IPN 2022 October

Pharmacist Prescribing: Learning from international models and opportunities for pharmacists in Ireland

Independent and supplementary/collaborative prescribing, also known as non-medical prescribing, has been introduced in many countries in recent decades. Since 2007, nurses and midwives in the Republic of Ireland have been able to become registered prescribers with An Bord Altranais, upon completion of a programme of study1. The contribution of independent prescribers to the quality and safety of patient care has been studied and discussed within published literature.

Written by Mary-Claire Kennedy PhD SFHEA MRPharmS,

Programme Lead for Independent and Supplementary Prescribing,

University of Leeds

Pharmacist prescribers can make a meaningful impact on patient care, enhancing timely access to care which is delivered in a safe and effective manner. Focusing on a specialty or specific clinical area helps pharmacists to become established and integrated as prescribers in a multidisciplinary team. Within secondary care pharmacist prescribers have been demonstrated to make a positive contribution to the management of acute conditions in addition to the ongoing management of chronic conditions through outpatient clinics 2,3 . There are also studies currently being conducted to understand the contribution of pharmacist prescribers to care home or nursing home settings 4 . A Cochrane review examining prescribing by medical and nonmedical prescribers for chronic disease management in primary and secondary care concluded that specific outcomes such as the extent of diabetes control, adverse events and patient adherence were comparable when care was overseen by a medical practitioner or independent prescriber 5 . Furthermore, a study examining prescribing errors has demonstrated that independent pharmacist prescribers make fewer errors than their medical counterparts 6 . It is reasonable to say that pharmacist prescribers make a meaningful and highquality contribution to patient care.

I have been Programme Lead for Independent and Supplementary Prescribing at the University of Leeds since 2016 so I have first-hand experience of the education of trainee prescribers who are pharmacists, nurses, midwives, physiotherapists, paramedics and podiatrists. Since I joined the University, more than 500 healthcare professionals working in many different practice settings across Yorkshire and the Humber, including small and large hospitals, GP surgeries, community pharmacies, prison and custody settings, nursing homes and palliative care have completed the prescribing programme at Leeds. Having arrived as a novice Lecturer in Pharmacy Practice to the University in 2015, scarcely aware

of the existence of prescribing pharmacists, it has been a source of pride (and sometimes bemusement) that I could play such an instrumental role in the progression of the profession in the UK, while longing to see similar advancements in Ireland.

The UK could be considered to have the most advanced model of independent and supplementary prescribing, which has evolved over time, having existed in some form since 1992. It was introduced following the publication of the Cumberlege Report (1986) and the Crown Report (1989), these reports suggested that patient care would be enhanced by permitting nurses to prescribe medications, although limited these items to the Nurse Prescriber Formulary 7 . From 2003, pharmacists were permitted to become supplementary prescribers, and in 2006 could become independent prescribers. Independent prescribing powers enable pharmacists to prescribe licensed and unlicensed medications, and controlled drugs, although there are some exceptions (i.e. drugs prescribed to treat addiction) 8 . Supplementary prescribing is defined as a partnership between an independent prescriber and supplementary prescriber to implement an agreed patient specific clinical management plan (CMP) with the patient’s agreement, particularly but not only in relation to prescribing for a specific non-acute medical condition or health need affecting the patient. For example, if managing a patient with hypertension, the supplementary prescriber might be able to implement dose adjustments or introduce new medications to the management plan, provided this has been set out in the CMP and has been agreed with an independent prescriber.

At present in the UK, becoming an independent or supplementary prescriber requires that the pharmacist undertakes an accredited training programme with a Higher Education Institution (HEI) and completes a specified period of training in practice. There is an established model of funding

of prescribing programmes and accreditation of these programmes by professional regulators. Health Education England (HEE), an executive non-departmental public body of the Department of Health and Social Care, which commissions places on prescribing training programmes in HEIs. Usually commissioned places can only be offered to healthcare professionals working within the geographical proximity of the HEI and providing care to patients through the NHS. Those who wish to attend an HEI outside of their geographical area or those caring for patients outside of the NHS, can opt to pay privately for a place on an accredited course. A large part of the success of the prescribing pharmacist role within the UK is the development of roles such as advanced clinical pharmacists in secondary care or GP based pharmacists where prescribing is a fundamental part of effective care, and also the allocation of specific funding for training of these pharmacists. There are currently around 9000 pharmacists registered as prescribers in the UK, representing approximately 15% of the total number of registered pharmacists

. However, this number will increase considerably in the coming years, as from this academic year onwards, prescribing training will be integrated into the MPharm curriculum, such that pharmacists will be automatically permitted to prescribe upon initial registration with the General Pharmaceutical Council (GPhC) or Pharmaceutical Society of Northern Ireland (PSNI) 10 .

