Prescribing: lessons from the frontline

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Like many colleagues, I completed my independent prescribing (IP) qualification long before I started using it in earnest. I chose hypertension as my area of competence, not because I had anywhere to prescribe, but because it is a logical, stepwise area of therapy.

I was very lucky to persuade a semi-retired GP to act as my designated prescribing practitioner. I will always be grateful to her because having a broadly experienced clinician, who was more interested in talking about the NHS than specific medical conditions, gave us a great rapport. The relationship with your tutor is so important.

I qualified in 2017, following a dreadful OSCE in which two-thirds of us failed. This was down to the dreaded Rinne Test, which, quite honestly, I had not revised. I am a community pharmacist and had not seen a tuning fork since music lessons at school.

At the time, IP was little used. The only outlet for my new skills was a private travel clinic, which I started, but it was nowhere near enough to keep me fully occupied. Life in pharmacy continued with the usual routine of checking, OTC advice and stock ordering.

Few pharmacies had checking staff at the time, as the extra capacity was not needed. NHS and private services used up only a very small amount of time.

Use it or lose it

Being very aware that I could lose my new-found knowledge if I did not use it, I signed up to work one day a week at a GP surgery close to home. They were not sure what to do with me at first, but we formed a routine in which I would see patients in the morning, then help with queries and sign off prescriptions in the afternoon.

My behaviour may well have seemed odd to them, in that I would check whether an item was actually due before signing it off. It is only when you have worked in pharmacy that you see all the wasted medication caused by over-ordering.

I had a very steep learning curve, as the practice did not know I had never seen EMIS before or practised writing up patient notes. The other surprise was the amount of online training thrown at me: pretty much all the safeguarding, equality, infection control, digital safety and hazardous waste courses that could be found through the NHS.

I had never seen or had access to these in community pharmacy. It was quite a surprise to know they existed and even more of a surprise to be given time in work to complete them. How the other half live!

Additionally, for the pharmacy role, I attended the Liverpool School of Tropical Medicine so the pharmacy could become designated as a yellow fever vaccination centre. This attracted new patients from a wider area, many of whom also needed other travel vaccines and antimalarials, so it helped to grow my private business.

Then the Covid pandemic happened, and any developments on the prescribing front took a back seat while I ran a Covid vaccination centre.

Returning to ‘normal’ pharmacy after Covid, there were still no further developments for prescribing in community pharmacy. However, more and more pharmacists were training as IPs and pharmacy degree courses were being developed to incorporate prescribing.

My journey towards getting ready for prescribing in community pharmacy began back then with the realisation that I could only achieve safe and effective practice if I upskilled my own team to deliver more.

Team training

Being a pharmacy owner-operator, I needed to find cost-effective ways of developing skills within the team. First, during Covid, operating under national protocols, I was able to train my dispensers as vaccinators. As a result, we were able to manage the Covid and flu seasons, and the pressure was shared rather than all being on the pharmacist to deliver everything alongside their other duties.

Next, I trained all team members as accuracy checkers, so they could support me by assembling and checking prescriptions I had clinically reviewed.

Of course, robust SOPs, understood by all, were needed. Once a denigrator of SOPs, I now understood their value in spelling out exact roles and responsibilities to ensure safe and effective working.

Close relationship

In 2023, the NHS prescribing pathfinder project was announced. Fortunately, I already enjoyed a close relationship with my ICB following my work on Covid and hosting various local leaders to see what we did in pharmacy. This was invaluable in understanding what was required of me to get ready for NHS prescribing. Luckily, we had a fantastic pharmacy technician employed by the ICB to support prescribing sites.

Together, we reviewed my training records, SOPs and the risk assessment I carried out to understand how existing services and patients could be affected if I were to deliver consultations much more frequently.

In terms of facilities, I had a second consultation room put in. Legislation was changing to enable team members – pharmacy technicians – to carry out hypertension case finding. I also trained one of my dispensers under the pre-registration trainee pharmacy technician programme to become registered as an ACT. Subsequently, changes in the regulations allowed her to undertake oral contraception supply.

Almost ready, our journey to becoming a pathfinder site also involved our local GP practices. As a quirk of geography, although most local residents were registered with a GP practice across the border in another county, ICB funding meant I could only see patients from the county in which I was physically located. So I had to form brand new relationships with two practices from which I had historically received less than 5% of my patients.

Although this meant meeting new practice staff and practitioners, we could all see how the scheme would relieve pressure and support workload. I prepared a presentation and trained all the practice staff over two sessions. During those sessions, we agreed which medical conditions could be referred to me and how we would manage the process.

Software solutions

As part of the pathfinder scheme, we were each asked to source our own consultation software. My previous experience had been in a GP practice, so I visited a couple of friends who were using consultation tools and also had demonstrations from a number of companies.

My prerequisites were that my notes went back to the GP practice, that I could see previous notes and observations, and that I could copy and paste NHS numbers into the CLEO NHS prescribing software and National Care Records Service.

Unusually, because the people I was seeing were not existing patients, I had no PMR records to show me what medicines they were already taking. So it was vital that I could find out this key information in another way.

