Perceptions of prescribing development and practice

The views of pharmacist prescribers on their current practice and how prescribing could be utilised to enhance the pharmacy professions clinical role in the future

David Gibson MPharm MSc

Ros Prior BPharm

Claire Thomas BPharm

Lesley Davidson BPharm PhD

North East and Cumbria Clinical Pharmacy Network, UK

The first prescription produced by a UK pharmacist was written in 2004 in the North East of England.1 Ten years on prescribing has become embedded in many pharmacists practice within the North East region. During this time significant changes have been made to how pharmacists can prescribe including developing independent prescribing,2 changes to unlicensed medication regulations and pharmacists prescribing controlled drugs.3 With the evolution of pharmacist prescribing, the day-to-day practice of many pharmacists has changed. To understand these changes, the North East regional clinical pharmacy network undertook a workforce review to evaluate current prescribing practice, including how pharmacists perceived prescribing developing in the future. The workgroup had representation from all the acute and mental health Trusts in the North East of England. A survey was circulated to all pharmacists employed by hospital Trusts in the North East of England in July 2014. In total 182 pharmacists replied of which 82 were qualified prescribers, 12 were currently on a prescribing course and 88 were not registered as prescribers.

Who is prescribing?

Many now see prescribing as the next step after a clinical diploma for the career progression of newly qualified pharmacists. It is only natural that the initial wave of prescribing pharmacists were more experienced, however as prescribing has become more embedded, pharmacists who have only recently completed their clinical diploma are registering for the prescribing course. The changing nature of the pharmacists who are prescribers needs to be considered in developing the workforce of the future. The traditional model of highly specialised clinical pharmacy skills being supplemented by prescribing is being replaced by a pharmacist with less than five years’ experience using prescribing to develop their clinical practice. Any future workforce plan for pharmacy needs to support newly qualified prescribing pharmacists with integrating prescribing into their developing clinical practice.

An important consideration is that many pharmacists’ roles remain unsuitable to facilitate prescribing. This may include management roles, governance and other non patient-facing jobs. The Single Competency Framework for Prescribers states that the prescriber ‘ensures confidence and competence to prescribe are maintained’.4 Without regular prescribing practice and appropriate patient-facing contact it is difficult to maintain an adequate level of competence. It is essential that as pharmacist prescribing evolves local, regional and national plans are in place to transition pharmacists into and out of prescribing roles; central to this is a mechanism of revalidation. 

The most significant factor in senior pharmacists no longer being active prescribers has historically been management. It is important for pharmacists that there is a clear career progression available. Having clear career pathways will result in more motivated and focussed employees.5 To ensure that pharmacist prescribers are motivated to improve, a clear career ladder is needed. The historical default of senior pharmacists moving to management roles when they are reaching the peak of their clinical career needs to be rethought.

Within large teaching hospitals with large specialist centres, a senior pharmacist clinician role is often in place, including consultant pharmacists. The challenge is in more generalist work and smaller hospitals. The pharmacy profession in the UK needs to consider how locally, regionally and nationally senior clinicians are not lost to management. Having pharmacists as managers within the NHS is essential to ensure that pharmacy has a voice in shaping the strategic direction of the NHS. Can the pharmacy profession learn from other healthcare professionals, in particular medical staff? They balance having a clinical career with management duties. The use of administration support, such as human resources and secretarial staff, would be one solution for pharmacy to consider. This would allow senior pharmacists to focus on developing the strategic direction of clinical pharmacy; prescribing would be integral to this development. 

A number of experienced pharmacists felt that with retirement on the horizon, a more junior pharmacist would be better able to maximise the patient benefits from achieving the prescribing qualification. The junior pharmacists questioned expressed the feeling that prescribing was a natural progression for their career. They had developed their abilities to clinically review and optimise medicines post registration and had sufficiently advanced their knowledge and skills. However, they felt that it was essential to have the two to three years of clinical experience, whilst they achieve their diploma, before considering a prescribing qualification. This supports the views of the Modernising Pharmacy Careers programme that only significant changes to undergraduate and pre-registration training would allow a prescribing qualification at the point of registration.6 Integral to being a competent prescriber is having the confidence and the abilities to use the qualification effectively. 

Where are they prescribing?

Supplementary prescribing lent itself to being utilised in a clinic-based setting more than wards. Pharmacist often stated that clinical management plans were restrictive when it came to managing acutely ill patients.7 Independent prescribing has meant that pharmacists can become far more active in prescribing for patients admitted to hospital. The traditional ward-based clinical role of pharmacists has been adapted to allow prescribing. This is now the care setting where the majority of pharmacist prescribing now takes place. With greater emphasis being placed on medicines reconciliation, it is only natural that pharmacists will use prescribing to correct issues identified. From a workforce planning perspective this may cause a number of issues.

Firstly, the patients’ safety needs to come first and this can only be achieved by consistent service delivery. Having robust clinical pharmacy services that are available for patients when they need it is essential. Pharmacy as a profession needs to continue the momentum around seven days-a-week clinical hospital pharmacy services. The profession needs to utilise its prescribing expertise to demonstrate the benefits of clinical pharmacy services delivered when the patients need them, as opposed to during standard opening hours. 

