Prescribing in community pharmacy: The next big thing or a risky business?

Johnathan Laird MRPharmS(IP)

 

Make no mistake pharmacist independent prescribing can easily become a very risky and potentially dangerous activity if the level of competence of the prescriber is not sufficient.

 

With so much political pressure to churn out endless independent pharmacist prescribers (PIPs) I thought it might be a useful juncture at which to share my thoughts on how my opinions have formed over the last four years after qualifying as an independent prescriber.

 

As with most topics, I tend to take the middle road. I think pharmacist prescribing is essential to secure the future purpose of our profession. I am however concerned at how rapidly it is expanding and also the lack of regulation around various aspects of being a pharmacist prescriber.

 

I qualified as a PIP back in June 2015. I have been actively prescribing since then. Before I begin my narrative, I thought it might be useful to explain for the uninitiated what a PIP actually is and what they are legally allowed to do.

 

I think it would surprise the vast majority of the general public if they knew that, with a few exceptions, PIPs can write prescriptions for almost every licensed and unlicensed medicine. PIPs must complete the GPhC accredited training course delivered by one of the accredited learning provider Universities around the UK. The GPhC has stated that when prescribing pharmacists must do so within their own sphere of competence.

 

The beginning

 

I completed the course delivered by the Robert Gordon University in Aberdeen. At that time the course basically involved a period of learning in practice, a small amount of face to face training, an assessed OSCE and a number of written assessments that had to be submitted.

 

I completed the required elements, my designated medical prescriber signed off my portfolio and off I went to apply for annotation on the GPhC register.

 

And that was that.

 

Into the sunset, I marched to begin my independent prescribing odyssey. I was working for a large multiple back then. There was no commercial interest for them in me providing independent prescriber led services in community pharmacy. Looking back, to be honest on both the commercial and the risk front they were absolutely spot on. There were some local NHS funds that we managed to access at that time. My employer was to be paid £150 for a three-hour independent prescribing session facilitated by me. My wage was unaltered.

 

I didn’t know it at the time but this was the first time I fell foul of being unconsciously incompetent. I was delighted to get a shot at my dream of beginning to manage patients and get going with my pristine prescription pad.

 

How wrong I was.

 

This level of investment is, to be honest laughable. If you attempt to quantify the extra risk to the individual pharmacist, the increased indemnity insurance premiums, the required competence based CPD, the medical supervision arrangements that should be in place you will lose money. In my view that hourly rate would need to be quadrupled at least to provide proper investment to nurture community pharmacist independent prescribing initiatives. My view would be that even at a much higher price if run well the service would pay for itself. That said, results may not be immediate which is never what ambitious political types at various levels of the system want to hear.

 

But it wasn’t about money for me. So I kept going.

 

My story is reasonably well known but to summarise, in partnership with my local GP colleagues, I began to identify high-risk respiratory patients and begin the process of bringing these patients back into the system. It is well known that people with asthma often don’t attend for annual review and in the meantime, can struggle to manage their condition themselves. Anyway, this was a success and I demonstrated that I could use the community pharmacy platform to reach people with asthma who were disengaged. I began to manage these patients. I even audited my practise and looked specifically at salbutamol use in this cohort. Interestingly the graph that I produced looked exactly like the one published in NRAD. The difference being all my patients were very much alive. It was food for thought and at that time these early audits gave me great motivation to continue. I did this early prescribing activity collaboratively with my colleagues at the surgery but I largely made it up as I went along treading as carefully as I could.

 

I may talk a good game on here but when it comes to the crunch I’m as cautious a pharmacist as the next person.

 

From a prescribing perspective, I began by using my qualification to address many of those annoying things that happen in community pharmacy. For example, I was prescribing alternative medications and informing my GP colleagues back then years before any mention of shortage protocols or the like.

 

I would always prescribe within my competence so that was fine, wasn’t it?

 

Of course, prescribing within your competence is absolutely essential but learning as I did basically unsupervised in those early days looking back was not a clever idea. These days I feel looking back that this was not the best approach and I wouldn’t advocate it now. Beginning to prescribe should be done under medical supervision in my view. I think there are very few pharmacists capable of supervising prescribers at this stage. Now the items I was prescribing were low-risk creams or swapping tablets for capsules but the fact remains if as a profession we intend to scale activity in this area, which our political masters seem intent on then there should be a standardised approach baked in from the start.

 

I would summarise my early community pharmacy prescribing days as largely consciously incompetent. My caution won the day and I would never overstep the mark into an area where I had very little competence. The result of this was a self-induced stalling of my progress. I spent most of my time prescribing inhaler spacers (absolutely nothing wrong with this btw) which was a useful activity but I wanted my impact to be broader than this. There were, and are largely now, no structures for training PIPs in the community. This is changing in Scotland but even those in charge of these endeavours would recognise that it is very early days and also I suspect that once they realise the cost of mitigating associated risk the cries for increased funding will appear and grow louder.

 

This stalling of progress led me to take the leap that so many others have made to the promised land of general practice. I have not really written about my experience of working in general practice largely because until now (2 years in) I had my head down finding my feet in this devilishly complex yet interesting role.