Live challenges

We went live as a pathfinder site in December 2024. Initially, the most challenging part was managing the appointments. We had agreed which practice could refer, when, and how many patients they could send. However, we were still doing Pharmacy First, private appointments and new services that I had introduced, such as weight management and hay fever clinics. All this was done with just one pharmacist (me) on duty, while the pharmacy continued dispensing NHS prescriptions and providing OTC medication.

We developed a routine where my staff contacted referred patients first thing and booked them around private and NHS appointments that had come through our own website. This became an additional daily task, and my staff took full responsibility for it.

Very soon, they became the conductors of the orchestra, with me often asking what was next – they were now managing me. We were busy with appointments all the time: not just me in my consultation room, but the team in theirs too.

Lost visibility

How did this feel compared with traditional pharmacy, and what response did we get from patients and practices?

At first, there were elements I enjoyed, but also things I really did not like. It was fantastic to use my skills, help patients and be able to prescribe, but I really missed my public – the day-to-day regulars who came to the pharmacy more for social support than anything in particular.

My staff still had the joy of chatting with them, but I lost all visibility. At first, many regular patients thought I had gone on holiday because I was always in the consultation room!

There was also a different pressure: sometimes I just wanted some downtime to do something else, or even just to see the team. We learned that breaks had to be built in between several appointments, just to give me time to breathe.

We were busy from the off. The GP practices were respectful of my capacity and, if they were really desperate to fit an extra person in, they would ring me first.

Competence assured

Predictably, especially over the winter, most of my work involved minor illnesses. At least half of referrals were for suspected chest infections. Of these, around 80% turned out to be not infectious and patients received self-care advice – but, importantly, they had been assessed and had not needed to take up a GP appointment.

At the very beginning, I was nervous about carrying out chest examinations, as I had not performed them since my prescribing course. I undertook a self-directed refresher, observing at the NHS 111 walk-in clinic and using Geeky Medics online, which gave me some reassurance.

Once I had examined many chests and identified crackles, wheezes and ‘walking on snow’ chest sounds, I felt confident that I was competent. I found that the best approach was to consider the whole patient, taking account of comorbidities, history, red flags and recent changes. The consultation itself followed a routine designed to include important clinical pointers, many of which emerged simply through talking to the patient.

We tried (although I often forgot) to provide ICB surveys to patients seen through the service to find out what they thought. Many asked to see me again when contacting the surgery. Perhaps this was because they knew they had more chance of getting an appointment with me than with a GP, rather than because they specifically wanted to see me. It was also a positive sign that they had seen value in the consultation and the system had improved patient access.

Surgery benefits

The surgery staff welcomed the flexibility of being able to triage patients to me. Although we were two miles away from the surgery, one practice manager said it was like having another consultation room along the corridor.

After holidays, I would be phoned by the practice to check I was back and able to take patients. Having previously worked in a single-handed pharmacy, this sense of being part of a team and a community was very welcome. It felt as though we were all working together to make a difference to patient care. The clinicians at the practice were also very supportive. It was odd sitting with them to discuss new ideas – odd because it was such a pleasure to be included.

There were also downsides, including my shock and embarrassment when I was told that an elderly lady I had seen had subsequently been diagnosed with late-stage cancer. I felt responsible, even though I knew I wasn’t. Being a community pharmacist rarely brings you in at the diagnosis stage – we tend only to learn about such things through patients themselves, if they choose to tell us. It was a reminder of the emotional impact that can come with taking on a greater clinical role in patient care.

Staff involvement

My staff embraced the change. After a rocky first few months, when I was stressed because I was so busy and they were stressed because they rarely saw me, we managed the workload effectively and created many new roles through delegation and personal development. My team managed the dispensary, appointments and stock, while I managed the patients.

We had initially been concerned about governance and separation of duties, particularly around prescriptions. We need not have worried. Prescribing and clinical checks by the pharmacist, supported by IT systems, followed by assembly and technical checking in the dispensary, worked well. There was always the option to send the prescription elsewhere if desired, but most patients wanted to go home with their medicine rather than spend more time waiting.

Psychologically, I would say the biggest shift was for me and my team. Patients were not concerned as long as they were receiving care. We did notice, however, how the pharmacy turned into an old-fashioned doctors’ waiting room, with patients sitting around the sides on chairs waiting for me.

Our capacity to deal with walk-ins did reduce and we had to have appointments for Pharmacy First unless I had spare capacity. Enabling more services to be carried out by other team members did, however, improve access.

The verdict

What would I conclude from my experience? Be open to change, don’t resist it, and let your team take over where they need to. Value your colleagues, as both they and the GP practice staff will make the system work. Also don’t be afraid: you will know your limitations, and as a pharmacist you are inherently cautious – no bad thing when you are responsible for patient safety.

There is no need to put extra pressure on yourself by expecting to establish a niche clinical service overnight. Start with what you know, moving on from Pharmacy First PGDs to prescribing beyond their scope and introducing other related conditions. Speak with your local practices to find out what will help them and the NHS most. By doing this, community pharmacy can truly become part of primary care.