Background

Pharmacists have been prescribing in the UK since 2003, following the success of nurse prescribing. The review of prescribing, supply and administration of medicines (the second Crown Report) in 1999 proposed that new groups of professionals could apply for permission to prescribe in specific clinical areas.1 Pharmacists were among a number of professional groups, including nurses, midwives, physiotherapists, podiatrists, optometrists and radiographers, that were considered for enhancements to their prescribing rights.2 Pharmacists were the second group of health professionals to become non-medical prescribers, following nurses.

Kocić and Stewart argued that internationally, 24% of pharmacists were already undertaking ‘some form’ of prescribing3; the UK approach is to provide a legal framework for roles that clinical pharmacists already undertake.

The journey

Pharmacists were first given prescribing rights (supplementary prescribing) in 2003 following the successful completion of a supplementary prescribing course at a UK school of pharmacy and subsequent registration with their regulatory body.4 The supplementary prescribing model was dependant on a prior diagnosis and an agreed and signed clinical management plan, developed in collaboration with the patient's general practitioner or hospital doctor (the independent prescriber), prescribing pharmacist, prescriber and the patient.1 Once this plan is in place, clinical responsibility and prescribing could be transferred to the supplementary prescriber from the doctor. Clinical management plans were individual to the patient but could be based on local, national or international guidelines. Supplementary prescribing was seen as an opportunity to release additional healthcare resource, using a group of experts to take on some of the responsibilities of doctors. Supplementary pharmacist prescribers could prescribe any licensed medicinal product, including controlled drugs (this was added in 2005 after changes in the law).2 This model of prescribing was similar to the American model of collaborative drug therapy.5

In 2006, pharmacist prescribing rights were extended to independent prescribing, allowing suitably qualified pharmacists to prescribe any medication for any condition, excluding controlled drugs and unlicensed medicines, limited only by their professional knowledge and ability (competence).6 This change gave pharmacists almost equal rights as independent medical prescribers. Subsequent changes in the law (2009) allowed pharmacist independent prescribers to prescribe unlicensed medicines, and in 2012 an amendment to the Misuse of Drugs Act Regulations allowed prescribing of controlled drugs, with the exception of schedule 1 and 2, for the treatment of drug misuse. At this point in time, independent prescribing pharmacists have the legal authority to issue prescriptions for any medicine, any condition in any patient; a situation that many in the profession would not have imagined only 15 years ago.

Pharmacist prescribing in the literature

Early supplementary prescribers were generally welcomed and perceived to be beneficial to patient care (improved access to medicines and fewer delays), although some barriers to implementing prescribing on a wider scale were identified.7 This was in contrast with an older study, undertaken in 1992, prior to the introduction of non-medical prescribing where general medical practitioners showed that they supported some pharmacy prescribing roles for minor interventions such as nicotine replacement but had concerns about pharmacists prescribing more complex drugs (eg, cimetidine).8

Patients' views were also positive, with one study showing that the majority of respondents agreed or strongly agreed when asked if they were satisfied with their consultation with a prescribing pharmacist. Respondents also agreed that they were happy with the treatment advice they received from the pharmacist and that the pharmacist was interested in them as a person.9 However, this research did show that given the choice, 65% they would see a general practitioner over a prescribing pharmacist.9

Prescribing by pharmacists is increasing, albeit slowly. The Regional Drug and Therapeutics Centre in Newcastle report on non-medical prescribing showed that in 2009, 592 pharmacists were registered as prescribers in England (Northern and Yorkshire Regional Drug and Therapeutic Centre, personal communication, 2012). Of 152 primary care trusts (strategic organisations that manage primary health care delivery in England), 70% (107 primary care trusts) had shown prescribing activity by pharmacists. This report shows that pharmacists prescribe a wide variety of medicines across all chapters of the British National Formulary. An analysis of prescribing data from 2004 to 2006 (England) showed a significant increase in the numbers of prescriptions written by pharmacists in primary care (2706 items in 2004 to 31 052 in 2006).10 However, this still only represented less than 0.5% all prescribing in England. Positively, pharmacists did prescribe a wide range of drugs from most British National Formulary sections, including cardiovascular, CNS, respiratory, endocrine and gastrointestinal medicines.10 Other authors have described pharmacist activity in a number of areas; cardiovascular care in a hospital setting,11 primary prevention of cardiovascular disease, hypertension in primary care12 ,13 and an HIV outpatient clinic.14 Hospital pharmacists reported pharmacist prescribing activity in more complex and specialist areas such as total parenteral nutrition, nutrition and cystic fibrosis.15 ,16

George et al,17 in 2005, investigated the experiences of the first supplementary prescribers; over two-thirds of pharmacists worked in a primary care setting and only half the respondents had actually written a prescription. Early prescribing was mainly undertaken by pharmacists working in general medical practices. This ‘clinic setting’ fitted well with the supplementary prescribing as many of these pharmacists were seeing patients who already had a diagnosis—for example, hypertension or diabetes. Pharmacists would create management plans with general practitioners and take on a caseload of patients. Examples of pharmacist prescribing in a hospital setting are mainly working in clinics as this again fitted well with the supplementary prescribing model. This model was restrictive for pharmacists working on acute wards, where it was difficult to make a decision and then write/agree a management plan before prescribing could take place. Furthermore, patients are only on the ward for a short duration, thus not justifying the time and effort needed to write a plan. The change in legislation allowing pharmacists to work as independent prescribers created more opportunities for hospital pharmacists to work with medical teams as prescribers.18 ,19