Pharmacist Independent Prescribers

Greater use of pharmacist independent prescribers, within the multi-professional team will increase patient access to care, improve capacity in the healthcare system and improve individual outcomes.

Introduction

As demand for health care increases and medication regimes become more specialised and complex, the role of the pharmacist independent prescriber has become increasingly important in the delivery of high-quality clinical care.

The fusion of the unique in-depth understanding of medicines by pharmacists together with the competence to prescribe without the need to consult another prescriber is a significant asset to our health services. It offers patients and other health professionals' real opportunities in improved access to care and shifting capacity in the health care system.  

While non-medical prescribing was introduced in the United Kingdom some 30 years ago, the opportunities to harness the skills of pharmacist independent prescribers in clinical care have yet to be fully realised.

This policy outlines the benefits that pharmacist independent prescribers can bring to high quality patient care and system efficiency and makes recommendations for realising the benefits of pharmacist independent prescribers in routine clinical care. It focuses on three mutually supportive conditions that must be met to deliver the full benefits of pharmacist independent prescribers in the delivery of multi-professional care and to drive quality improvement.

Our Recommendations

Professional Responsibility

For these recommendations to come to fruition, we believe there must be...

  • Openness among the pharmacy profession to act as independent prescribers
  • Attention paid by pharmacist to the training and up-skilling required to be a competent practitioner
  • Prescribing within individual levels of competence and in line with the RPS prescribing Competency Framework
  • Consideration by current prescribers to their part in developing the workforce to become prescribers of the future by becoming designated practitioners or providing development support to others.

Recommendation 1

Establish the right infrastructure, systems and tools to enable patients to benefit from pharmacist independent prescribers as part of routine care

The skills of pharmacist independent prescribers can help to build greater capacity and capability within the NHS workforce and ease pressure in areas such as acute and emergency care and primary care, including out of hours services.

The development of the health and social care workforce should be based on the needs of patients, with a focus on disease prevention and new, flexible service models tailored to local population needs. Transforming care to improve patient access to services and increase health service efficiency will require greater integration of health professionals and consistently strong leadership across the health and social care system11.

Recommendation 1.1

Commissioners should review service configurations and ensure patients can benefit from innovative service design that maximises the use of pharmacist independent prescribers.

When new services are commissioned by the NHS the opportunities for pharmacist independent prescribers to improve the patient experience/access should always be considered. 

Where there is a clear opportunity for improving access to care, local planning arrangements must integrate pharmacist independent prescribers into core models of care. This will contribute to improved patient flow and efficiencies, ensuring patients are able to see the right health professional at the right time and in the right place, from specialist clinics in secondary care through to prescribing for patients in their own home.

Career pathways must be redefined in the context of GPHC initial education and training (IET)12 reform and the future role of prescribing pharmacists. Employers and commissioners should consider how to best enable new qualified pharmacists to use their prescribing skills in a safe and effective way.

Pharmacists with advanced capability should be enabled to develop and deliver prescribing services for patients with complex needs, autonomously managing their care. Opportunities for pharmacists to work across pathway settings; inpatient clinics and out of hours should be explored and implemented.

The number of pharmacists working within general practice has increased rapidly over the last five years. These roles have an important role to play in delivering patient facing care and supporting medicines optimisation including the deprescribing of medicines where appropriate. Pharmacist working in general practice should be supported to deploy their prescribing skills to those patients who would benefit the most. 

Community pharmacists as the first contact for minor ailments and conditions is an important development13 14. Developing this role will provide greater access for patients and the public and supports community pharmacy integration into primary care teams. However, community pharmacists with an independent prescribers qualification can deliver beyond a minor ailment service, managing an extended range of common and long-term conditions. For example, pharmacist independent prescribers are equipped to provide treatment and expertise for long term conditions or vaccination programmes, working alongside their primary care colleagues to support innovation and the capacity of NHS services

Delivering pharmacist independent prescriber services in a community setting will require parity with other prescribing colleagues. The allocation of a drug budget to facilitate effective NHS prescribing in the community will be imperative in unlocking the potential role of pharmacist independent prescribers in community pharmacy. Pharmacist independent prescribers prescribing for NHS services should expect the same scrutiny of their prescribing as other health care professionals, such as formulary compliance reviews, in order to provide assurance of the quality of the service. Equity with other professions is important.

