Led by Northumbria Healthcare NHS Foundation Trust, this project aimed to reduce the amount of medicines prescribed to care home residents unnecessarily and to involve patients and their families o...
Pharmacy and pharmacists have been long been recognised for their role in ensuring the safe and effective supply of medicines to patients. In the UK, pharmacists have been able to prescribe for almost a decade now, across a number of therapeutic areas and clinical settings. Having worked as a pharmacist in the NHS for 15 years, I’ve really welcomed this shift – as a prescribing pharmacist I have seen my clinical progress and confidence grow.
By changing the pharmacist’s role from one of ensuring the prescription is clinically correct to one of doing the prescribing, are we making care safer or adding in additional risks? To date, there have been two studies published that have reported on the safety of pharmacist prescribing: four errors (0.3%) from 1,415 medication orders written for inpatients across three hospitals in north east England; and a study in a London NHS trust shows error rates on discharge prescription orders of 0.3% and 8.8% written by pharmacists and doctors respectively.
So, it seems that pharmacist prescribers can prescribe safely. Based on these studies, Northumbria Healthcare NHS Foundation Trust (an acute secondary care trust) now doesn’t clinically check prescribing by pharmacists. And other organisations are also thinking of following suit. Of course, we will have to remain vigilant and observe for any trends in errors and poor prescribing but further, larger studies will no doubt follow to provide a greater evidence base.
But will all of this leave junior doctors deskilled? It’s a common concern that I’ve heard, but I don’t think it would. Prescribing on a ward is rarely an individual decision but is usually the result of a discussion among a wider team of health professionals. Through these discussions, the pharmacist prescriber has the opportunity to influence and teach better prescribing. And with much of the medicines reconciliation (ensuring that the medicines prescribed on admission are correct and appropriate) being done by pharmacists already, if they can also prescribe in the first place it will free up the time of junior doctors to undertake other tasks.
Less well-understood is the role of stopping medicines in the prescribing process. Can leaving a patient on a drug for many years without review be considered a medication error? As part of our Shine 2012 care home project we stopped over 700 medicines in 422 patients with the main reason for stopping these medicines being ‘no current indication’ – in other words, there’s no apparent reason for the patient to currently be on that particular medication.
I’m sure that no prescriber willingly prescribes inappropriately, but often medicines become inappropriate through the passage of time. In one case I encountered a 92 year old lady on folic acid but with no clear reason. It later emerged that she was prescribed this when she was 18, following the birth of her first child who had spina bifida. This perfectly illustrates a common situation with older people and medicines; prescribing for a good reason initially then becomes inappropriate through a lack of review and questioning. Our project shows that that prescribing pharmacists can work independently, making complex prescribing decisions.
As pharmacist prescribing has evolved, trusts have started to think about generalist prescribing roles for pharmacists, rather than pharmacists prescribing in specialist situations. This model has been adopted by Northumbria Healthcare NHS Foundation Trust who recently reported that their pharmacists prescribed for 40% of all inpatients, accounting for 13% of all medication orders prescribed. Pharmacists can prescribe for any patient in any clinical situation as long as the pharmacist believes they are competent to do so. Learning from West Midlands (being published soon) suggests that pharmacists in A&E can support acute clinical teams and undertake a number of duties relating to medicines that are currently undertaken by junior or mid-level medical staff, who face significant demands on their time.
As primary and secondary care struggle to meet the demands from an ever ageing population, the NHS needs to adapt and we need to start thinking about skill mix better. In my experience, prescribing pharmacists are an opportunity to deliver safe and effective care for many patients, releasing resource and capacity for medical and nursing practitioners. Now is the time to create the environment where these skills can be harnessed and used for the benefit of the patients and our NHS.
Wasim is a Research & Development Pharmacist at Northumbria Healthcare NHS Foundation Trust