A Pecking order

The Author: Martin Anderson is the director for NHS policy & partnership for the Association of the British Pharmaceutical Industry Association (ABPI)

The advent of new prescribers should increase patients' choice in where, when and how they can access medicines. Pharmacist prescribing can offer real benefits to patients and improve efficiency in the health service, but concerns exist which must be addressed for it to succeed.

In certain settings, such as NHS Walk-in centres, pharmacist prescribing should permit faster and broader access to care and a more patient-centred approach, improving choice and enabling services that are better shaped to patients' needs.

Pharmacists are highly skilled and trained professionals, and prescription rights will enable the health service to employ this expertise more effectively, with benefits, for example, such as improved management of long-term conditions.

Boosting prescriber numbers should also reduce the workload of doctors, enabling them to spend time on complex cases, as well as facilitate patient concordance.

The development of more nurse- and pharmacist-led care, where traditionally professionals have been able to adopt a more consultative approach with patients, offers the potential to improve partnerships in treatment decisions, thus improving the effectiveness of medicines and health outcomes, and reducing wastage.

However, the development of new prescribers is not without its challenges.

Challenges
Perhaps of greatest concern from the patient's perspective is that, as the prescriber base becomes fragmented, so too does the care. This has importance particularly where there are multiple, concomitant long-term conditions.

There are also safety implications in using multiple contacts, especially in the absence of shared patient records and good quality IT systems.

For these reasons, the ABPI believes that the extension of non-medical prescribing should take place in the context of strong team working and clear leadership which, for many organisations and individuals working in the NHS, represents a major cultural shift.

Independent pharmacist prescribing should be different in the primary and secondary care sectors. In secondary care, it is likely to be more appropriate that pharmacists prescribe for any condition from a full formulary within individuals' areas of competence and with appropriate levels of support and mentorship.

Pharmacist prescribers should work within, and be supported by, a team that includes a clinician, from whom they can draw support in uncertainty, and receive appropriate initial and ongoing training.

Full independent prescribing is currently, in the ABPI's view, inappropriate in the community pharmacy setting; here, supplementary prescribing to agreed care pathways might be the best approach.

Pharmacists are taking on a range of new roles within the terms of the new contract, and play a vital role in improving the quality of care through diagnosis, support, screening and medicines use reviews. This role should be fully developed.

Pharmacist prescribing in community pharmacy is impractical in the absence of shared access to medical records. If the present failsafe of formally separating prescribing and dispensing is changed or removed altogether, thought must be given as to how safety is maintained.

Additionally, the pharmacist is often responsible in community pharmacy for purchasing medicines. While not impugning their professional integrity, it is widely recognised that a potential conflict exists should personal commercial benefit come through prescribing.

This potential conflict of interest must be addressed before independent prescribing commences in primary care.

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The Author: Denise Taylor is senior teaching fellow, Programme Lead for Prescribing, in the department of Pharmacy and Pharmacology at Bath University

If one defines an independent prescriber as a practitioner who elicits a relevant history from the patient, decides upon a diagnosis and then recommends and provides an appropriate treatment; then community pharmacists have been independent prescribers of over-the-counter medicines for many decades.

Legislative changes which enabled pharmacists to register as supplementary prescribers in 2004 permitted them to develop a three-way therapeutic partnership with a medical colleague and an individual patient, and prescribe any medicine for any disease state within their own competence, within the framework of a Clinical Management Plan (CMP).

However, patients do not bring their healthcare problems in ordered boxes; they present with whatever is affecting them on that particular day. Hence, a pharmacist supplementary prescriber (PSP) may also be asked about headaches, fungal infections or respiratory tract infections during a regular consultation.

While experienced in such therapeutic encounters, the PSP may only prescribe within the confines of the CMP. This often means another appointment for the patient with another healthcare professional.

Independent prescribing will enable pharmacists to prescribe for any condition for which they feel competent. Benefits for the patient include, accessibility, a dedicated session to a particular complaint and regular medication review.

Most important, however, seems to be the continuity of care to the individual. Patients like to see the same healthcare professional at each review clinic. PSP's also tend to have longer consultation time (15 minutes) than medical colleagues (10 minutes), which gives patients the time to share their own agenda.