Until now only pharmacists who were more than two years qualified could apply to complete a prescribing programme offered by one of the more than forty

accredited HEIs within the UK. These courses focus primarily on developing pharmacists’ clinical evaluation, communication, diagnostic and decision-making skills. Courses usually combine a number of face-to-face study days as well as online learning materials. All teaching, learning and assessment materials are mapped to the thirty-two learning outcomes defined by the GPhC 11 . The Royal Pharmaceutical Society’s Core Competency Framework for All Prescribers, which details the skills, knowledge and behaviours that all prescribers should demonstrate, also informs teaching and assessment for many courses. The RPS Framework can also assist with planning learning and undertaking reflection when working as prescriber 12 . During the period of learning with the HEI, pharmacists are also required to complete 90 hours in practice under the supervision of a Designated Prescribing Practitioner (DPP). DPPs can be a medic, pharmacist, nurse or allied health professional with more than 3 years’ prescribing experience and who have sufficient training or experience of clinical supervision in the workplace. During this period of supervised practice, pharmacists have an opportunity to develop the knowledge and skills specifically relevant to their specialist area so that they can become a competent prescriber. It is therefore essential that a trainee pharmacist prescriber has the

full support of their employer and the clinical team they work with, as they will need to work closely with these individuals to gain a sufficient depth and breadth of experience in practice.

Other International Models

Many other countries have a version of independent and supplementary/collaborative prescribing for pharmacists, although the latter is most common. I will mention a few different models here to give you a sense of the various approaches that are adopted by different countries. Prescribing rights for pharmacists in Canada differ between provinces. Pharmacist practising within the province of Alberta are permitted to prescribe all Schedule 1 drugs (those requiring a prescription) and blood products. There are no lists of drugs; instead, all pharmacists are expected to limit their prescribing to situations where they have an adequate understanding of the patient, the condition being treated, and the drug being prescribed. Pharmacists may not prescribe drugs regulated by the Controlled Drugs and Substances Act such as narcotics, benzodiazepines and anabolic steroids. Prescribing pharmacists can order laboratory tests, access laboratory test results and authorise the administration of medications and blood products. Pharmacists are reimbursed for their prescribing in a deal brokered between the advocacy body, Pharmacists Association of Alberta and Alberta Health 13 .

One of the key drivers for independent prescribing in New Zealand was the number of GPs due to retire within the next

decade, this mirrors issues with the number of GPs in Ireland that have been widely discussed within the media. Prescribing powers were therefore broadened to other groups of healthcare professionals in New Zealand to enable equitable access to healthcare and timely access to medications. Pharmacist prescribers must work collaboratively with a medical prescriber whereas nurse prescribers can work independently

. Recently a further 200 medications were added to the list of medications that be prescribed by pharmacists. However, the number of registered pharmacist prescribers remains relatively low with only 37 currently registered as such in New Zealand. These pharmacists generally work as part of a multidisciplinary team 15 .

There are four broad models of prescribing in place in the USA, patient specific collaboration of prescribing through collaborative prescribing agreements (CPAs), population specific prescribing, state-wide protocols and class specific prescribing 16 . CPAs create a formal practice relationship between pharmacists and other health care professionals, whereby the pharmacist assumes responsibility for specific patient care functions that are otherwise beyond their typical “scope of practice,” but aligned with their education and training. Services can include initiation and modification of drug therapy. The extent of the services authorised under the collaborative agreement depends on the state’s statutory and regulatory provisions, and the specific agreement between the pharmacist and other health care professionals. There are acknowledged to be a number

of opportunities for further development of pharmacist prescribing in the USA including standardisation of prescriptive authority and giving pharmacists greater access to electronic medical records 16 .

Prescribing Pharmacists in Ireland: The opportunities and challenges

The role of pharmacist prescribers differs considerably among countries, this is likely to be a product of many different factors such as health service systems and structure, the legislative context and the perceived need for pharmacist prescribers by key stakeholders. A common feature amongst many countries is the evolution of prescribing powers over time, initially restricted to a limited formulary or collaborative/ supplementary prescribing and moving to independent or autonomous prescribing over time, with fewer restrictions on what can be prescribed. Additionally, the introduction of independent and supplementary prescribing rights is rarely implemented in isolation, they are combined with advanced practice skills such as diagnostic and clinical decision-making skills, which further enable the pharmacist to work autonomously and effectively in a range of settings.

The Future of Pharmacy Practice report identified opportunities for pharmacist prescribing in Ireland 17 . Indeed, there are pockets of innovative practice within some of our hospitals, striving to upskill pharmacists as prospective prescribers, supported by medical staff. However, there are undoubtedly several major changes required before such an advancement can be widely

introduced in Ireland. Firstly, there is the legislative change which would rely upon the support and leadership of key stakeholders. Training and education programmes would need to be established and models of funding for such programmes considered. Support of medical and nursing colleagues will be essential for training of pharmacist prescribers in practice. There is also the challenge of placing pharmacists within roles and practice settings where their contribution as a prescriber is routinely incorporated into the delivery of care to patients, such as outpatient clinics or GP-based consultations. Consideration also needs to be given to pay and reimbursement for an enhanced role and responsibility. Perhaps of greatest consequence is the acceptability of pharmacist prescribers to other groups of healthcare professionals, to patients and to the pharmacy profession itself. It must be acknowledged that gaining annotation as a prescriber without then utilising the skill will not benefit the healthcare system nor will introduction of the qualification with relatively few pharmacists seeking to become annotated as prescribers. In other words, there must be a determination and willingness for the profession to embed prescribing as part of our professional practice. Gaining acceptability and support is likely to be incremental. Perhaps starting with supplementary/collaborative prescribing could provide evidence of the value of pharmacist prescribers. Over time, as has been the case in many countries, this can evolve into a greater breadth of prescribing powers.