Opportunities and support must be assured for practising pharmacists to participate in research to demonstrate value in existing pharmacist independent prescriber services.

There is a perverse relationship between the need for health care and its actual utilisation15. In other words, those who most need medical care are least likely to receive it. The network of more than 14,000 community pharmacies across Great Britain helps to buck the trend of the inverse care law. Commissioning of community pharmacy prescribing services will16 ensure that people living in the most deprived areas have access to good healthcare services.

Many pharmacist independent prescribers are also working in patient facing and non-patient facing roles in out of hours centres prisons, substance misuse centres and outreach and voluntary organisations. In these role pharmacists contribute to prescribing and triage as well as providing their medicines expertise to the wider multidisciplinary team.

Recommendation 1.2

Pharmacy teams must have the right skill mix and a sufficient number of staff to be able to meet the needs of the population. 

The workforce must be aligned around patient pathways with the right person undertaking the right activity with the right skills underpinned by the right training and support.

To enable pharmacist independent prescribers to routinely use their skills and knowledge in all care settings it is essential that all pharmacy teams have appropriate skill mix within their teams and that the health professional with the right skill undertakes the right task for the patient. The clinical and technical roles of pharmacy team members such as pharmacy technicians are growing rapidly. They are skilled and knowledgeable professionals, whose skills must be used in full.

For instance, dispensaries in hospitals in the NHS are now largely pharmacy technician-led with pharmacy technicians also undertaking roles as accredited checkers, thereby releasing pharmacists to undertake more clinically orientated duties. Technology such as dispensary robots and electronic prescribing may also have improved the productivity of pharmacy staff and enabled the redeployment of staff to more person-centred roles.

Recommendation 1.3

To support optimal care, pharmacist independent prescribers must have access to appropriate information and systems for safe and effective care.

This includes:

  • Read and write access and be able to input into the patient health record,
  • The ability to request and view results of investigations
  • Recognised referral pathways
  • Input into the wider multi-professional team.
  • Access to a drug budget to facilitate effective NHS prescribing in the community

To assure safe and effective care pharmacist independent prescribers must have read and write access to appropriate information and systems in all settings. Access to relevant sections of the patient health record, including medical history and laboratory test results, will allow pharmacists to make more informed, and safe, clinical decisions in partnership with patients and other health and social care professionals. This will support improvements in the safe and effective treatment of individual patients.

All pharmacists, directly involved in providing patient care, must have access to appropriate IT systems that are interoperable with other primary and secondary care IT systems. In order to optimise the use of medicines and deliver more integrated patient care. The ability to access and share essential patient information electronically will reduce risk and improve patient safety across all care sectors.

In order to support better, and safer, patient pathways pharmacists working as prescribers in any care settings must have the ability to request and view results of investigations and access to recognised referral pathways. Pharmacist independent prescribers will be responsible for receiving the result and then acting on it. Recognised referral capacity will help integration into the wider multi-professional team, create greater autonomy of service and assure patient safety.

Greater digital capability has the potential to support prescribers and improve prescribing safety and efficiency. Pharmacist prescribers must have access to these tools in line with other healthcare professional who prescribe. These tools include remote consultations, electronic prescribing and prescribing support systems.

We welcome the arrangement for Pharmacy First Plus which gives all independent prescribers in community pharmacy across Scotland instant access to a service & funding model. To enable pharmacist to prescribe in the community they must have access to a drug budget.

