The future for pharmacist prescribing
Views on why pharmacists should prescribe, what training
they should receive, how supplementary prescribing will work in practice
and what
legal responsibilites prescribing brings were all presented at the seventh
annual Hospital Pharmacist conference held in London on 30 October. Gareth
Jones and
Rachel Graham (on the staff of Hospital Pharmacist) report
Tony West: independent prescriber status may legitimise current practices |
Risks must be balanced with potential benefits as the
pharmacy profession move forwards with prescribing, according to Tony
West, clinical director of Guy’s and St Thomas’ NHS Trust.
There are concerns about the acceleration in the time frame for developing
new prescribers and how quickly things are happening.
The Act of Parliament to allow nurse prescribing was passed in 1992.
Nurse prescribing was rolled out in 1999. It has taken 10 years to get
to the start of nurse prescribing, and since then things have moved quickly.
Much of this has been driven by the desire to sort out what is legal
and what is not. More recently, group protocols, the third Crown report,
the NHS plan and “Pharmacy in the future” have been brought
out. Finally, the “Vision for pharmacy” which is raising
the spectre of independent prescribing for pharmacists. This means there
has been 30 years of little change, and a few years of massive change,
Mr West added.
Many factors have driven the changes allowing wider prescribing status.
First, the aim is to make things better for patients, and improve their
access to medicines. Shortages of doctors is an increasingly significant
issue, and new prescribers can alleviate this problem. Many other health
professions are also looking at opportunities for prescribing. Training
new prescribers increases flexibility in the workforce, and is part of
the modernisation process. New prescribers may be able to ensure better
value for money from the £8bn spent on drugs in the NHS: 20 per
cent of drugs are not taken, and 20 per cent are taken other than as
intended. Ministers may be asking why the NHS is not maximising the health
gain of all this money which is being spent on drugs.
Mr West gave his thoughts about the development of the different types
of prescribing models for pharmacists. The advent of supplementary and
independent prescribing does not mean an end to patient group directions
(PGDs). The “see and treat” principle of PGDs is simple,
and will have a place. Supplementary prescribing is likely to be used
when treating chronic conditions and is likely to be used more in primary
care.
Mr West outlined the areas in which
pharmacists could become independent prescribers. In the acute hospital
setting, pharmacists may become independent prescribers, but work within
parameters set by the hospital. This may be similar to nurses in minor
ailments clinics. At hospital admission and in pre-admission clinics
pharmacists often take drug histories and write the drug chart, but currently
ask a doctor to sign the chart to ensure that the drugs can legally be
administered. Independent prescribing would allow pharmacists to be the
prescriber in this situation, where the doctor does not add value.
Mr West asked participants to consider several areas of prescribing practice
where there have been questions over their legality. Examples of grey
areas include substituting by protocol (swapping proton pump inhibitors),
subtractive prescribing (crossing off an intravenous product), discharge
prescribing, and amending an electronic prescription order. The question
is who is the prescriber and what is the position of the nurse who administers
or the pharmacist who makes the supply, when the status of the prescriber
is unclear? Mr West suggested that independent prescribing rights would
legitimise this practice. There are also opportunities in the non-acute
setting and pharmacists are likely to be working in the same areas as
independent nurse prescribers.
We must ensure that, with the addition of supplementary prescribers to
the team of people able to prescribe for a patient, we do not increase
confusion for patients, said Mr West. Many patients already become confused
when they have both a GP and hospital consultant prescribing. It is also
known that transfer of care from one setting to another, eg, discharge
from hospital, is the most risky event in terms of prescribing errors.Similar
problems must be expected to occur when transferring between multiple
prescribers.
Supplementary prescribing may offer more convenient supply, but can it
be demonstrated that it is safe? Mr West warned that there is likely
to be a situation where a mistake is made by a supplementary prescriber,
whether a nurse or a pharmacist, and this reported on the front page
of a national newspaper. Do we have the mechanisms to cope with that,
and how do we support each other?
A concern with the new prescribing role is that pharmacists may be undervaluing
the current role, which is getting the medicines right for the patient.
A further problem with the increase in prescribers is how pharmacists
know on what basis any given prescriber signs a prescription. Mr West
asked participants how comfortable they felt with all the new prescribers.
Mr West concluded by saying the pharmacists can take on the new prescribing
roles, but should make sure that they are well prepared for it, and do
a good job.
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