Pharmacist Prescribing – It’s Time!

Australian pharmacists lag behind their counterparts in other western economies (particularly the UK) in their scope of practice involving independent prescribing.
In Scotland, for example, around 40 percent of pharmacists are registered as prescribers.
The problem in Australia is a cultural one.
Firstly, there has been disharmony within the pharmacy profession through disruption of the development of clinical pharmacist practitioners.
And secondly, there has been disharmony between the medical profession leadership and the pharmacy profession leadership with the war cry being “turf wars!”
The solution requires a continuous cultural change by all healthcare leaders, which promotes harmony and fosters collaboration that enables a common patient engagement and focus.

It is time to end disruptive political power games!

There is a commentary in the editorial column in this edition of i2P which discusses the nucleus of a cultural solution titled “Bridgebuilders”.
It is worth reading about, and it is a solution derived from within the medical profession.
It deserves support.

The alternative is not acceptable – patient disappointment, professional disillusion and exacerbating health care costs, with disappointing patient care delivered from a system of dubious value.
From a pharmacist perspective, patient care needs to be driven through the enablement of clinical pharmacist practitioners able to deliver a range of clinical services in a variety of settings.
These settings include:

1. A community pharmacy;

2. A GP practice;

3. A hospital setting (both public and private);

4. A nursing home setting;

5. As an independent practice setting located in a health precinct or primary health care service;

6. Any other setting suitable for a patient engagement.

Suggested activities suitable for delivery by clinical pharmacist practitioners include:

1. Health literacy consultations – particularly as a driver for Self Care and a Minor Ailments programs;

2. Aged care services;

3. Chronic illness monitoring;

4. Public health programs – Stop Smoking, Mental Health, Weight Loss, Sexual Health;

5. Advanced clinical services in a hospital

6. Any other program that can be delivered collaboratively or independently that fills an unmet patient need.

The enabling skill that would drive the entire process is that of independent prescribing that observes and acknowledges that there has to be a separation between prescriber and dispenser, to avoid conflict of interest issues.

So how are clinical pharmacist prescribers created in other countries?

Using the UK, (and Scotland in particular), as being a reasonably developed model, it is worth commenting and understanding their prescriber evolution.

In the UK, regulations to allow pharmacists to prescribe independently came into effect in 2006.
However, there existed prior to independent prescribing, an alternative form of prescribing in the UK called supplementary prescribing.
This is prescribing performed by a pharmacist under a protocol created by a medical practitioner.
And this type of prescribing would not necessarily be deemed to create conflict of interest with a community pharmacy, provided the choice of the pharmacy was made by the patient.

A pharmacist independent prescriber may prescribe autonomously for any condition within their competence.
The only exclusions are three controlled drugs for the treatment of addiction.
In order to qualify as an independent prescriber, you must complete a General Pharmaceutical Council accredited program. (GPhC-accredited program )

With the successful completion of the program a practice certificate in independent prescribing is issued creating eligibility for annotation on the official register.
Programs typically run over a six-month time period delivered part-time, with a combination of face-to-face teaching (one day per week) plus self-directed study.

Some universities offer a program with a larger distance learning option.
However, all programs will involve a minimum of 26 days of teaching and learning activity.
In addition to this, each pharmacist must successfully complete at least 12 days of learning in a practice environment whilst being mentored by a medical practitioner.

Several universities now offer GPhC-accredited conversion programmes to allow supplementary prescribers to become qualified independent prescribers.
The conversion course consists of at least two days’ teaching and learning activity and two days’ learning in practice.

Independent prescribing entry requirements

The GPhC requires that pharmacists applying to undertake an independent prescribing program must:

* be a registered pharmacist with the GPhC or the Pharmaceutical Society of Northern Ireland (PSNI)

* have at least two years’ appropriate patient-orientated experience in a UK hospital, community or primary care setting following their pre-registration year.
(There is some debate currently as to the removal of this requirement (to align with GP training), but there is opposition within pharmacist ranks wishing to retain this requirement.)

Those wishing to undertake the conversion program must:

* be a registered pharmacist with the GPhC or the PSNI with annotation as a supplementary prescriber

* be able to provide evidence of prescribing experience which is no more than two years old

* provide a statement of support from a medical practitioner that confirms their competence as a supplementary prescriber.

Applicants to both the full and conversion programs must:

* have identified an area of clinical practice in which to develop their prescribing skills and have up-to-date clinical, pharmacological and pharmaceutical knowledge relevant to their intended area of prescribing practice

* demonstrate how they reflect on their own performance and take responsibility for their own CPD.

* Additionally, the provider must ensure that the designated medical practitioner (DMP), identified by the pharmacist, has training and experience appropriate to their role.
This may be demonstrated by adherence to the Department of Health Guidance (2001).
The DMP must have agreed to provide supervision, support and shadowing opportunities for the student, and be familiar with the GPhC’s requirements and learning outcomes for the program.
Course providers may stipulate additional entry requirements, so it is best to check the full entry requirements with your chosen place of study with (see Accredited independent prescribing programs).

New roles for independent pharmacist prescribers.

