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BPharm MPharm PhD
Prescribing Research Fellow
School of Pharmacy
The Robert Gordon University
Initiatives for improving patient access to medicines without compromising their safety are underway in the UK.(1–4) Central to these developments is the aim to make more effective use of the skills and competencies of various allied health professionals, including pharmacists and nurses, to reduce doctors’ workloads, freeing up their time to concentrate on patients with more complicated conditions and more complex treatments.(3) The final Crown Report in March 1999 proposed that nonmedical health professionals such as pharmacists and nurses should be permitted to take on additional prescribing responsibilities. The report defined two new types of prescribers: the independent prescriber (a doctor or dentist) and the dependent prescriber.(2) Section 63 of the Health and Social Care Act 2001 allowed for the introduction of dependent prescribing status (implemented into practice as supplementary prescribing) for allied health professionals, including pharmacists.(5)
Supplementary prescribing (SP) is defined as “a voluntary partnership between an independent prescriber and a supplementary prescriber to implement an agreed patient-specific clinical management plan (CMP) with the patient’s agreement”.(2) The CMP is the foundation stone of SP. Before SP can take place, it is obligatory for an agreed CMP to be in place (written or electronic) relating to a named patient and to that patient’s specific condition(s) to be managed by the supplementary prescriber. Within this framework there are no legal restrictions on the clinical conditions that may be treated or drugs that can be prescribed by supplementary prescribers. A template for CMP is given in Figure 1.
Supplementary prescribing in the UK
Pharmacists with at least two years experience since registration with the Royal Pharmaceutical Society of Great Britain (RPSGB) as a pharmacist can undertake SP after training at a higher education institution (200 hours at degree/masters level over 25 days) and completing a “period of learning in practice” (supervised by a designated medical practitioner for a minimum of 12 days) in accordance with the curriculum specified by the RPSGB.(3,6) Pharmacists working in various practice settings across Great Britain have been practising SP since early 2004.(7) On 18 March 2004, a pharmacist from a general hospital in England became the first pharmacist to prescribe officially. Pharmacists working in primary care and community settings started prescribing soon afterwards.(7)
The first national survey of SP pharmacists registered with the RPSGB (June 2005) found that the majority (40%) have a hospital pharmacy background, followed by those working in primary care (30%) and community pharmacies (20%).(8) However, the proportion of those practising as a prescriber to those registered as a supplementary prescriber was much less in the hospital setting (46.3%) than that in primary care (63.9%), but comparable to the average across all practice settings (48.6%).(8) The main therapeutic areas of focus for early supplementary prescribers during their “period of learning in practice” include: cardiovascular diseases, multiple conditions and respiratory diseases. Of those who had started practising SP, the majority (79%) had written at least one prescription. The major drug classes covered in the first prescriptions by the early SP pharmacists were: cardiovascular agents (antihypertensives, lipid-regulating drugs, antiplatelet agents, anticoagulants, etc) and bronchodilators, reflecting their background clinical training.
SP has been regarded to be highly beneficial for both patients and pharmacists.(9) However, more than half of the pharmacists registered as prescribers were not practicing SP,(8) suggesting that there are several challenges to the implementation of SP. Most of these challenges are known to be either logistical or financial.(9) Hobson et al carried out a survey of pharmacists working in primary and secondary care trusts in England to evaluate their perceptions on the implementation of SP.(10) It was found that barriers for the implementation of SP were more in primary than in secondary care. The perceived benefits and challenges(9) in delivering prescribing services in the views of pharmacists practising SP are summarised in Box 1 and 2, respectively. Greater publicity of pharmacists’ role in medication management, support from the medical profession and healthcare organisations and high standards by early practitioners are essential for the success of SP by pharmacists.
Views of health professionals and patients
The concept of nonmedical prescribing has been welcomed by both health professionals and patients, although there have also been criticisms for the proposals and concerns regarding patient safety.(10–14) Some members of the medical profession have expressed concerns about pharmacists’ proficiency in diagnosis, awareness of clinical and patient details and the likely communication problems when they take up prescribing responsibilities.(14) There are concerns even among some members of the pharmacy profession itself about the extended role of pharmacists.(10) Primary and secondary care pharmacists have expressed concerns about the lack of clinical assessment during SP training and also professional competence and responsibility once trainees qualify.(10)
Limited studies have been carried out to evaluate objectively clinical outcomes of prescribing initiatives by pharmacists. In a study carried out at two intensive care units of a London hospital to evaluate drug dosing in haemofiltration, adherence to clinical guidelines for optimal dosing of anti-infectives was better for pharmacist supplementary prescribers than for doctors.(15) In these early days of prescribing by pharmacists, more evidence is required in terms of outcomes to establish the role of the pharmacist as a prescriber. This is crucial in deciding the future roles of pharmacists, not only in the UK, but also in other parts of Europe (eg, The Netherlands) and the rest of the world (eg, USA and Australia), where changes in legislation are being considered to provide additional prescribing responsibilities for pharmacists.
Independent prescribing by pharmacists
Consultations regarding the implementation of independent prescribing by pharmacists started in 2005.(4,16) The Medicines and Human Use (Prescribing) (Miscellaneous Amendments) Order of May 2006 and associated medicines regulations enable pharmacists who have successfully completed a pharmacist independent prescribing course to prescribe any licensed medicine (with the exception of controlled drugs), for any medical condition (diagnosed or undiagnosed) within their clinical competence.(17,18)
The Department of Health is working with the RPSGB and other stakeholders to finalise the education and training requirements for pharmacist independent prescribers. In the early phases of independent prescribing, its uptake may be more likely by those with previous training in SP.(19)
Additional training in evidence-based medicine, communication skills and the generic issues of prescribing, diagnostic and consultation skills would ensure confidence, quality and safety when independent prescribing responsibilities are undertaken by pharmacists.