Pharmacist prescribing

Pharmacist prescribing

Pharmacists share a common history with general practitioners (GPs). In 1815 the Apothecaries Act saw the professions divide to become either apothecaries, who later became GPs, or chemists and druggists, who today are known as pharmacists. The pharmacist has long been the first port of call for the public on matters of health, be that due to convenience or, in the past, a less costly alternative to medical practitioner care. So perhaps we can say that the profession has now regained its past prescribing rights.

To ‘prescribe’ was defined in the Review of Prescribing, Supply and Administration of Medicines of March 1999, also known as the second Crown report and widely acknowledged as the document that launched non-medical prescribing in the UK in its present form. The detail is as follows:

Prescribe: in the strict legal sense, as used in the Medicines Act: to order in writing the supply of a prescription-only medicine for a named patient.

But commonly used in the sense of:

To authorise by means of an NHS prescription the supply of any medicine (not just a prescription-only medicine) at public expense.

And occasionally

To advise a patient on suitable care or medication (including medicine which may be purchased over the counter).

The third definition confirms that pharmacists have a long history of pre-scribing, when we consider the large number of medicines sold over the counter. The range of these medicines available over the counter has increased over recent years with rescheduling from prescription-only medicines (POM) to pharmacy only (P). Pharmacists have had a tradition of allowing timely and appropriate access for patients to medicines and care through their efforts. This has become a founding principle of expanding prescribing rights outside the traditional groups. This chapter will focus on the first two definitions of prescribing, where the recent changes have been seen.

The journey towards non-medical prescribing started in the 1980s: the first milestone was the Cumberledge report (1986) recommending ‘a limited list of items and simple agents’ that could be prescribed by community nurses to streamline care. Informed by the first Crown report of 1989, independent prescribing for nurses came into being in 1992, again from a limited formu-lary³ The list of medicines that could be prescribed, in defined circumstances, was published in the Nurse Prescribers’ Formulary. The first Crown report also recommended that nurses could supply medicines within group proto-cols, with the second report a decade later remodelling these protocols as patient group directions. Group protocols allowed nurses (or other healthcare professionals) to supply medicinal products to patients according to a strict protocol signed by a registered doctor or dentist.

The road to pharmacist prescribing, as we know it today in hospital practice, owes much to those pharmacists who practised and promoted clin-ical pharmacy in the 1980s. They demonstrated the important contribution pharmacists can make to the care of patients, instigating pharmaceutical care, and they were commended in the second Crown report for their profession-alism. In the early work around pharmacist prescribing, community and primary care pharmacy was perceived as the obvious area of practice. However, the challenges relating to sharing the medical record with commu-nity pharmacists, that have not been resolved, make this difficult. This has led to the majority of active pharmacist prescribers practising in primary care clinics or within hospital pharmacy where shared records are the norm.

Between 1998 and 1999, the committee established at the request of the Department of Health to review prescribing, supply and administration of medicine led a consultation exercise engaging all areas of the National Health Service (NHS) and the varied professions involved in the provision of health-care. The information gathered was used to inform a two-part report under the chairmanship of Dr June Crown, past-president, Faculty of Public Health Medicine and the chairman of the Advisory Group on Nurse Prescribing 1988–1989. As noted earlier, the first Crown report established group pro-tocols which this later review modified to become patient group directions. The second part of this later report focused on non-medical prescribing. The report, published in 1999, recommended that pharmacists be given prescrib-ing rights. However, the initial recommendation was that this should be in a ‘dependent’ capacity (now termed supplementary prescribing), which is sup-ported by a medical prescriber. Evidence, submitted under the consultation exercise, from other countries that already had pharmacist prescribers dem-onstrated those pharmacists involved in prescribing can often focus more time on patient concerns regarding their treatment, thus supporting greater con-cordance with therapy.

The second report from the Crown review set out its recommendations with the overriding principle that any changes to the roles of professionals ‘must at the very least maintain, and preferably enhance, patient safety’ and ‘bring about demonstrable benefits to patient care’. The need for the review was driven by changes in the roles of medical professionals and the increased complexity of care. It also noted the increase expertise of patients themselves in the management of their conditions, especially patients with long-standing disease states. It set out that changes in care should improve the convenience of services for patients as well as enabling them to be more involved in their treatment and in the control of their own health. To this end the extension of prescribing rights outside the traditional doctor and dentist model was pro-posed. The concept of two classes of prescribers was also proposed: indepen-dent and dependent prescribers, with the definitions shown in Text box 10.1. The concept of a dependent prescriber was later replaced with that of the supplementary prescriber but essentially this was just a change of nomenclature.

Box 10.1 Prescriber definitions from Crown II

The independent prescriber

Responsible for the assessment of patients with undiagnosed conditions and for decisions about the clinical management required, including prescribing. At present, doctors, dentists and certain nurses in respect of a limited list of medicines are legally authorised prescribers who fulfil the requirements for independent prescribers and this should continue. Certain other health professionals may also become newly legally authorised independent prescribers.

The dependent prescriber (now known as supplementary prescriber)

Responsible for the continuing care of patients who have been clinically assessed by an independent prescriber. This continuing care may include prescribing, which will usually be informed by clinical guidelines and will be consistent with individual treatment plans; or continuing established treatments by issuing repeat prescriptions, with the authority to adjust the dose or dosage form according to the patient’s needs. There should be provision for regular clinical review by the assessing clinician.