Workforce shortages have been studied in-depth for many years. Across NHS Trusts there is a reported shortage of more than 100,000 staff with all groups being affected, including pharmacy. To meet this challenge, the NHS Long term Plan has prioritised a strategy for workforce transformation.
Aligned to the NHS Long Term Plan and to help deliver on workforce demands, Health Education England published Advancing Pharmacy Education and Training: A review. One strand focusses on the changes needed to the Initial Education and Training of Pharmacists (IETP) in order to develop the talent to enable flexibility and step into the shortfall in providing complex care.
Following the reviews at the start of 2021, the General Pharmaceutical Council (GPhC) announced changes to the format and terminology associated with the pharmacist pre-registration training year. The new ‘foundation’ training year and associated learning outcomes were launched for the intake of trainee pharmacists from 2021. One of the key changes was the proposed incorporation of prescribing into the training years.
The history and prevalence of prescribing pharmacists
The role of pharmacists as prescribers has evolved over the last two decades with the introduction of the supplementary prescribing qualification for pharmacists in 2003. This enabled pharmacists to prescribe specific medications for patients in accordance with a clinical management plan following initial diagnosis by an independent medical prescriber and with the patient’s agreement. The independent prescribing qualification for pharmacists was introduced in 2006, allowing pharmacists to prescribe autonomously for any condition within their clinical competence.
Many pharmacists felt that they were potentially being left behind by not already having a prescribing qualification
Delivering high-quality patient focused care was the drive behind this change. There has been an increase in the number of pharmacists qualifying as independent prescribers, with a particular surge over the last five years as pharmacists became embedded in GP practices and Primary Care Networks (PCNs) following the GP pilot schemes of 2015.
As of May 2020, there are over 8800 pharmacists registered as independent prescribers of the approximately 66,800 qualified pharmacists, and this growth does not seem to be slowing down. Independent prescribing (IP) has helped to re-design NHS services, providing patients with quicker, more efficient access to medications. It has also improved patient safety, upskilled the pharmacy workforce and has provided greater job satisfaction. It has also helped in reducing doctors’ workload pressures and provided them with greater flexibility in their work, allowing them to focus on complicated patients and complex treatments.
Seeking the views of practising pharmacists on prescribing
To understand wider views around prescribing, we distributed a survey to both pharmacist independent prescribers and non-prescribers within our Trust to elicit their views and experiences of prescribing, and to help understand the barriers and facilitators to the implementation of pharmacist independent prescribing. In addition, we sought to understand the importance of the place of non-prescribers in undertaking prescribing and understand the views of our current workforce, which will therefore equip us to support our staff.
How current prescribers practice
Of the fifteen pharmacist independent prescribers surveyed, approximately half currently use their independent prescribing in practice. Those that no longer use their qualification have moved into other roles which are either not patient facing or do not involve prescribing. The prescribing confidence and perceived competence was deemed high, with many pharmacists regularly prescribing medications that were high risk, including complex medication regimens such as chemotherapy, immunosuppression, controlled drugs, or critical care medications. These prescribers work closely with the multidisciplinary team and provide support in facilitating prescribing decisions.
Some pharmacists worked independently in clinics to prescribe medications.
“…[I] reviewed patients in the oncology clinics prior to chemotherapy treatment and helped to manage patients’ side effects to medications, alongside optimising the prescribing of chemotherapy medications each cycle, as well as prescribing supportive medications.” Oncology pharmacist
Medicines optimisation was at the heart of pharmacist prescribing. Patients were comprehensively counselled on their medications, improving the patient experience and encouraging adherence to medications. The supply and unnecessary dispensing of medications was reduced, and this was vital to reducing medication wastage. The prescribing pharmacists were valuable in improving patient safety by reducing prescribing errors. For example, prescribers would adjust medications prescribed according to a patient’s renal function and therapeutic drug monitoring.
“…create efficiencies for the NHS by switching patients from one brand of tacrolimus to another and this saved the hospital approximately £350,000 each year”.
Renal pharmacist
Views on newly qualified prescribers
There were mixed opinions from the current prescribers on the future of graduated pharmacists with the independent prescribing qualification. The majority felt that this was a positive step, but supervision was essential alongside a strong framework. Prescribers felt that a support forum to share experiences and learn from one another would be a step in the right direction for the future.
When considering the views of non-prescribers within the department it is worth noting that this group ranges from newly qualified pharmacists right through to experienced senior pharmacists who, for various reasons, do not currently hold a prescribing qualification. There was a total of 25 responses to the questionnaire in this category.
As seen in the prescribers group, there was a range of thoughts on the upcoming changes to pharmacist training:
“That’s really good news for the profession.”
“…don’t want experienced pharmacists left behind.”
“…I think it leaves scope for prescribing errors.”
Many pharmacists felt that they were potentially being left behind by not already having a prescribing qualification and with newly qualified pharmacists soon to be coming out as prescribers, they were worried about their development and future employability. Pharmacists asked if there were any plans for extra funding regionally or nationally to help existing pharmacists gain a prescribing qualification or whether funding would be focussed on supporting the upcoming cohorts of trainee pharmacists.
The current GPhC consultation on changes to the requirements for training as a pharmacist independent prescriber seeks to remove the current two years of post-qualification experience and need for a prescribing scope to undertake a prescribing course. Some pharmacists demonstrated concern about this in the survey as participants asked how newly qualified pharmacists prescribing would be safeguarded if this is removed:
“I feel that due to lack of experience, it would not be fully utilised and potentially unsafe.”
However, the majority felt this would still be a positive step forward for the profession as a whole once a new system has been embedded.
“That’s really good news for the profession. It might overcome the challenges in today’s NHS and improve patient’s access to care.”
Closing the gap
Of those that responded, 86 percent wanted to become a prescriber and almost half stated that they had discussed independent prescribing with their line managers. The top two perceived barriers were funding and a lack of support, but 54 percent felt they would be able to find a Designated Prescribing Practitioner (DPP). When asked if it was important to have a Designated Medical Practitioner (DMP) rather than a DPP, 44 percent felt that it was.
Of the staff who undertook the survey three-quarters felt that they wanted to do a prescribing course that included teaching around health assessment. Most pharmacists felt that the advantages of becoming a prescriber included increasing efficiency in the way they work and reducing delays that lead to patient harm, such as missed doses. Staff felt that an enablement policy would support closing the gap between themselves and the cohorts qualifying with their prescribing. This is something that would potentially provide improvements in patient care and support efficiencies within workflow experienced by non-prescribers and therefore increase their job satisfaction.
Summary
This survey predominantly acknowledged positive views and experiences in prescribing. Most respondents felt fully supported by pharmacy for funding and enrolling onto the course, and also praised their training and the DMPs. Staff felt that the incorporation of prescribing into the pharmacist’s training years was a positive step that should be encouraged, with some happy to extend that support to prescribing supervision. It must be recognised that there will be a gap for some of the workforce and the importance of a strategy to address this gap will become increasingly important.
The opinions expressed in this article are those of the author. They do not purport to reflect the opinions or views of the UKCPA or its members. We encourage readers to follow links and references to primary research papers and guidance.
Acknowledgement
This article was written alongside co-authors:
- Amandeep Kaur, Senior Pharmacist (Renal)
- Virginia Simkin, Senior Pharmacist (Aseptic Services)
- Jaime Miks, Senior Pharmacist (Teacher Practitioner)
- Aaron Teoh, Specialist Pharmacist (Oncology)
Competing interest statement:
The author declares: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.