Case study 1

The Northumbria NHS Integrated Pharmacy Service

The Northumbria NHS Integrated Pharmacy Service17 supports patients with medicines across care settings, with pharmacists working with the multidisciplinary team and patients, optimising medicines wherever the patient presents. Northumbria Healthcare NHS Foundation Trust has embraced pharmacist prescribing across generalist and specialist areas. All services allow for pharmacists to autonomously prescribe (or deprescribe), increasing quality, reducing risk and saving healthcare resources.

Enabling pharmacists to prescribe in an integrated system has demonstrated benefits in a variety of care settings. In care homes, the medicines burden was reduced by an average of 1.7 medicines for every resident reviewed.18 The most common reasons for stopping medicines were no current indication (57%) and residents not wanting to take the medicine after risks and benefits were explained (17%). Forty-one medicines (6%) were stopped because of safety concerns.

In the hospital setting, pharmacists prescribed 1 in 8 items for over 40% of patients, with a very low error rate of 0.3%.19 Pharmacists prescribed a wide variety of medicines from 12 out of the 15 BNF therapeutic categories. The majority of prescribing was for central nervous system, cardiovascular and respiratory medicines. 13% of the medication orders prescribed by pharmacists were for new therapy, suggesting that pharmacists are not just using their prescribing rights to correct errors, but are actively managing patients.

A key feature of the Northumbria prescribing model is patient centred care; by working within a shared decision making framework, Northumbria pharmacists are making a positive impact on patient outcomes, through prescribing.20

Case study 2

Pilot of Independent Prescribers’ Service (IPS) in Community Pharmacies in Wales

The IPS module enables community pharmacists who are also Independent Prescribers to record clinical information and medications prescribed during a consultation on the Welsh community pharmacy platform, Choose Pharmacy.  It provides independent prescribers with secure access to the patient’s Welsh GP record (WGPR). The module went live as a pilot in 13 sites in June 2020. 

Since the launch, over 2,500 consultations have been recorded, with 320 consultations recorded during the month of February 2021. The number of people accessing this service are likely to be considerably lower due to reduced footfall during the pandemic, and show the huge untapped potential of offering this service.  

Almost every user of the service (97%) said they would have visited another healthcare provider had the service not been available in pharmacy.  

Pharmacists participating in this pilot described the service as a ‘game changer’ for community pharmacy.

IPS PIP


Recommendation 2

Develop the highly trained pharmacist independent prescriber workforce required to work routinely as part of multi-professional teams in all health care settings

Expanding the number of pharmacist independent prescribers who see patients in a range of care settings across the NHS, taking responsibility and accountability for their care, will be critical in the routine integration of pharmacist independent prescribers in multi-professional service models.

Changes to initial education and training21 will lead to pharmacists qualifying as prescribers upon entry to the profession. This will transform pharmacist access to prescribing by including this training as part of the undergraduate degree. To qualify as an independent prescriber currently, pharmacists must successfully complete a General Pharmaceutical Council (GPhC) accredited independent prescribers programme operated by an accredited training institution. Pharmacists must meet the GPhC entry requirements 22 which include: identifying an area of clinical practice in which to develop their prescribing skills, having clinical or therapeutic knowledge relevant to their intended area of prescribing practice and identify a supervisor to supervise their learning in practice and sign off on their competency.

To fully realise the potential of a highly trained pharmacist independent prescriber workforce these must be a focus on supporting both initial training and the existing workforce.

Recommendation 2.1

Appropriate resources and support are needed to implement the GPhC initial education and training standards. 

The implementation of these standards will enable pharmacists to better fulfil their roles as medicines experts and realise their potential as independent prescribers

The review of initial education and training standards from the GPhC in January 2021 will enable pharmacists to better fulfil their roles as autonomous clinicians when the new standards are fully implemented.

The underpinning skills and knowledge needed for prescribing roles must be incorporated into teaching, learning and assessment at undergraduate level and throughout pharmacy careers. It is essential that the necessary additional resources and support is provided so they can be implemented correctly. To achieve these skills, it will be essential for MPharm students to be exposed to increased number of clinical placements. These placements will increase professional socialisation at an earlier stage, support earlier development of clinical skills and support a focus on applied prescribing in the foundation years.