Research conducted in the West Midlands from April 2013 by Health Education England – West Midlands, identified a potential role for the Pharmacist in areas such as pre-discharge medicines optimisation in the Emergency Department (ED) and Acute Medicine Units, as well as within Clinical Decision Teams in the undertaking of medicines-related and minor-focussed clinical duties.
Such duties are often undertaken by junior medical staff; staff who face significant demands on their time with emergency admissions.
This new independent prescriber role:

  1. Provides advanced clinical skills training for pharmacists
  2. Develop a medicines-focused clinician; able to practice as a pharmacist prescriber, while also assisting in wider clinical duties
  3. Develops a program relevant in terms of content and transferability in urgent and acute settings across secondary, primary and community care. These independent prescribing pharmacists have been given the title of Clinically Enhanced Pharmacist Independent Prescribers (CEPIP).

CEPIP development offers the ‘hands on’ training opportunities to produce the pharmacist of the future – a practitioner with advanced skills to confidently and competently manage patients with health assessment, diagnostic and clinical examination skills comparable with that of an Advanced Clinical Practitioner.
Finally a pharmacist is being recognised as part of the health care team!

Research supporting Independent pharmacist prescribers.

Support for pharmacist prescribing is growing globally, with many doctors calling it a “logical step”.
A group of UK researchers recently reviewed 65 studies — including 13 from Australia — exploring patient, doctor and pharmacist attitudes before or after implementation of pharmacist prescribing in a country.
The majority of studies were positive about pharmacist prescribing, the researchers write in the British Journal of Clinical Pharmacy.
The main benefits of pharmacy prescribing are seen as increased access to healthcare, a perceived improvement in patient outcomes, decreased workloads for doctors and better use of pharmacists’ skills.

Some insights from the review:

* Patients believe pharmacist prescribing improves access to care.
But those who haven’t yet experienced pharmacist prescribing believe it should be for a restricted list of medicines or only for minor ailments.

* The majority of patients exposed to pharmacist prescribers consider them as competent as doctors.

* Doctors generally acknowledge that prescribing for limited conditions, including minor ailments, is a “logical step”.
But they worry about the impact on their relationship with patients, pharmacists’ lack of access to clinical records, and communication between the pharmacists and other people treating the patient.

* The majority of doctors who have worked alongside prescribing pharmacists in the UK support their new role.
They believe it’s a good use of pharmacists’ skills.

* Some policymakers believe pharmacist prescribing will reduce costs and doctors’ workloads, and improve patient outcomes.

* Pharmacists agree they need training, but have different ideas about their prescribing role.
Some want to prescribe within an agreed clinical management plan or for patients with stable chronic conditions.
Others want to be able to modify treatment based on lab tests they’ve ordered.

* Pharmacists are worried about increased liability, lack of time and resistance from doctors when trying to develop a management plan for a patient.
They have differing views on whether independent or supplementary prescribing is best for pharmacists and patients.

* Pharmacist prescribing is most advanced in Scotland, where around 40% of pharmacists in 2017 were either prescribers or undertaking training.

While the “overwhelming finding” of their review was positive, the researchers say countries looking to establish pharmacist prescribing still need to conduct their own investigations.
It’s important that implementation studies explore ways to remove the barriers such as lack of funding and pharmacist access to patient records, they conclude.

Our comments on this report

* It is interesting to note pharmacist attitudes to prescribing – some feeling more confident with a supplementary clinical-plan driven protocol, while others favour the independent role and the challenge to prescribe or de-prescribe based on tests they have ordered.
From an i2P perspective it seems obvious that the supplementary version is suited to the control of a community pharmacy setting, while the independent prescriber is more suited to advanced clinical settings but could also suit a community pharmacy setting provided “arms-length” practice (separate ownership) was involved.
Independent prescribers would add value to a community pharmacy because they would be additive to the prescription volume for that pharmacy.

* Patients not previously exposed to pharmacist prescribing believe that prescribing pharmacists be limited to a restricted list of items for minor ailments.
From an i2P perspective these patients may have simply reflected the attitudes and values of their community pharmacist who would have had a leaning towards protocol driven supplementary prescribing.
If a community pharmacy was to develop a “minor ailments program” one of the first items that I would expect to find would indeed be an internal pharmacopeia listing items supported by that pharmacy with evidence notes published with each monograph.
Such a publication would harmonise the prescribing by the pharmacists attached to that pharmacy with the expectation that those same pharmacists could research and have other items inserted as additions to the list.

* Doctor concern relating to pharmacist not having access to clinical records may be a problem in the UK.
In Australia, that problem may be overcome with an improved MyHealth system.
However, the Australian system is the identical version to that recently rejected in the UK for lack of privacy provisions.
There is some comment on this problem in the editorial column of this edition.
The medical profession in Australia is voicing concern – have pharmacy leaders caught up with the potential of the MyHealth system to drive independent prescribing and the negatives if the system is not respecting patient privacy?

* Pharmacist prescribers may reduce health care costs (as voiced by the policy makers).
i2P believes that this would be true, particularly if integrative prescribing initiatives were followed.
UK pharmacist prescribers attached to GP surgeries, state that they were found to have value through educating doctors and staff to the economics of prescribing choices (processes or selection), not always realised or understood by people attached to GP surgeries.
This flowed through to increased patient satisfaction – always a positive.

What now?

That ought to be obvious.
Australian pharmacists lag behind most other western economies in pharmacist clinical development.
Pharmacy leaders must lead and accelerate the Bridgebuilding process to create a harmonious profession that is capable of collaborating with all other health professions.
And they must promote and support independent clinical service practitioners with an independent prescribing role.
In other words culture change – It’s a “no-brainer”.



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