Explanation
Current situation
We are issuing a position statement on the separation of prescribing and dispensing / supply / administration by the same healthcare professional. This is to reflect the changes to education, training and practice related to prescribing.
Our guidance, published in March 2020 states that dispensing and supply by the same healthcare professional should only take place in exceptional circumstances. We recognise that education, training and practice is evolving, in particular with increasing prescribing services in community settings, especially in Scotland and Wales.
There is no regulation or legislation restricting prescribing and dispensing for the same person, the focus is on safe / best practice. All current guidance (including RPS/RCN guide, MEP) provide the same message on the topic of separation of prescribing and dispensing or prescribing and administering. The wording stems from the Department of Health Review of prescribing, supply and administration of medicines (the Crown Report) (published 1 March 1999) led by Dr June Crown. It was Dr Crown’s two reviews which introduced non-medical prescribing to the UK, and subsequently supplementary and independent prescribing for pharmacists, nurses and other allied healthcare professionals such as physiotherapists.
Our current guidance, jointly developed and published with the Royal College of Nursing (RCN) states that:
The prescribing and dispensing/supply and/or administration of medicines should normally remain separate functions performed by separate health care professionals in order to protect patient safety.
It goes on to clarify that:
..Wherever possible, the actions of prescribing, dispensing/supply and administration are performed by separate health care professionals. Exceptionally, where clinical circumstances make it necessary and in the interests of the patient, the same health care professional can be responsible for the prescribing, dispensing and/ or supply/administration of medicines. Where this occurs, an audit trail, documents and processes are in place to limit errors.
Currently, the separation element means that one healthcare professional prescribes a medicine and a different individual supplies/dispenses/administers the item.
Changes in practice
There have been significant changes in practice since the original Crown review in 1999. We are working in different systems, aided by both advances in digital and technology, and advanced skill mix of all staff members, with more registered healthcare professionals enabled to prescribe with numbers increasing.
Independent prescribers across all professions are already prescribing and supplying or administering medicines. For example, nurses prescribe and administer routinely in urgent care and sexual health settings, doctors prescribe and supply medicines in walk in centres and paramedics prescribe and administer medicines in everyday practice when attending emergencies.
A different example is the prescribing, administration and/or supply of medicines in an out-of-hours setting which may be routine practice, the clinical circumstances are however, “exceptional” overall and it would be inappropriate to send the person to another health care professional when the aim is to prevent hospital admission.
As more pharmacists become prescribers, particularly in community settings, they are often prescribing and dispensing the medicine for the same patient. If the pharmacist was unable to both prescribe and dispense the medicine for the individual this would potentially have a negative impact on the patient experience and care.
Following a consultation with a prescribing pharmacist, a patient may be asked to go to a different pharmacy to have the medicine dispensed, this may not be practical in some cases, such as rural settings and also may delay or prevent patients who are unwell accessing medicines for an acute condition in a timely manner.
Whilst we believe that systems should continue to develop to operate in a way such that a different healthcare professional should be involved in the dispensing, supply and administration of medicines to the one prescribing the medicine, we know that this is increasingly not always possible.
With the increasing number of prescribers working in community settings, we believe that where clinical circumstances make it necessary, and in the best interests of the patient, the same healthcare professional can safely be responsible for the prescribing and dispensing / supply / administration of medicines. In these situations, a risk assessment should be conducted to establish if prescribing, dispensing and supply and administration of medicines is in the best interests of patients being served.
A robust audit trail of the decisions and the actions taken needs to be made. Prescribers need to ensure that accurate records of prescribing and supply or administration are made and appropriately communicated with other professionals supporting the patient’s care.
Risk assessment should consider the circumstances and skill mix available which could affect patient safety, the medication to be supplied, impact on patient’s access to medicines and the utilisation of the skills and knowledge of the healthcare team to be able to support the supply. Steps should be taken by the prescriber to work within their competence and professional judgement.
Independent prescribers should be supported and enabled to prescribe and dispense / supply / administer medicines for an individual person within professional guidance and by the systems in which they work.
During consultation we have been made aware of some concerns around potential financial conflicts of interest if a pharmacist is able to prescribe and dispense for the same person. Independent prescribing services are being provided through community pharmacies in Scotland and Wales to date, improving access to medicines for patients and relieving pressure and releasing capacity in other parts of the primary and secondary care system. These concerns have not been borne out in practice in these areas, with the services integral to the health of the local population, but this situation should continue to be monitored. A review of current guidance has implications across all of the professions, not just pharmacy.
A review of current guidance has implications across all of the professions, not just pharmacy.