Hospital Pharmacist Vol 7 No 4
p107-108
April 2000 Articles
Pharmacist prescribing - a reality in the year 2000?
By H. Remington, MPharm, MRPharmS
The issue of whether pharmacists should be allowed to prescribe has generated a lot of debate. This article discusses the progress that has been made so far in securing such a role
The Government has recently acknowledged and supported the main thrust of the Crown "Review of prescribing administration and supply of medicines". This will now require legislative change. At present, it is unclear what timescale the Government will pursue; Parliamentary time was said not to be available. However, with the Government's new imperative and new cash for the National Health Service, it is likely that previous plans will be reviewed. Necessary legislative changes may be achieved promptly.
Two opportunities for pharmacist prescribing are available. The first relates to "Crown" and the second arises from government plans to develop a community pharmacy strategy which has not yet been published. This is likely to deal initially with products that are not prescription only medicines (POMs), making them available at NHS expense through community pharmacies. This work will be important because it establishes some of the groundwork and cultural changes pertaining to confidentiality, accountability and probity, without trespassing onto the need for new underpinning knowledge requirements, since the products involved are currently provided by community pharmacists outside the NHS framework. Some additional new skills, with appropriate training, plus the development of a clear, evidence-based practice framework, perhaps based on a decision support basis, will undoubtedly be required. However, issues such as fragmentation of patient records and general practitioner (GP) awareness of the patient care provided will be little different from what they are today.
The Crown report on prescribing was very clear that non-medical prescribing of POMs required postgraduate training. In fact, Crown wanted an assurance of competence before any medicines were prescribed.
A set of general principles was developed, against which any future model of prescribing should be tested. The report contains factors which would determine when health professionals could undertake new roles. These factors were concerned with patient safety, patient choice and convenience, professional appropriateness to prescribe and effective use of resources. The work was robust and offered a framework with which the professions could move forward.
Patient safety was the key area for the Crown team's attention. Although the Medicines Act has limited our profession's desire to improve patient care, it has nevertheless served patients well for over 30 years. Any change can only be executed if there is an assurance that patients' safety would be protected as well as, if not better than, is currently the case. The focus on clinical governance and risk management in the NHS today does, however, underline the importance of managing the existing prescribing error rate. Obviously, things can be improved by using properly trained individuals.
Patient safety
The Crown team identified the following factors to secure the safety of patients.
Registration All staff should be qualified and registered. Registration gives the ultimate means of identifying trained staff who can legitimately practise as prescribers, and permits accountability, through statutory committees and de-registration, where there has been incompetence.
Post-qualification training Postgraduate training will be necessary until the requisite skills and underpinning knowledge components are part of undergraduate courses. It will also be necessary to assess training needs and these will depend on the prescribing models to be adopted. Making prescribing optional, rather than compulsory, is obviously an essential element for existing pharmacists, and this will be made clearer with postgraduate training.
Continuing professional education Continuing professional education (CPE) perhaps should be more accurately described as continuing professional development (CPD). Whichever term is used, the point is that after initial training, competence must be retained. The Crown report stated that evidence was required. This is not currently demanded of doctors, but is possibly necessary for them too.
Competency to assess The prescriber should be competent to assess relevant aspects of care management. This allows for the different models of prescribing that are possible under the framework described by Crown and includes the dependent and independent prescriber.
Independent prescribers need to have good assessment and diagnostic skills, whereas dependent prescribers can rely on another professional for this element of the patient's care. Repeat prescribing, for instance, would be a dependent model of prescribing. The diagnosis would be established as would the initial treatment choice. The dependent prescriber is required to: monitor response to, and side effects of, the drugs; make dose adjustments, if necessary; know when to refer back to the initial prescriber.
Boundaries This factor follows on from the previous one and emphasises that prescribing can only be within the competency of the individual. In other words, prescribing can only be from within the sphere of a pharmacological knowledge base. This would be particularly relevant to specialist practitioners, perhaps nurses, who had trained in only one therapeutic area.
The lead prescriber role The GP or consultant must retain the lead prescriber role. This ensures an overview in the context of several potential prescribing practitioners. This is not necessarily achieved today with the nurse, dentist, pharmacist (over the counter medicines), consultant and GP partners in the provision of medicines to patients.
