Seeing the light

A new wave of prescribers offers pharma the opportunity to extend its marketing activities beyond doctors' prescription pads

Until recently, doctors (and dentists for dental and oral conditions) were the only healthcare professionals permitted to prescribe prescription-only medicines (POMs) in the UK.

However, changes to the law mean that there are now new prescribers ñ suitably qualified nurses, pharmacists and optomertrists are able to prescribe a number of medicines.

The advent of new prescribers, which is in line with government policy, signalled the extension of prescribing responsibilities to 'non-medical professionals' in order to:

• Improve patient care without compromising patient safety
• Make it easier for patients to get access to the medicines they need
• Increase patient choice in accessing medicines
• Make better use of the skills of health professionals
• Contribute to the introduction of more flexible teams working across the NHS

These changes have been driven by the Department of Health's (DoH's) non-medical prescribing programme which is part of a grander scheme of role and professional redevelopments in many disease areas and extensive service re-design. This has already been widely seen in ophthalmology and cancer services.

Clearly, these prescribers are an important new audience for marketing activities. It is, therefore, important to understand:

• Who they are
• Who they might be in the future
• The regulations under which they are permitted to prescribe
• How to access them
• Possible ways of assisting them to meet their changing needs

Nurses and pharmacists were initially chosen as the primary extended prescribers as they are the two largest non-medical professions from which it was felt that maximum benefit to patient care could be expected.

Extended prescribing programmes have been achieved through the introduction of both supplementary and independent prescribers. But just what is the difference between these two new prescribing groups?

Supplementary prescribing is a voluntary prescribing partnership between an independent prescriber and a supplementary prescriber to implement an agreed patient-specific clinical management plan with the patient's agreement.

It was introduced in April 2003 for nurses and pharmacists with appropriate training and from 2005 it included physiotherapists, chiropodists/podiatrists, radiographers and optometrists with appropriate training.

Supplementary prescribers may prescribe any NHS medicine provided that it is in partnership with an independent prescriber who establishes the initial diagnosis and starts the treatment, within agreed clinical management plans. The supplementary prescriber then monitors the patient and prescribes further supplies of medication when necessary.

Independent prescribing is prescribing by a practitioner (currently doctor, dentist, nurse or pharmacist) responsible and accountable for the assessment of patients with undiagnosed or diagnosed conditions and for decisions about the clinical management required, including prescribing.

It is felt that independent prescribers have the potential to change the way that GPs/Primary Care Trust (PCT) leads/commissioners provide services to patients, not least in the reduction of waiting times. A greater number of professionals who can act as independent prescribers provide a wider range of skills and expertise on which to draw in order to meet patient needs.

Using nurse and pharmacist independent prescribers can, among other things, help to:

• Fill geographical or skill gaps in services
• Meet the needs of patient groups who find it hard to access services, eg, housebound, those with busy lifestyles
• Manage long-term conditions

Extensive training systems are in place for nurses and pharmacists to allow them to become independent prescribers.

In most circumstances, it is thought that independent prescribing by pharmacists is likely to be carried out as an enhanced (directed) service and conditions to restrict prescribing may be imposed by the commissioning PCT.

From May 1, 2006, the Nurse Prescribers' Extended Formulary was discontinued and qualified nurse independent prescribers (formerly known as extended formulary nurse prescribers) are now able to prescribe any licensed medicine for any medical condition within their competence, including some controlled medicinal products.

Community practice nurses (formerly called district nurses and health visitors) however, will continue to prescribe from the Nurse Prescribers Formulary for Community Practitioners. This includes mainly dressings and wound care products, appliances, some pharmacy (P) and GSL medicines, and selected POMs.

It is estimated that there are now over 10,000 nurse independent prescribers/nurse supplementary prescribers (NIPs/NSPs) across the UK. Unlike pharmacists, the majority of nurses are dual qualified due to the nature of the prescribing course. Additionally, there are over 30,000 community practice nurses prescribing from the Nurse Prescribers Formulary for Community Practitioners.

Also from May 1, 2006, a new category of prescriber, namely the pharmacist independent prescriber, was introduced. Once qualified, pharmacist independent prescribers will be able to prescribe any licensed medicine for any medical condition within their competence, except for controlled drugs.

At present, there are 78 pharmacist independent prescribers in Great Britain and 1,227 supplementary pharmacist prescribers, out of a total of around 37,000 practising pharmacists. The number of pharmacist independent prescribers is set to increase significantly over the next few years.

