New prescribing powers put pharmacists in the front line of healthcare

New pharmacy services being rolled out across the country are improving health care for patients and boosting the job satisfaction of pharmacists.

Many of us already tap into the expertise of our local pharmacist by asking their advice on a range of issues from allergies to skin rashes. But most of us are unaware that some pharmacists are already able to prescribe medicines.

There are currently around 700 supplementary prescribers among the 46,000 pharmacists in Britain. This means that once a GP has made an initial diagnosis and prescribed the medication, if the patient is getting worse, or has side effects, the pharmacist can make changes to their medication within boundaries set out in the patient's clinical management plan.

Many community pharmacists already liaise with GPs in overseeing patients' use of medicines, and provide clinics for stopping-smoking, obesity or minor ailments. However pharmacists are about to take another leap forward. From April they will be able to train as independent prescribers - able to prescribe medication for patients under their care.

Under the new system the NHS will identify a need for and commission a particular service from a community or hospital pharmacist. The pharmacist, equipped with a budget and a new prescription pad, will start to receive referrals. Those who already specialise in a particular field such as skin conditions will quickly develop a caseload of their own patients.

Helen Williams, pharmacy team leader for cardiac services at King's College Hospital NHS Trust in London, has been a supplementary prescriber for a year. She says: "By becoming independent prescribers we will be able to prescribe for a much larger group of disease states and to a much wider group of patients. It's an important development because we will not be limited to one medical area."

Ms Williams has worked in cardiac care for 10 years and she and a senior nurse are the principle prescribers for heart patients whom she sees on a day-to-day basis. She feels sure that independent prescribing will improve patient care. "It will allow me to take responsibility for decisions that I am making. We will follow the patient up ourselves and be much more responsive to their needs."

It is hoped that the first batch of independent prescribers will come on stream at the end of this year. Hailing the development - which was announced in November - as a "significant milestone" in the development of pharmacy services, the President of the Royal Pharmaceutical Society of Great Britain, Hemant Patel called it "good news for patients, pharmacy and the wider healthcare community."

Hospital pharmacists are expected to be among the first independent prescribers. David Pruce director of practice and quality improvement at the Royal Pharmaceutial Society of Great Britain says: "Hospital pharmacists often take a patient's medical history on admission, they suggest what should be prescribed initially and outline their medication regime when the patient is discharged. Independent prescribing will allow them to write the prescription instead of simply advising the doctor on what to prescribe. They can also use their skills in specific areas such as intravenous feeding which is a complex process."

Some pharmacists who work in GP practices, will not be far behind in becoming independent prescribers due to their proximity to GPs and their access to patients' notes.

David Pruce says independent prescribing status hasn't come a moment too soon for pharmacists. "At last we will be able to use our expertise. We spend five years learning all about medicines, and now we won't simply just advise others, we'll be able to do it ourselves. When I worked in a hospital I used to advise the young trainee doctors what to prescribe. Pharmacists have been advising doctors how to prescribe for years, this is just the next step."

To become supplementary prescribers pharmacists complete an accredited education and training programme. Programmes last the equivalent of 25 days, with an additional 12 days' learning in practice supervised by a medical practitioner.

First they have to establish a prescribing partnership with a medical practitioner, then get their local hospital trust or PCT to agree that a supplementary prescribing partnership will meet a local service need. Once they have successfully completed their training, they can register with the Royal Pharmaceutical Society.

Training needs for independent prescribers are currently under discussion between the RPSGB and the Department of Health. Conversion courses for existing supplementary prescribers are being devised.

Patient care is benefiting from the Medicines Use Review - another new, optional service that has been available in some English and Welsh pharmacies since April 2004.

David Pruce explains how it works: "Pharmacists identify and target patients most at risk. If a patient has a chronic disease and is on a number of medicines, the pharmacist will ask 'Would you like to make an appointment to sit down with me and review your medication?' The pharmacist will help the patient understand their medication, and check for any problems or side effects. The pharmacist can also recommend to a doctor that they make some changes."

This service is of particular benefit to patients on complex medication regimes such as heart patients who often don't take their medicines properly, which can have a severe impact on their health.

Graham North, branch manager of the Alliance Pharmacy in Milford-on-Sea, has been providing the MUR service since last June. He says: "Patients can spend time one to one with the pharmacist and make sure they are getting the best out of their medicines whether they are prescription or bought over the counter."

Some intervention has been needed with 72 per cent of his patients. "Sometimes we modified the prescription to reduce side effects, or the patient was taking two tablets when they only needed one. The patients often say 'I'm so glad I came to you, the doctor says my health has improved."

He feels he has benefited too. "We can provide a more extensive and personal service, in private, rather than via cursory questions over the counter. It's much more interesting, it's an extension of a role we have always had."

Of the quiet revolution taking place in pharmacy, David Pruce says "Ten years ago a major consultation of pharmacists found that these changes were exactly what they wanted so the vast majority of pharmacists are on board. For the first time pharmacists are using all their skills and they are very excited about that."

Felicity Davies: 'People know us and are used to coming to us for advice'

Felicity Davies, based at Corden pharmacy in Pulborough, west Sussex, was one of the first supplementary prescribers in the UK.

I started my career at Guy's Hospital and have always felt that community pharmacists need to associate more closely with doctors in clinical work. In the past we only spoke to GPs when a problem arose, we were perceived as a bit of a nuisance. Now we meet the GPs, practice nurses and district nurses every Monday. We exchange information and discuss patients we have concerns about. Once a month the pharmacists take the lead, and bring up issues about medicines.

Our clinic for people who wanted to quit smoking used to be run by a health visitor, but when she retired I approached the Primary Care Trust to ask if we could carry on that work.

We now have a very successful scheme with three pharmacists trained by the PCT. In the daytime patients come for counselling and replacement therapy. Our success rates are 75 per cent, 25 per cent higher than the national average. I think that is because people know us and are used to coming to us for advice. A bit like the local witchdoctor.

I love the clinical work, I love seeing someone succeed in not smoking, or the look in someone's face when they have managed to lose weight. I love helping people fulfill their dreams and ambitions. I love my job full stop.

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