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.
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.