Upon introduction of non-medical prescribing many senior doctors where concerned about deskilling of junior doctors.8 The challenge for pharmacist prescribers working within general ward roles is to complement the work of other medical professionals. The prescribing role can be used to help educate junior doctors whilst still ensuring patient safety. The NHS is facing a reduction in medical post-graduate trainees.9

This shortfall presents an opportunity for prescribing pharmacists to adopt some of their roles. Pharmacist prescribers need to grasp this opportunity by using our unique selling point. The feeling from the registered pharmacist prescribers within the North East was that they had a focus on getting the appropriate treatments to patients in a timely manner. They were able to facilitate this by excellent communication with other healthcare professionals including GPs, community pharmacies and specialist nurses. Pharmaceutical knowledge and a focus on medication were seen to be less important as differentiating features between medics and pharmacists. Ultimately patients want access to the medications when they need them. The NHS faces a funding gap of £30 billion in the next five years.10

The NHS therefore needs to consider how it can deliver its services in a more streamlined and cost-efficient manner. The pharmacist prescriber can help deliver this vision by providing the treatments that the patient wants, when they need them. By avoiding delays in treatment and ensuring patients are on the most appropriate medicines, mortality is reduced in a wide variety of conditions.11–12 Delayed treatment can also increase the complications experienced by patients.

Pharmacist prescribers are therefore ideally suited to improve patient experience, reduce complications and minimise complications in the patients they see. Unfortunately, there is still only limited high quality outcome data demonstrating the benefits of pharmacist prescribing. Within the North East of England research has shown that pharmacists are integrating themselves into hospital prescribing practice to deliver safe and effective care for patients.13 Further research needs to be undertaken to truly understand the place of pharmacist prescribing as a core service available to all patients.

Perceived barriers to prescribing

With any new healthcare development there will always be barriers to implementation. To drive quality areas for improvement need to be identified, actions agreed and implemented to continually evolve. The main barriers encountered by pharmacist prescribers in the North East of England revolved around the balance between prescribing and traditional clinical pharmacist duties. In general prescribing has been incorporated into existing clinical pharmacists’ job descriptions. They need to balance the traditional clinical pharmacist role; ensuring patient’s treatments are appropriate and safe, with the enhanced prescribing function taking responsibility for a patient’s treatment. A number of pharmacists have found that this has led to challenges around time pressures and accountability.

Moving forward prescribing pharmacists would benefit from clarification about their role as a prescriber. A number of key areas need to be considered to embed pharmacist prescribing as a consistent feature of pharmacy practice within all areas of clinical pharmacy. These include looking at skill mix of pharmacy staff utilising technical and operational staff effectively to free pharmacists for clinical prescribing duties. Using role models and sharing of good practice allows integration and learning from developing practice. Also needed is ongoing support, mentoring and clinical supervision to be applied across regional networks. Pharmacists stated that lack of confidence was integral to preventing the further development of pharmacy prescribing. Supporting pharmacists to become active and effective prescribers is essential to ensure the ongoing development of pharmacist prescribing.

Pharmacist prescribing has positively affected the development of clinical pharmacy in the last ten years. Pharmacists now use their prescribing in many different healthcare settings to provide the highest quality pharmaceutical care for patients. Within the North East of England, pharmacy is ideally situated to use prescribing to tackle the challenges of efficiency, increasing complexity, ageing populations and new methods of delivering patient-centred healthcare. The North East England clinical pharmacy network believes that the foundations of the pharmacist prescribing have been embedded into practice. We now need to build on these foundations. Pharmacy prescribing still has massive untapped potential to deliver quality healthcare to patients. The challenge moving forward is to ensure that pharmacists are supported to allow their confidence to grow, demonstrate the benefits of their prescribing and utilise prescribing as a tool in the evolution of clinical 

pharmacy.

References

1. First prescription signed by a hospital pharmacist. Pharm J 2004; 272:369.
2. Bradley E,  Nolan P. Non-Medical Prescribing – Multidisciplinary perspectives. Cambridge Uni Press 2008;9–29.
3. Baqir W, Millar D, Richardson G. A brief history of pharmacist prescribing in the UK. Eur J Hosp Pharm 2012;19:487–8.
4. NICE/NPC. A Single Competency Framework for all Prescribers. NICE. 2012.
5. Noe RA, Noe AW and Bachhuber. An investigation in to the correlates of career motivation. J Voc Behaviour 1990;37:340–56.
6. Medical Education England. Modernising Pharmacy Careers programme. Pharmacist Prescriber Training Working Group Report for the MPC Programme Board. Jan 2010.
7. Cooper RJ et al. Nurse and pharmacist supplementary prescribing in the UK—A thematic review of the literature. Health Policy 2008;277–92.
8. Bissel B et al. An Evaluation of Supplementary Prescribing in Nursing and Pharmacy. Final Report for the Department of Health. October 2008.  Health Education England. Workforce Plan for England- Proposed Education and Training Commissions for 2014/15. HEE 2014.
9. NHS England. The NHS belongs to the people; a call to action. July 2013. Online: www.england.nhs.uk/2013/07/11/call-to-action/ (accessed 25 March 2015).
10. Gaieski DF et al. Impact of time to antibiotics on survival in patients with severe sepsis or septic shock in whom early goal-directed therapy was initiated in the emergency department. Crit Care Med 2010;38:1045–53.
11. Canto JG et al. Prevalence, clinical characteristics, and mortality among patients with myocardial infarction presenting without chest pain. JAMA 2000;283:3223–9.
12. Heymann A et al. Delayed treatment of delirium increases mortality rate in intensive care unit patients. J Int Med Res 2010;38:1584–95.
13. Baqir W et al. Pharmacist prescribing within a UK NHS hospital trust: nature and extent of prescribing, and prevalence of errors. Eur J Hosp Pharm doi:10.1136/ejhpharm-2014-000486.