With these changes being implemented it is essential that systems are in place to support pharmacist independent prescriber to use these skills and get the most from this investment.

Recommendation 2.2

The existing workforce must not be left behind

Adequate resources are required for the existing pharmacist workforce to undertake training and qualify as pharmacist independent prescribers. To support greater access to pharmacist independent prescribers a competency-based model should be explored.

Initial education reforms mean that newly qualified pharmacists will become prescribers at qualification. This will allow new and different service models to be commissioned. In order for this to be deliverable it is essential that the existing workforce is not left behind. Whilst not all pharmacists will need, or want, to become prescribers, the opportunity should be available to all.

Ongoing support will be essential to assure that all patient-facing pharmacists are able to access independent prescribing courses, suitable clinical supervision and ongoing education resources. Current challenges to starting the training include funding of courses, finding cover whilst training and finding a suitable supervisor. There has been government funding and support to encourage uptake in Scotland 23 and Wales 24. This support has been essential for many and these models should be considered across Great Britain.

Alongside this support other models are used globally and should be explored. For example, a competency-based model has been used in Canada for many years 25 26 27. Models vary across provinces. For example, in Alberta pharmacists can apply for prescribing authorisation. The application involves a self-assessment, review of practice and case studies 28. The applications are assessed by peers who are trained to assess in accordance with the criteria approved by the pharmacy council. To get prescribing authorisation the assessors must see evidence that the pharmacist’s practice is at a level and in an environment that would benefit from your having prescriptive authority.

Case study 3

Community pharmacy Warfarin clinic

A community pharmacist based in Hywel Dda LHB, West Wales has established a Warfarin clinic where she utilises her IP status routinely to ensure patients anticoagulant therapy is managed close to home.

Previously, patients would have attended an INR Clinic at a hospital for monitoring. For one gentleman, who is a regular patient at the pharmacy, this involved driving over 30 minutes each way and spending up to 2 hours at the

hospital depending on the number of patients waiting at the clinic.

On one occasion, three attempts were made to draw blood via a venous sample. Even after these attempts, there was insufficient blood for the laboratory to test and the patient had to travel back to the hospital again.

The patient had found the episode extremely upsetting.

The patient was offered the pharmacy based INR service. Testing is done via a finger prick test and the result is immediate. During the 7 months that he has been attending the pharmacy for testing, the frequency of his INR monitoring has reduced from weekly to every 8 weeks.

This service has made a dramatic difference to patients and ensures that they have continuity of care from their already trusted community pharmacist.

- Rachel Davies, Burry Port Pharmacy Ltd

Case study 4

Pharmacist led cardiology clinics

SIGN Guideline 148 and NICE CG172 recommend treatment with Angiotensin Converting Enzyme Inhibitors (ACEI) in patients with post-myocardial infarction (Post-MI) left ventricular systolic dysfunction (LVSD)

Figure 1 below shows an example of the improvement in the use and target dosing following the introduction of pharmacist-led clinics within cardiology in NHS Greater Glasgow & Clyde.

PIP_policy_diagram2

Achievement of ACEI dosing of baseline hospital audits vs pharmacist-led clinics for post-MI LVSD patients fit enough to return to cardiac rehab

See below link- here is the formal publication for updated results:

https://bmjopenquality.bmj.com/content/8/3/e000676

- Courtesy of Paul Forsyth MRPharmS, Lead Pharmacist, Clinical Cardiology, (Primary Care) / Heart Failure Specialist

Recommendation 3

Ongoing professional development for pharmacist independent prescribers as well as expanding their role in teaching and peer support

Through engagement with the profession there are clear indications that pharmacists feel isolated from other pharmacists and the wider multi professional teams. The development of further formal ongoing support is needed. To assure a safe prescribing environment this needs addressing. Ongoing professional support and networking opportunities for all pharmacist independent prescribers will be essential for the future roles of pharmacist independent prescribers.

