Pharmacist prescribing is an evolving component of modern healthcare systems across Europe, including in hospital settings. As hospital pharmacists continue to expand their roles, the ability to prescribe medications – either independently or in collaboration with medical prescribers – presents an opportunity to alleviate the growing pressure on healthcare systems while enhancing patient care. Here, Gerry Hughes examines the emerging practice of pharmacist prescribing across Europe, focusing on two neighbouring regions that are at vastly different stages of implementation: the UK and Ireland.
Despite their geographical proximity, Ireland and the UK are at very different stages of implementing pharmacist prescribing, highlighting the varying levels of its adoption across Europe. While pharmacist prescribing is still not present in many European countries, the UK has been benefiting from prescribing pharmacists since 2003.
Ireland, on the other hand, is just beginning its journey. By contrasting the evolution of pharmacist prescribing in these two regions, this article will explore how the practice benefits patients, pharmacists and the wider healthcare system. Published evidence suggests that pharmacist prescribing has not only improved patient care but has also brought about notable benefits for the UK healthcare system as a whole, highlighting the potential for other nations to follow suit.
Evidence to support pharmacist prescribing
From the outset, pharmacist prescribing has been grounded in solid evidence base, positively received both from within the profession and from other healthcare professionals and patients. A 2016 Cochrane review on non-medical prescribing reported that pharmacist prescribers were able to deliver comparable prescribing outcomes to that of doctors.
A recent umbrella review highlighted that pharmacist prescribing models contributed to better patient care, including improved therapeutic outcomes and fewer prescribing errors. Key stakeholders in that study noted largely positive views towards pharmacist prescribing, with a reduction in physician workload, an improvement in pharmacist job satisfaction, better utilisation of pharmacist knowledge and skills being noted.
Within secondary care specifically, pharmacist prescribing quality has been shown to be as safe, or safer, than physician prescribing.
One observational study in a UK NHS hospital found that pharmacists make significantly fewer prescribing errors (0.7%) than doctors (9.8%).
Furthermore, the clinical benefits of pharmacist prescribing are not just limited to medication safety. Management of chronic medical conditions, such as cardiovascular disease and diabetes, were also comparable to that of medical prescribers.
Despite the evidence demonstrating the positive impacts of pharmacist prescribing, some countries have been slow to adopt the initiative.
Pharmacist prescribing in Ireland
The UK is arguably the leader with the European region, while the Irish healthcare system has just begun to explore pharmacist prescribing.
In July 2023, the Irish minister for health established an Expert Taskforce to Support the Expansion of the Role of Pharmacy. The Taskforce examined how pharmacists in Ireland could expand upon their present scope of practice for the benefit of patients, the public and the wider health system.
One early output from the Taskforce was legislation changes to allow pharmacists to use their discretion to extend prescriptions from six to 12 months, where clinically appropriate. The Taskforce also made three overarching recommendations which are to be implemented over the coming years:
- Pharmacists should be enabled to exercise independent, autonomous prescriptive authority
- This authority will be implemented in a stepwise manner, commencing with the introduction of a common conditions service
- The development of models of pharmacist prescribing within primary and secondary care settings.
The transition to pharmacist prescribing in hospital settings is not without its challenges. During the Expert Taskforce consultations, the Irish Medical Organisation (IMO) – the representative body for all doctors in Ireland – proposed that the role of the pharmacist is solely ‘to dispense prescribed drugs, ensuring appropriate supply and counselling patients on the use of prescribed and non-prescribed drugs’.
Notwithstanding the strong evidence base to support the safety and efficacy of pharmacist prescribing, the IMO went on to say that the ‘transfer of tasks from doctors to pharmacists is unsupported by the evidence and has implications for patient safety, quality of care and healthcare sustainability’.
Despite these misgivings about the expansion of pharmacist roles in Ireland, the IMO did consider a role for pharmacist prescribing in, as they describe, ‘non-retail’ settings such as GP surgeries and hospitals. The submission of the IMO contrasts with public consultation submissions to the Expert Taskforce, where 83% of the public were in favour of commencing pharmacist prescribing as part of a Common Conditions Service.
Reflecting on the overall outcome of the Expert Taskforce, the committee chair Dr Pat O’Mahony noted that ‘empowering pharmacists to prescribe will significantly enhance patient care and provide timely access to the medications that patients need’.
He added: ‘Pharmacist prescribing will be of tremendous benefit to patients and will also lead to reduced workload for other prescribers, while delivering enhanced care and outcomes for patients.’