Access to records The prescriber should have full access to records. These records should be integrated and confidential. Having such access avoids fragmentation of care and maintains patient confidentiality.
Transfer of information To accommodate the single patient record concept, the doctor should be informed about prescribing by others. This is not achieved currently, but does feature in the government's information technology (IT) strategy.
Separation of prescribing and dispensing Crown acknowledged that separation of prescribing and dispensing may not occur in repeat prescribing by pharmacists. However, any proposal to implement repeat prescribing and supply by the same practitioner would require issues of patient safety and probity to be addressed. The issue may be one of risk assessment; an established patient on chronic therapy poses few risks in this model of patient care.
Patient/practitioner relationship The relationship between the patient and the practitioner may have an effect on concordance. The Crown team acknowledged the importance of ensuring that the trust and dependency of the patient was not affected by the changing roles.
Crown proposed a new statutory body which would receive applications for prescribing rights from nationally recognised professional organisations on behalf of a group of their members. This body would require legislation to establish it, and a multidisciplinary approach for it to function. At present, we are still a long way from such a body being established. The criteria that may be used to judge applications were suggested by the Crown team as:
- the clinical benefit to patients
- the impact on patient convenience and choice
- qualified, trained and registered practitioners
- evidence of audit and CE frameworks
- details of the training accreditation
- a case for the benefit of prescribing at public expense
Training for prescribing will need to be developed by the profession. As the complexity of the medicines application in the therapeutic context develops, the need for postgraduate clinical training in therapeutics will be evident. Traditional postgraduate courses in clinical pharmacy can be adapted to include principles of prescribing, including prescription writing. The Centre for Pharmacy Postgraduate Education (CPPE) has an excellent track record in modular training and will doubtless embrace elements of training needs.
Clinical governance will be relevant in terms of CPD, evidence-based approaches, audit and error management. The quality of prescribing will be under scrutiny and IT systems will permit controls over issues of probity and risk reduction. The guidelines produced by Prodigy and the National Institute for Clinical Excellence (NICE) will assist in promulgating a systematic approach. The Royal Pharmaceutical Society has begun the process of developing practice guidelines for the use of OTC medicines. These guidelines have been required of us by the government.
Will we have pharmacist prescribing in the year 2000? It is already with us, although we are finding ways to secure technical observance of the law with doctors' signatures being added to our prescriptions. Anti-coagulant clinics operated by pharmacists, mostly in hospitals, but some in community, have been with us for over ten years. Therapeutic drug monitoring (TDM) clinics for lithium also operate. Hospital pharmacists prescribe total parenteral nutrition (TPN) daily. The largest area of pharmacist prescribing is in discharge management and pre-admission clinics. The latter allow planned arrangements and problem solving for elective patients.
Discharge medication management by pharmacists is occurring in many UK hospitals now. It is a growing area of practice, often driven by the need to improve the quality of prescribing and reduce duplication of supplies to patients. When combined with assessment and then re-use of patients' own medicines on admission, it can reduce waste. Research at our hospital has also documented admission prescribing error rates of 13 to 20 per cent. Such pharmacist discharge practice improves the opportunities for patient counselling and understanding. It also speeds discharge and offers opportunities for improved communication with GPs about the rationale for changes in regimens. Doctors could carry out many elements of the practices described, but they have no time for them. There has been no national debate about the criteria required to operate such services. This is urgently required. All aspects require research and publications to offer a robust evidence base for progress.
In community pharmacy, there is a long history of supplying medicines after an assessment of patients' needs. The NICE is keen to see this standardised. The algorithmic approach of NHS Direct is commendable. It is possible to view what is already in place for access to medicines as a continuum, that is, from self-care to NHS Direct to pharmacy supply to doctor's prescription. Within this, in the near future, there will be the opportunity to add group protocol supply of POMs and pharmacist prescription of non-POMs. After that will come the Crown prescribing models.
Perhaps in this millennial year we are at a crossroad. During the year, we will see a change in community prescribing on the NHS, and perhaps, too, the Crown prescribing recommendations will be taken forward. This year will be a key to the future achievements of 2001 and for the next two to five years of change in the profession.