Recommendation 3.1

Ongoing support must be available to all independent prescribers .

Support may include peer-support, mentoring, ongoing network opportunities and educational resources.  

It is a professional responsibility for a pharmacist independent prescriber to learn and improve from reflecting on practice and make use of networks for support, reflection and learning. How this is achieved will vary across the profession and is often reliant on individual contacts or local initiative. There is a need for greater ongoing support for all pharmacist independent prescribers.

Of the fifth of pharmacist independent prescribers who had never prescribed in the 2019 GPhC survey the reason stated by over a quarter (27%) was a lack of support, training or guidance. More needs to be done to create the right support infrastructure to develop and hone pharmacist prescribing skills throughout their careers.

Peer support and mentoring provides a structure for pharmacy professionals to reflect on their practice, share experiences and explore their professional development need. In order to find peers and mentors networking opportunities must not be reliant on individual contacts but open to all pharmacists, in many cases a multi-professional approach will be beneficial. Engaging with networks can be a tool for support, reflection and learning.

The competency framework for all prescribers 29 is published to support all prescribers to prescribe effectively. It is used as a basis for establishing initial competence by prescribing assessment courses, normally mapped using a portfolio of evidence. When pharmacist independent prescribers wish to expand their competence, it is less clear how to achieve this. There is a need to support pharmacist independent prescribers with guidance of how to expand their current scope of practice and record ongoing competence post qualification.

Recommendation 3.2

Funded learning time for pharmacists must be embedded within workforce planning. 

Improve the quality of patient care by guaranteeing protected learning and teaching time for pharmacists across all sectors.

Pharmacists do not routinely receive protected time to learn new skills, develop and maintain prescribing competency or support multi-professional team learning. Equity across all professions is now needed, ensuring protected and funded learning time for pharmacists embedded within workforce planning. For example, full time salaried GPs employed under the model contract are entitled to a minimum of 208 hours (4 hours per week on an annualised basis) of protected time for professional development a year 30

Recommendation 3.3

Training to support pharmacists to become designated prescribing practitioners (DPP’s) should be funded and accessible to all that are eligible to fill the roles. 

Experienced pharmacist independent prescribers should be supported, and given time to train, support and development new independent prescribers, to take on the role of designated practitioner as part of their leadership and a multi-professional team approach to clinical learning.

Since the introduction of non-medical prescribing, learners have undertaken a period of learning in practice to consolidate and contextualise the academic learning delivered by the programme provider. This period enables the trainee to put theory into practice and to develop and demonstrate competence as a prescriber under the supervision of an experienced prescribing practitioner.

In 2006, the Department of Health and Social Care described the role of the Designated Medical Prescribers (DMP) as critical and highly responsible for educating and assessing the trainee prescriber31. Finding a suitable practitioner for this role can be problematic and can cause difficulties in eligibility for courses, limiting the entrance numbers.

Professional regulatory changes in 2018/19 have enabled appropriate pharmacists, and other non-medical practitioners, to take on this designated practitioner role. These regulatory changes improve access to training opportunities for those eligible to prescribe, with potential to increase numbers of pharmacy prescribers. Currently, 18 of the 47 (38%) accredited independent prescribing programmes allow DPP 32. Programmes are dependent on being reaccredited with the GPhC to enable DPP, we expect this number to increase. 

Despite this change in regulation the number of pharmacists prescribing practitioners taking on the role as a supervisor is low. Pharmacists must be supported to take on the role of designated practitioner as part of their clinical leadership and a multi-professional approach to clinical learning. Education, training, and development of others is a key pillar of advanced practice, becoming a DPP demonstrates this key element of advanced practice working.

