Tackling barriers to independent prescribing
Pharmacist independent prescribing is billed as the key to a more clinical future but there are many hurdles still to be overcome
Independent prescribing (IP) has been hailed as a boon for an overstretched health service. Community Pharmacy Scotland chief executive Harry McQuillan describes it as a “game changer” for the NHS in Scotland and sees the NHS Pharmacy First Scotland service — which currently focuses on minor ailments — as a gateway to allowing community pharmacists to prescribe for chronic conditions in the future.
So far, so promising, but niggling questions remain. Are community pharmacists getting adequate training and support to use their prescribing skills? Is the right infrastructure in place to ensure opportunities are seized? And how do you persuade local commissioners to make use of this growing workforce?
• In its recently published recommendations on growing the IP workforce, the Royal Pharmaceutical Society delved into some of these concerns.
• A quarter of all UK registered pharmacists now hold an independent prescribing qualification (11,134 out of 42,990, according to GPhC figures)
• A quarter of the trained prescribers who had not used their qualification felt they did not have the right support infrastructure
• Every UK pharmacist entering training in the future will be a qualified IP upon registration.
The RPS first looked at the infrastructure needed to help patients access pharmacist IPs as part of their routine care. “Where there is a clear opportunity for improving access to care,” it says, “local planning arrangements must integrate pharmacist independent prescribers into core models of care.”
The RPS says that while the growing use of community pharmacists as a first contact for minor ailments is “an important development”, pharmacists with a prescribing qualification can “deliver beyond a minor ailment service, managing an extended range of common and long-term conditions”.
This means giving IPs working in a community setting “parity with other prescribing colleagues”.
The allocation of a drug budget to facilitate effective NHS prescribing in the community will be imperative to achieving this, says the RPS.
Establishing the right skill mix in the pharmacy is another key requirement. Staff members such as pharmacy technicians are “skilled and knowledgeable professionals whose skills must be used in full”.
The RPS also insists that IPs in any setting must have the same read and write access as other prescribing health professionals, as well as access to other digital tools such as remote consultations and prescribing support systems.
A case study highlights a 2020 pilot programme in Wales in which IPs working in the community sector were given access to patients’ Welsh GP record (WGPR) to record clinical information and the medicines they prescribed. A huge majority of patients using the service (97 per cent) said they would have gone to another healthcare provider had the service not been available.
Lack of support
Lack of support is another barrier to the effective deployment of IPs, the RPS said, pointing to a 2019 GPhC survey showing that a quarter of trained prescribers who had not used their qualification felt they did not have the right support infrastructure.
The survey also noted that despite their medicines expertise, many pharmacists felt they lacked clinical assessment skills after qualifying and “did not always feel confident in diagnosing”, commenting that “pharmacists do not generally receive opportunities to develop physical assessment skills as part of their training”.
More needs to be done to create the right support infrastructure to develop and hone pharmacist prescribing skills throughout their careers, said the RPS.
For some community pharmacists, the real challenge is finding opportunities to use their skills once they are qualified – and geographic location may be a big factor here. One pharmacist in England told Pharmacy Magazine that she had “never been able to prescribe anything in community pharmacy as employers frowned upon it”.
Meanwhile, a pharmacist working in Wales said she had just started writing prescriptions for an INR service, although she acknowledged that she had seen many IP services become “non-starters because of barriers at local health board level”.
It may be that creating a critical mass of IPs will bring about the pull factor needed to bring NHS commissioners on board. Landmark changes to pharmacist initial education and training (IET) announced at the end of 2020 mean every UK pharmacist entering training in the future will be a qualified IP upon registration.
It is certainly an exciting time for those joining the profession – but the existing workforce must not be left behind, says the RPS, insisting that all patient-facing pharmacists should have access to training courses, clinical supervision and CPD resources. The cost of training and sourcing backfill can also pose significant barriers, it adds, suggesting that the support offered by the Scottish and Welsh governments should be available across the UK.
Announcing the changes to IET in December, GPhC chair Nigel Clarke told Pharmacy Network News that it would take action on this in 2021. “We can’t lose sight of supporting people who may need to do the necessary [prescribing] training who are already on the register,” he said. “This is something you will hear more from us about over the next year… we understand there will be that demand and we will seek through our regulatory work to support that.”
When approached recently for an update on this, the regulator said it was working with other stakeholder organisations and looking into issues such as whether the entry requirements to IP courses should be changed. The GPhC also highlighted the plans being developed in each country of the UK to increase training opportunities and encouraged pharmacists to contact course providers directly with any queries.
Led by the Celtic nations, pharmacist prescribing is on the move at last towards a target of enhanced clinical patient care. It could be both an exciting journey and destination for the sector.