Pharmacist prescribing in the UK
In contrast, pharmacist prescribing has been firmly established in the UK for many years. Its safety and efficacy in practice has been resoundingly endorsed and supported by Royal Pharmaceutical Society (RPS).
For example, the RPS references a case study of a hospital pharmacist-led cardiology clinic at NHS Greater Glasgow and Clyde that resulted in better medication optimisation in left ventricular systolic dysfunction after acute myocardial infarction and has demonstrated medication safety and deprescribing benefits.
Indeed, the management of chronic conditions, such as cardiovascular disease, is a key part of the pharmacist’s role within an integrated healthcare system, explains Niamh McMahon, Chief 2 hospital pharmacist at St James’s Hospital in Dublin, Ireland. She notes that pharmacist prescribing ‘will enable pharmacists to optimise patients’ medicines in a timely manner, while working closely with interdisciplinary colleagues’.
And Stuart Evans, lead cancer pharmacist at Swansea Bay University Health Board and member of the Royal Pharmaceutical Society’s Hospital Expert Advisory Group, says: ‘Pharmacist independent prescribing has had a demonstrable impact on patient care, particularly in areas such as cancer treatment and symptom management.’
Extending practice in hospitals
For hospital pharmacists looking to transition into prescribing roles, several factors need to be considered, including changes in recognition and regulation.
In recent years, the Irish hospital pharmacy profession has succeeded in developing the Advanced Specialist Pharmacist (ASP) role, which recognises the subspeciality expertise of hospital pharmacists.
While this is somewhat associated with industrial relations negotiations for public service pharmacist contracts, the move to recognise ASP roles will likely assist the development of hospital pharmacist prescribing in Ireland over the coming years. However, these advancements require a clear regulatory framework, adequate training programmes and sufficient support for pharmacists transitioning to become prescribers – which is the case for many European countries.
Again, in the UK, these frameworks and supports are more readily available to pharmacists wishing to extend their practice to prescribing. Along with postgraduate training courses to grant pharmacists prescribing licensure, the RPS has developed practical guidance and information for pharmacists wishing to become prescribers, including advice for those practicing in specialised roles in hospitals.
To further support pharmacists in clinical decision-making and other necessary prescribing skills, the RPS has published the Prescriber Competency Framework, which hospital pharmacists can use to assess their abilities and expand their scope of practice. Central to all of this, of course, is understanding patients’ individual needs, preferences and values within the prescribing paradigm.
As Stuart emphasises: ‘Pharmacist prescribers often develop stronger relationships with patients, sometimes knowing more about the individual than a rotating registrar or locum consultant, which improves continuity of care.’
The UK pharmacy regulator, the General Pharmaceutical Council (GPhC), indicates that there were 18,498 independent pharmacist on the GPhC register as of 30 April 2024, representing 28.7% of all UK registered pharmacists.
This figure will increase significantly in the coming years as all newly qualified pharmacists will be licensed prescribers on the day of their registration from 2026 onwards.
Perceptions, challenges and future outlook
The broader reception of pharmacist prescribing has been positive but varied. Patients generally accept it, with many reporting higher levels of satisfaction due to the timeliness and efficiency of care. However, the IMOs reaction to proposed pharmacist prescribing in Ireland exemplifies concerns that might exist among the wider clinician community about the scope of practice for pharmacists.
Hospital pharmacists must work to build trust with both patients and medical colleagues in embedding pharmacist prescribing to clinical practice. This can be achieved through education, open communication and evidence-based practice that demonstrates the efficacy and safety of pharmacist prescribing – values and aspirations that are included in the Expert Taskforce Final Report.
Looking forward, pharmacist prescribing in Europe is expected to expand, as it has done in the UK and, increasingly, in Ireland. Here, the pharmacy profession is likely to see further integration into hospital prescribing teams, with regulatory changes expected to support the growing role of hospital pharmacists as prescribers.
‘This is an exciting time for the pharmacy profession in Ireland, as expanded pharmacist roles will result in better use of their extensive medicines knowledge and skills, enhanced recognition of their unique role by both healthcare professionals and the public, leading to improved job satisfaction for pharmacists,’ says Niamh.
The evolution of pharmacist prescribing in the UK to include all newly qualified pharmacists in the near future is a prime example for other countries embarking on this role expansion.
But the story won’t end there as the international literature on this topic is now beginning to move beyond a focus on prescribing to consider the placement of pharmacists in wider clinical assessment, diagnostic and clinical management responsibilities, too.
