This month saw the publication of a White Paper which may lead to important changes in the practice of pharmacy, and pharmacists’ relationships with doctors1. One area of particular interest is prescribing, historically a monopoly of the medical profession. Initially restricted to supplementary prescribing, where treatment was dictated by predefined treatment plans agreed with clinicians, pharmacists are now becoming independent prescribers.
Initial analysis of 2004-2006 Prescription Analysis and Cost (PACT) data relating to supplementary prescribing showed a limited impact confined to chronic disease states2. Although lack of awareness of the potential usefulness of non-medical prescribing and funding issues may have been factors in the limited uptake of pharmacist prescribing, a lack of enthusiasm from the medical profession, or professional defensiveness, may also have been present3.
Not all pharmacists will want to make the leap to prescribing. However, there are confident and capable pharmacists who can provide additional skills to aid patients with their medicines.
Despite the White Paper, pharmacist prescribing could be held back by GP concerns about professional independence. Such concerns have existed since the inception of the NHS in 1948, but seem heightened at present. In a climate where some argue that general practice is undergoing a form of "creeping privatisation", this week saw David Cameron claiming that government plans for Polyclinics would lead to the closure of up to 20% of general practice surgeries4. Some may see the extension of pharmacists' role into prescribing and management of long-term conditions as part of a drive to blur and weaken professional boundaries. In other words: another threat.
This would be a shame. Issues of medication compliance, monitoring for adverse effects of medication, dosing adjustments, and application of evidence-based medicine in chronic diseases seem an ideal place to use the skills of modern pharmacists. Preventable drug-related admissions are associated with common drugs, often related to prescribing problems, adherence issues, and monitoring5. Pharmaceutical companies often market new products using improved compliance or reduced monitoring requirements as unique selling points. Prescribing pharmacists could be another mechanism for ensuring the safe and effective use of medicines. Why not use them?
An example of the beneficial working relationship that can be produced is that of Stephen Inns, a pharmacist who is managing 1,800 patients with hypertension in a GP practice6. As well as dispensing lifestyle advice, he also prescribes anti-hypertensive medication. He is not seen as a threat by the medical staff within his practice, but rather an asset.
"Stephen has got a very strict delineation of what he's allowed to do and what he can't do," said Dr. Simon Hunter, a general physician who trained Inns and works with him in the Winchester clinic. "His skill is manipulating medicines. He doesn't make diagnoses."
Not all pharmacists will want to, or be capable of, making the leap to prescribing. However, there are confident and capable pharmacists who can provide additional skills to aid patients with their medicines. Although further research looking at outcomes in patients would be welcome, there is a case for using the specialist skills of pharmacists to help manage increasingly complex medicines and patients with chronic conditions. However, they will need the confidence of general practitioners to facilitate this new role.
- Pharmacy in England: Building on strengths - delivering the future. Department of Health, April 2008
- Guillaume L, Cooper R, Avery A, et Al. Supplementary prescribing by community and primary care pharmacists: an analysis of PACT data, 2004-2006. J Clin Pharm Ther. 2008 ;33(1):11-6
- Cooper RJ, Anderson C, Avery T, et Al. Nurse and pharmacist supplementary prescribing in the UK--a thematic review of the literature. Health Policy. 2008; 85(3): 277-92.
- Fifth of GP surgeries 'at risk'. BBC News on-line (accessed 23rd April 2008)
- Howard RL, Avery AJ, Slvenburg, S. Which drugs cause preventable admissions to hospital? A systematic review. Br J Clin Pharmacol 2006; 63(2) : 136-147
- British pharmacists blur line with doctors, treat patients, prescribe drugs. The Canadian Press (accessed 23rd April 2008)
Author’s competing interests: None declared
(Picture: Wellcome Images)