doctors’ surgeries for years.There are pharmacists who work in the community who have qualified as supplementary prescribers. I am one. Hospital pharmacists are frequently consulted on prescribing choices. Pharmacists have long been on local drug and therapeutics committees. They will not suddenly be confronted by an array of strange substances that they have never heard of.

3. “Researchers for consumer groups are bound to find examples of poor practice leading to allegations of ‘prescribing for profit’ and not in the best interests of the patient.” This is, of course, true. However, examples of poor practice are not restricted to pharmacy. Mr Cotton, who describes himself as a “corporate social responsibility practitioner” working for a huge chain of pharmacies, is in a great position to ensure that this sort of thing does not happen. If the ethos within a company is that prescribing is to increase corporate profits, then disaster awaits. There has always been the allegation that pharmacists “counter prescribe” for profit. There may be some truth in that when we see the vast numbers of, for example, cough mixtures (with no evidence base supporting their use) sold through pharmacies. Commercial and professional pressures have frequently conflicted in the past so it is not a new development over which we will need to justify ourselves.

4. “Errors in diagnosis would be jumped on by some GPs as evidence of some members of our profession, if not the entire profession, being unfit to prescribe.” Could the same not be said of other professionals with prescribing rights? Dentists, nurses and, oh yes, GPs?

When I qualified in the late 1970s, “ward pharmacy” was in its infancy. The debate in these columns was not about whether pharmacy made a contribution but whether doctors would allow us to practise ward pharmacy at all. We, as an autonomous profession, chose to get out there and make a difference. A difference was made and hospital pharmacy is now unrecognisable from the way it was in the 1970s — and the result is that patients have benefited immensely.

Opportunity

We have now been offered the opportunity to make a major contribution to improving the health of the nation. If we do not grasp it and make that contribution we will have let down ourselves, our profession, the Government and the NHS — but most of all we will have let down the patients whose care could be so effectively managed by appropriately trained pharmacists. Devolving this work to pharmacists will release doctors to look after patients who are currently treated more expensively in hospital.

Having been offered this opportunity, we would be taking terrible risks with our reputation if we “look at the floor” and ask permission from other “stakeholders”. The call has come. Let us heed it.