The RPS competency framework for designated prescribing practitioners33 is in place to support DPPs. Additional resources and support are required to allow for the time commitment and ongoing development of current pharmacist independent prescribers. The training needs will vary, but many pharmacist independent prescribers may not be familiar with multiple teaching methods and may face challenges allocating sufficient time to supporting the trainee.

When supervised by a pharmacist independent prescribers in training must continue to have the opportunity to work alongside medical and other healthcare practitioners. Trainees should also have as much opportunity as possible to gain experience working within a multi-professional team.

Case study 5

Support for pharmacist independent prescribers through Teach and treat centres in Scotland. 34

NES Pharmacy, in collaboration with several Health Boards, have developed Teach & treat centres to support qualified pharmacist independent prescribers working in a range of settings including community pharmacy and primary care. Many who are not using their prescribing qualification and are looking to offer specific clinic services or add to their scope of practice.  These training programmes, led by experienced pharmacist independent prescribers, help develop appropriate clinical skills to deal with a specific patient caseload and/or clinic model. This peer-led on the job experience and learning could help to support the fifth of pharmacists with a prescribing annotation not currently prescribing.

Context for change

The NHS must adapt to deal with the progressive demands of an increasing and ageing population, more people living with long term conditions1, financial constraints and challenges with recruitment and retention of health professionals.

These pressures have been further magnified by the COVID-19 pandemic which has put enormous stress on healthcare services. To provide care where it’s needed professionals are empowered to work at the height of their clinical competence2.

As the NHS moves into the pandemic recovery phase and beyond, it will be imperative to address the backlog of care and unmet need across the health care system in addition to meeting other social demands. Innovation will be the key for health services in meeting increased patient need.  

Employing pharmacist independent prescribers across healthcare settings and making the best use of pharmacists’ skills and knowledge in medicines has been recognised across Great Britain for some time and outlined in the following strategic frameworks:

  • England: NHS Long Term Plan3, Clinical Pharmacists4, Carter Review5, Integrating NHS Pharmacy and Medicines Optimisation6
  • Scotland: Achieving Excellence in Pharmaceutical Care7
  • Wales: Pharmacy: Delivering a Healthier Wales8

Whilst utilising the skills of pharmacist independent prescribers has been widely recognised and called for, innovation in service design has been slow to develop. The GPhC Survey of registered professionals9 revealed that in 2019 only 17% of pharmacists were qualified as independent prescribers and that 20% had not prescribed since their annotation. The main reasons for this were highlighted as: lack of opportunity (57%), lack of funding/resources/facilities (35%) and lack of support, training or guidance (27%).

In December 2020 the GPhC approved the new standards for the GPHC initial education and training (IET)10 of pharmacists. The standards make prescribing skills an “integral part” of pharmacists’ training and will enable pharmacists to independently prescribe from the point of registration.

When implemented these will enable pharmacists to better fulfil their roles as medicines experts and realise their potential as independent prescribers.

To realise the full patient benefit from pharmacist independent prescribers the barriers to qualifying and prescribing in practice must be addressed.

Next Steps

Implementation of each of the recommendations within this document will undeniably help to drive quality improvement in the delivery of care. This is a positive contribution to increase health care provider capacity and to reduce demands right across our health and social care system, from primary care and community services to acute and emergency care.

The Royal Pharmaceutical Society is committed to supporting pharmacists to become independent prescribers through resources to support practitioners to continue to prescribe confidently and safely 35. Including:

  • Continue to publish and maintain the updated competency framework for all prescribers in collaboration with the other prescribing professions (latest update in 2021)
  • Continue to publish and maintain the competency framework for Designated Prescribing Practitioners DPP
  • Showcase and share best practice
  • Facilitate meaningful networking opportunities for pharmacist independent prescribers.

We will continue to work with the NHS and other partners to drive this important agenda forward and to evaluate its effectiveness in improving patient care across all pharmacy sectors. This policy has been developed to instigate action at national and local levels to ensure that patient benefit from increased access and better outcomes through pharmacist independent prescribers, it is vitally important that the professions grasp this opportunity.