Many patients even feel able to admit to their pharmacist prescriber (PP) that they are not taking some of their medicines as prescribed; this allows an appropriate solution to be found and wastage to be reduced by reviewing unnecessary prescribing.

Teamwork
Some healthcare professionals may feel threatened by pharmacists taking on new roles, and the potential for conflict over final clinical responsibility is well acknowledged, although easily resolved by open dialogue.

Each healthcare professional has different skills to bring to an organisation and the benefits to patient care and the medicines budget speak for themselves. Some PPs also have a role as prescribing adviser to a general practice surgery and work with clinicians in order to attain cost-effective use of medicines.

Regular use of PPs in chronic disease clinics in primary care can ensure that Quality and Outcomes Framework points can be achieved, leading to increased financial gains for the surgery.

Due to the success of their prescribing outcomes, PPs, increasingly, are joining GP surgeries as either a pharmacist GP partner or a salaried member of the organisation.

Pharma influence?
The influences on prescribing are many and well known, but often seen as the most sinister (rightly or wrongly) is the influence of the pharmaceutical industry.

How should an effective working relationship be developed between PPs and pharma? Perhaps by supporting the prescriber in such a way that therapeutic outcomes can be readily achieved.

It has been suggested that PPs are now being targeted as a `new marketing channel.' Should PPs start running, or should they meet this head on and start to ask for information to support prescribing decisions; for example, unpublished data about efficacy and safety in other population groups, and treatment outcomes that are achievable in primary care settings. Help with monitoring and audit tools may be welcome, but these will need to be generic rather than branded;

Is pharma ready for this type of request?
Yet, as evidence suggests that prescribers influenced by pharma have less appropriate prescribing practices, perhaps PPs should be cautious about this new relationship. Ultimately, they will be governed by their professional Code of Ethics and local trust policy, ensuring they work to protect the patient, the public and the NHS.

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The Author: Ray Rowden is a health policy analyst and columnist in PM

The government is proposing that independent pharmacists be allowed prescribing powers, already enjoyed by many nurses and NHS pharmacists; and as usual, a variety of vested interests may wish to block change.

Primary care is undergoing a revolution. Government policy suggests increased choice for patients, easier access to services and increased activity outside of hospitals. Allowing independent pharmacists to prescribe makes total sense.

Pharmacists are all graduates, well trained, committed to continuous profess-ional development and regulated by the Pharmaceutical Society of Great Britain and the equivalent body in Northern Ireland. They are governed by a strong code of conduct and can be removed from practice by regulatory bodies if found guilty of professional misconduct.

Indeed, this already fervent level of professional regulation is likely to become tougher still, following a Department of Health review of professional regulation published last month.

Critics may suggest that increased numbers of prescribers might fragment care and that the absence of a shared patient record makes the idea impractical. Nurses have been prescribing in large numbers over many years, in hospital and community settings. Lack of a single record has not been an insoluble problem and good protocols that are clear about information sharing can and do work.

In the absence of a shared record, what is wrong with the use of email, fax and good old-fashioned postage stamps to share prescribing activity with the GP? Better still, let's give patients their own record, held by them, which they can share with whomever they need to.

Others might suggest that independent pharmacists could compromise safety by having a mixed role as prescriber and dispenser. This is frankly an insult. Most pharmacists make patient safety the top priority and are registered professional practitioners who are fully accountable for their practice. In fact, in many rural areas GPs act as both prescriber and dispenser, and there are sensible safeguards in place; surely similar arrangements could be made for independent pharmacists.

Modern IT allows PCTs to track prescriber behaviour more accurately and I see no reason why the same arrangements for monitoring could not extend to new prescriber groups; rogues could be picked up with reasonable IT infrastructure. The NHS counter-fraud service is also getting more robust at exposing bad practice.

Finally, I've heard suggestions that the commercial role of the independent pharmacist and the profit motive might conflict. Independent pharmacy chains in the high street are well placed to extend healthcare in a safe environment and still make a profit. What is so bad about that?

GPs and dentists are all self-employed working as small businesses; they make a profit to survive and does anyone suggest that it conflicts with the interests of patients? Certainly not, so let's get on with reform and allow pharmacists to use their skills and give better choice and access to care for patients.