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Monday 26 September 2016
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PIPped to the post? The role of the independent prescriber

Patients and services

Ailsa Colquhoun

Freelance journalist specialising in pharmacy

Pharmacists are certainly very excited about the chance to become independent prescribers. From 1 May 2006, legislation started rolling out across the UK that allows qualified pharmacist independent prescribers (PIPs) to prescribe within their competence any licensed medicine for any medical condition (excluding controlled drugs*). Responding to this change, the Royal Pharmaceutical Society of Great Britain (RPSGB) President, Hemant Patel, said: "This is a significant milestone in the development of pharmacy services. This move is good news for patients, pharmacy and the wider healthcare community."

The first pharmacy students started courses in December 2006 so, as you might expect, numbers of registered PIPs remain small – only around 53 had registered (as of 3 May this year).(1) There are, however, 1,201 pharmacists qualified as supplementary prescribers, who are in a prime position to convert to independent prescribing status. Both the RPSGB and the Pharmaceutical Society of Northern Ireland have plans to include independent prescribing in future undergraduate degree curricula.

The Department of Health (DH) is also keen to see independent prescribing develop, seeing it as a way to give patients better access to healthcare services and choice of prescriber, and to make better use of nonmedical prescribers' skills. It believes that independent prescribing will give GPs and other commissioners the opportunity to broaden their service offering and, particularly in the case of a PIP, keep a lid on spiralling NHS drugs budgets. Recently, both the National Audit Office and the Office of Fair Trading concluded that there is scope for more efficient and effective prescribing in primary care, particularly among GPs.(2,3)

Getting the best out of your PIP
Although few in number, PIPs are being used in a wide variety of patient- and nonpatient-facing roles. The former may include: ongoing management of patients previously diagnosed with chronic conditions and minor ailments, as well as travel vaccination prophylaxis. Non­patient-facing roles may include: reviewing patients' discharge summaries and repeat prescriptions, and conducting patient medicine reviews.

Practices report that the greatest benefit of a PIP lies in their knowledge of pharmacology, and consider them instrumental in tangibles, such as meeting Quality and Outcomes Framework (QOF) targets, hitting generic prescribing targets and achieving practice-based commissioning (PbC) budget underspends. Some practices also attribute their ability to manage high prorata case lists and offer 15-minute appointments to their PIP.

As Dr Carole Buckley, mentor GP to pharmacist prescriber Rachel Hall, says: "We felt that Rachel had greater value than another doctor; she was less expensive and she does a better job on medicine reviews. Since employing her, we haven't  looked back."

Success-limiting factors
But are there factors that may limit the success of pharmacist independent prescribing? PIPs themselves accept that, to be truly effective, the pharmacist has to fit in with existing practices and staffing structures. Practice nurses, whether prescribing or not, may feel that a PIP is encroaching on their territory. As Karen Acott, a PIP who is also a partner at a Devon-based dispensing practice, says: "There is no real value in taking on an additional person when there's nothing really wrong with the processes that you have in place."

Also, there needs to be a high degree of interdisciplinary trust. As Dr Buckley, GP at The Old School Surgery, Fishponds, Bristol, says: "We knew Rachel and so have been able to trust her. We have enormous faith in her judgement."

Interestingly, Dr Buckley adds that she would have more reservations if she was dealing with a community pharmacist prescribing in isolation – a point that is also recognised by pharmacists' representatives. As Peter Wilson, head of post­registration division at the RPSGB, accepts: "If a pharmacist is not working closely with a GP, then it will be more difficult to gain the confidence that is needed for the GP to take on the mentor role." But, he notes: "Pharmacists are by nature conservative and don't tend to take risks. So they can be trusted to stay within their levels of expertise."

Certainly, the DH envisages that prescribing is carried out in the context of practice within a multidisciplinary healthcare team, and within a single, accessible healthcare record. For would-be community PIPs, this may prove a rate-limiting step, particularly as the recent Committee of Public Accounts inquiry highlighted that the rollout of the full electronic patient record is some two years behind schedule.(4)

However, legislative changes, allowing community pharmacists to be absent from their premises, have been mooted in the 2006 Health Act. And recently, the DH indicated that supporting legislation could be in place before the end of the year.(5)

It is not yet clear whether the changes will mean that practices have to pay a PIP a higher salary – currently, this is not universal practice, and pharmacist representatives accept that PIPs are not in it "for the money", but for professional recognition. But as the RPSGB's Mr Wilson says: "PIPs have the legal responsibility for their prescribing decision. There is a big difference between that and simply making a recommendation that a medical prescriber endorses with a prescription."