 

Do I love it? Hell yes but I still want to own a community pharmacy someday. It’s where I feel most professionally at home.

 

I have developed professionally more in the last two years than I have since I qualified, except perhaps in the first couple of years post qualification when the learning curve is steep.

 

My final thought on this topic is around what it means to be a pharmacist. I think we need to get back to championing the notion of professionalism. Without professionalism, we are simply painting by numbers. Independent prescribing provides a mechanism for pharmacists to eventually work autonomously and provide excellent care for patients. I actually see it as a lifeline for our profession to survive and thrive into the future and I would hope in years to come pharmacists will qualify as prescribers. I am completely optimistic about the future of our profession and I hope my concerns don’t put pharmacists off completing the qualification.

 

One of the highlights of my professional life was when I signed my first prescription. I got a glimpse of profound professional autonomy and I think it is this professional autonomy that we should aspire to.

 

If we choose not to take this step we will forever be followers not leaders in patient care.

 

In my next article in this mini-series, I will reflect on my experience working in general practice so far.

 

Community pharmacy prescribing in Scotland

Sam Falconer is a community pharmacist. His current role is that of pharmacy manager at Kilwinning’s Townhead Pharmacy.

 

Sam and his team are carving out a reputation for innovation and excellence in the delivery of pharmaceutical care a the heart of their community. Sam is an independent prescriber and he has been using this qualification to deliver a common clinical conditions service.

 

This service involves him assessing and prescribing for conditions like tonsilitis, ear problems, chest complaints and other ailments not covered by the Scottish Minor Ailment Service. He is already making an impact locally and the people that use his services are extremely satisfied with the work he does for them.

 

He was good enough to join me on the podcast to talk through how he has achieved this but also some of the challenges along the way.

 

If you want to understand how to run a well thought through independent prescriber led community pharmacy common clinical conditions service then this podcast is for you.

 

 

If you prefer to never miss an episode you can subscribe on your preferred podcast platform. Just click on the links below to get going.

 

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£1 million investment in Scottish community pharmacy prescribing clinics

Community pharmacy contractors in Scotland can once again avail of funding to run community pharmacy independent prescribing clinics.

 

The total value of money allocated for the financial year 2019/20 remains unchanged from last year at £1 million. The level of payment for a clinic session will remain unchanged at £150. Community pharmacy contractors may claim a one-off payment of £750 for new clinics starting up.

 

The announcement comes following the review of the funding model. Allocation of the funding is to be controlled by the Directors of Pharmacy at a local Health Board level. The funds available to each Health Board are outlined below.

 

Community Pharmacist Supplementary and Independent Prescribing Clinics 2019/20 Share – £1million

Ayrshire and Arran

£73,933

Borders

£21,050

Dumfries and Galloway

£21,719

Fife

£68,114

Forth Valley

£57,565

Grampian

£98,954

Greater Glasgow and Clyde

£222,776

Highland

£64,443

Lanarkshire

£126,662

Lothian

£148,529

Orkney

£4,842

Shetland

£4,914

Tayside

£78,497

Western Isles

£0

 

Matt Barclay Director of Operations at Community Pharmacy Scotland commented;

 

“We welcome this funding intended for IP clinics based in community pharmacies where access and expertise is readily available. We also have the first of two cohorts of community pharmacy focussed independent prescribing intakes going through our university courses with funding, this is also to be welcomed.

 

“We are looking to engage with Scottish Government to ensure that sustainable services can be developed for all independent prescribing in community pharmacy and to this end, we will look at developing a robust framework to support this.

 

“This should look at how this can be best achieved through Health Board support, infrastructure and funding so that the policy objective of enhancing IP use through community pharmacy can be achieved. The current IP intakes focus is on developing skills to deliver IP common clinical conditions services and this aligns with the policy. It is important for SG, the pharmacy network, the wider primary care team and ultimately patients that we help find a sustainable solution for everyone.”

 

Jonathan Burton a community pharmacist independent prescriber who runs clinics in his community pharmacy in Stirling said:

 

“I welcome this continuation of independent pharmacist prescribing clinic funding for community pharmacists in Scotland, which supports vital, accessible local services and encourages innovation in community pharmacy practice. It is worth noting that there are an increasing number of community pharmacists going through the independent prescribing qualification and additional NES clinical skills training with a view to running walk-in clinics from their pharmacies for common clinical conditions, very much an expanded Minor Ailments or ‘Pharmacy First’ service model, and we are fortunate in Scotland to have specific funding arrangements to support this pipeline of new community-based independent prescribing pharmacists.

 

“However, with such walk-in clinic models becoming more commonplace and more ‘active prescribers’ working in the community sector it is vital that IP clinic funding keeps pace, whether that is via an increase in the currently allocated £1 million, or indeed a more comprehensive overhaul of our current core contractual funding model to reflect the additional workload and complexity involved in operating IP clinics in an accessible, effective, safe and sustainable way.

 

“We also need to be mindful of the ongoing training and support needs of community pharmacists offering an increasingly wide range of walk-in clinic and public health services, and ensure that resources are in place to support their peer review and continuing education/CPD activities.”

 

You can read the full Scottish Government circular here.