Pharmacists share a common history with general practitioners (GPs). In 1815 the Apothecaries Act saw the professions divide to become either apothecaries, who later became GPs, or chemists and druggists, who today are known as pharmacists.
Pharmacist
prescribing
Pharmacists share a
common history with general practitioners (GPs). In 1815 the Apothecaries Act saw
the professions divide to become either apothecaries, who later became GPs, or
chemists and druggists, who today are known as pharmacists. The pharmacist has
long been the first port of call for the public on matters of health, be that
due to convenience or, in the past, a less costly alternative to medical
practitioner care. So perhaps we can say that the profession has now regained
its past prescribing rights.
To ‘prescribe’ was
defined in the Review of Prescribing, Supply and Administration of Medicines of
March 1999, also known as the second Crown report and widely acknowledged as
the document that launched non-medical prescribing in the UK in its present
form. The detail is as follows:
Prescribe: in the
strict legal sense, as used in the Medicines Act: to order in writing the
supply of a prescription-only medicine for a named patient.
But commonly used in
the sense of:
To authorise by
means of an NHS prescription the supply of any medicine (not just a
prescription-only medicine) at public expense.
And occasionally
To advise a patient
on suitable care or medication (including medicine which may be purchased over
the counter).
The third definition
confirms that pharmacists have a long history of pre-scribing, when we consider
the large number of medicines sold over the counter. The range of these
medicines available over the counter has increased over recent years with
rescheduling from prescription-only medicines (POM) to pharmacy only (P).
Pharmacists have had a tradition of allowing timely and appropriate access for
patients to medicines and care through their efforts. This has become a
founding principle of expanding prescribing rights outside the traditional
groups. This chapter will focus on the first two definitions of prescribing,
where the recent changes have been seen.
The journey towards
non-medical prescribing started in the 1980s: the first milestone was the
Cumberledge report (1986) recommending ‘a limited list of items and simple
agents’ that could be prescribed by community nurses to streamline care.
Informed by the first Crown report of 1989, independent prescribing for nurses
came into being in 1992, again from a limited formu-lary3 The list
of medicines that could be prescribed, in defined circumstances, was published
in the Nurse Prescribers’ Formulary. The first Crown report also recommended
that nurses could supply medicines within group proto-cols, with the second
report a decade later remodelling these protocols as patient group directions.
Group protocols allowed nurses (or other healthcare professionals) to supply
medicinal products to patients according to a strict protocol signed by a
registered doctor or dentist.
The road to
pharmacist prescribing, as we know it today in hospital practice, owes much to
those pharmacists who practised and promoted clin-ical pharmacy in the 1980s.
They demonstrated the important contribution pharmacists can make to the care
of patients, instigating pharmaceutical care, and they were commended in the
second Crown report for their profession-alism. In the early work around
pharmacist prescribing, community and primary care pharmacy was perceived as
the obvious area of practice. However, the challenges relating to sharing the
medical record with commu-nity pharmacists, that have not been resolved, make
this difficult. This has led to the majority of active pharmacist prescribers
practising in primary care clinics or within hospital pharmacy where shared
records are the norm.
Between 1998 and
1999, the committee established at the request of the Department of Health to
review prescribing, supply and administration of medicine led a consultation
exercise engaging all areas of the National Health Service (NHS) and the varied
professions involved in the provision of health-care. The information gathered
was used to inform a two-part report under the chairmanship of Dr June Crown,
past-president, Faculty of Public Health Medicine and the chairman of the
Advisory Group on Nurse Prescribing 1988–1989. As noted earlier, the first
Crown report established group pro-tocols which this later review modified to
become patient group directions. The second part of this later report focused
on non-medical prescribing. The report, published in 1999, recommended that
pharmacists be given prescrib-ing rights. However, the initial recommendation
was that this should be in a ‘dependent’ capacity (now termed supplementary
prescribing), which is sup-ported by a medical prescriber. Evidence, submitted
under the consultation exercise, from other countries that already had pharmacist
prescribers dem-onstrated those pharmacists involved in prescribing can often
focus more time on patient concerns regarding their treatment, thus supporting
greater con-cordance with therapy.
The second report from the Crown review set out its recommendations with the overriding principle that any changes to the roles of professionals ‘must at the very least maintain, and preferably enhance, patient safety’ and ‘bring about demonstrable benefits to patient care’. The need for the review was driven by changes in the roles of medical professionals and the increased complexity of care. It also noted the increase expertise of patients themselves in the management of their conditions, especially patients with long-standing disease states. It set out that changes in care should improve the convenience of services for patients as well as enabling them to be more involved in their treatment and in the control of their own health. To this end the extension of prescribing rights outside the traditional doctor and dentist model was pro-posed. The concept of two classes of prescribers was also proposed: indepen-dent and dependent prescribers, with the definitions shown in Text box 10.1. The concept of a dependent prescriber was later replaced with that of the supplementary prescriber but essentially this was just a change of nomenclature.
Box 10.1 Prescriber definitions from Crown II
The independent prescriber
Responsible for
the assessment of patients with undiagnosed conditions and for decisions about
the clinical management required, including prescribing. At present, doctors,
dentists and certain nurses in respect of a limited list of medicines are
legally authorised prescribers who fulfil the requirements for independent
prescribers and this should continue. Certain other health professionals may
also become newly legally authorised independent prescribers.
The dependent prescriber (now known as supplementary
prescriber)
Responsible for
the continuing care of patients who have been clinically assessed by an
independent prescriber. This continuing care may include prescribing, which
will usually be informed by clinical guidelines and will be consistent with
individual treatment plans; or continuing established treatments by issuing
repeat prescriptions, with the authority to adjust the dose or dosage form
according to the patient’s needs. There should be provision for regular
clinical review by the assessing clinician.
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