How to become a PIP
The DH's working definition of independent prescribing is prescribing by a practitioner (eg, doctor, dentist, nurse, pharmacist) responsible and accountable for the assessment of patients with undiagnosed or diagnosed conditions, and for decisions about the clinical management required, including prescribing.

Such is the DH's commitment to establishing nonmedical prescribing that it has allocated funding to meet the cost of training NHS pharmacists in prescribing. Funding for pharmacists employed by non-NHS organisations, but which provide the majority of their clinical services to NHS patients (eg, pharmacists working in hospices and in community pharmacies) may also be available, depending on strategic health authority priorities. NHS or private organisations may also pay for the training of nurses and pharmacists through other sources of funding.

Course providers accept that funding availability is currently a "hazy" issue. Denise Taylor, programme lead for pharmacist prescribing at Bath University, said: "The new funding arrangement is too new to know who it will disadvantage and its effect on uptake." She even notes: "It is still unclear how community and primary care pharmacists can apply."

How to get a PIP
Recognising that there is likely to be both strong demand for, and a supply of, would-be independent prescribers, the DH has also set out a number of criteria to help stakeholders prioritise the applicant flow.6 It advises that priority should be given to applications for independent prescribing training that show benefits to:

  • Patient safety.
  • Maximum benefit to patients and
  • The NHS in terms of quicker and more efficient access to medicines for patients.
  • Better use of the professional's skills.

The guidance leaves it to employers to decide which – if any – pharmacists should train as an independent prescriber after assessing their local service and patient needs, but it stipulates that PIPs should also:

  • Have at least two years' experience practising as a pharmacist in a clinical environment, in a hospital or a community setting, following their preregistration year.
  • Be able to undertake a specific programme of training comprising at least 25 days' study, plus at least 12 days' learning in practice. The RPSGB has set out standards/curricula for pharmacists, and is validating course providers (the RPSGB's website contains further information on accredited providers – see Resources).
  • Be supported by an agreed local need for them to prescribe.
  • Be able to act as an independent prescriber immediately upon qualifying. There should be a budget to meet the costs of their prescriptions.
  • Be supported by employers' clinical governance frameworks, and be accountable to both their employers and their regulatory bodies for their actions.
  • Be supported by a medical prescriber willing and able to contribute to, and supervise, the learning in practice element of training. It is worth noting that this is not a paid role, despite the DH seeing this as a critical and highly responsible role in assuring competence in prescribing.

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References
1. Royal Pharmaceutical Society of Great Britain and Pharmaceutical Society of Northern Ireland data on file.
2. National Audit Office. Prescribing costs in primary care. London: The Stationery Office; 2007. Available from: http://www.nao.org.uk/pn/06-07/0607454.htm
3. Office of Fair Trading. The Pharmaceutical Price Regulation Scheme. An OFT market study. London: OFT; 2007.
4. Department of Health. The National Programme for IT in the NHS. 20th report of the Public Accounts Committee 2006–07. Available from: http://www.publications.parliament.uk/pa/cm200607/cmselect/cmpubacc/390/...
5. Department of Health. Departmental Report 2007. London: The Stationery Office; 2007. Available from: http://www.dh.gov.uk/prod_consum_dh/idcplg?IdcService=GET_FILE&dID=14040...
6. Department of Health. Improving Patients' access to medicines: a guide to implementing nurse and pharmacist independent
prescribing within the NHS in England. London: DH; 2006. Available from: http://www.dh.gov.uk/prod_consum_dh/idcplg?IdcService=GET_FILE&dID=8670&
Rendition=Web

Resources
Royal Pharmaceutical Society
of Great Britain
www.rpsgb.org.uk

*The joint DH/Home Office consultation, "Independent Prescribing of Controlled Drugs by Nurse and Pharmacist Independent Prescribers", closed on 15 June 2007.