In March 2007, two consultations began to propose changing the laws on prescribing controlled drugs by nurse and pharmacist independent prescribers. Such a change would increase access to controlled drugs for patients, resulting in improvements in areas such as palliative care, substance misuse, post-operative care and pain relief. The consultation is ongoing.

Pharmacists and nurses will continue to be able to train and act as supplementary prescribers and, in some settings, supplementary prescribing will continue to be the best option. This will also enable them to prescribe controlled drugs and unlicensed medicines, provided they are stipulated in a patient's clinical management plan.

The lastest group of healthcare professionals to become independent prescribers are optometrists. On August 28, 2007, the DoH announced that optomestrists will be able to train to prescribe medicines. It is felt that optometrist independent prescribers, by providing an effective primary eye-care service, will:

• Relieve pressure on GP practices and hospital eye departments
• Improve the triaging of more serious eye conditions requiring ophthalmological care
• Reduce antibiotic use

Is the disease area in which you are currently working one that new prescribers might get involved in? The disease areas in which nurses and pharmacists are currently focusing include dermatology and soft tissue injuries. Remember, however, that with training, they can prescribe any licensed medicine and some controlled drugs in all disease areas.

In an evaluation of 246 independent nurse prescribers conducted in 2005, the most common conditions prescribed for were:

• Skin conditions
• Family planning
• Soft tissue injuries

This national research found that patients, doctors and nurses viewed independent nurse prescribing positively, with patients citing accessibility as a major advantage when obtaining their medicine from a nurse rather than a doctor.

Further research at Reading University confirmed that disease areas for NIPs include dermatology, a host of minor ailments and minor injuries, asthma, diabetes, coronary heart disease and pain.

In 2006, the top disease areas in which supplementary prescribing pharmacists were working included: cardiovascular, central nervous system, respiratory, endocrine and gastroenterology. Other areas predicted to be key for pharmacist independent prescribers are: anticoagulation, diabetes, HIV and renal medicine.

The first pharmacist in the UK qualified as a pharmacist independent prescriber in January 2007, specialising in asthma. Others now specialise in oncology and hypertension.

The extension of prescribing to these new groups allows us to think further beyond the prescription pads of both doctors and dentists. New prescribers offer numerous possibilities for pharma to further extend marketing activities. While this remains a new aspect of marketing, by working within the Association of the British Pharmaceutical Industry Code of Practice (ABPI) and Medicines and Healthcare products Regulatory Agency (MHRA) guidance, you will find that many new opportunities are now presenting themselves.

Here are some pointers on how you might go about accessing new prescribers and suggestions as to how you might assist them in their new role.

When considering any marketing activities, remember that the 2006 Association of the British Pharmaceutical Industry Code of Practice and Medicines and Healthcare products Regulatory Agency guidance on advertising and promotion of medicines apply equally to new prescribers as to 'traditional' prescribers.

1. Indeed, these industry regulations provide your first potential opportunity to work with new prescribers. New prescribers may not be familiar with the advertising and promotion regulations in the UK and you could consider providing this support.

2. You might want to approach the non-medical prescribing leads present in each Strategic Health Authority (or Primary Care Trust). A current list of these names is available on the Department of Health website (last updated April 5, 2007). Furthermore, know that a non-medical prescribing lead in each Trust regularly attends steering group meetings held in each locality with the education quality manager (non-medical prescribing) from the multi-professional deanery. Is this another point of access for you?

3. Consider setting up meetings with local GPs/PCT leads/commissioners of services and your local/regional independent prescribers to help show them how independent prescribers have the potential to change the way they provide services to patients. For example, explore ways in which you might be able to assist in service re-design.

4. You might consider helping with the costs of training independent pharmacist and nurse prescribers, currently available centrally through Strategic Health Authorities.

5. Clinical governance, the development of risk management plans, patient record keeping, auditing and adverse drug reaction reporting are all critical aspects of independent
prescribing. Could you offer assistance in incorporating these factors into local policies?

6. Patients need to be told who their independent prescribers are so that they can choose to visit them. Could you offer assistance in this?

7. Consider approaching your new prescribers via a third party, for example, via an agency with extensive experience liaising with your new audiences. Using such a third party approach could result in you getting closer to your new audience more rapidly and effectively.