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It may be an unfashionable thing to say at the moment – but prescribing might not be for everyone.
Data from last year’s salary survey by The Pharmaceutical Journal found that not all existing registrants actually want to become an independent prescriber. Family commitments making it difficult to find the necessary study time or older pharmacists feeling they are too close to retirement to retrain were two of the reasons given.
Other barriers to community pharmacists becoming active independent prescribers included minimal protected learning time, difficulty securing supervision and, for those who have managed to gain a prescribing qualification, the lack of opportunity to use it – none of which, incidentally, appear to have held back the roll-out of pharmacist prescribing in Scotland.
Nerve-wracking
“The training is challenging, even a little nerve-wracking,” admits Emma Boyle (pictured above), a pharmacist prescriber at Kennyhill Pharmacy on the Cumbernauld Road, part of the 33-strong independently-owned M&D Green group.
“Your practice as a pharmacist is being tested, so I completely understand that it might be difficult for longer qualified pharmacists. However, the role of pharmacy is changing and we have to get with the times. For me there was no question about it. I had to get on board [with prescribing].”
The risk for existing registrants who opt not to go down the prescribing route is that they may not have the skills that employers are looking for in the future, she says. “If you want to be at the forefront of community pharmacy, prescribing is definitely something you should do.”
So what next for Emma, who was in one of the first cohorts of community pharmacists in Scotland to undertake the Practice Certificate in independent prescribing in 2022? M&D Green has already taken part in an out-of-hours care pilot and is looking at sexual health interventions as well. Both provide prescribing opportunities.
“The role of pharmacy is changing and we have to get with the times. For me there was no question – I had to get on board with prescribing”
The company is also doing a great deal to support its pharmacist prescribers with six-weekly training sessions and experts coming to talk about certain subjects.
“Pharmacy First Plus is definitely where we have the most impact day-to-day at the moment but I want to develop my competencies in different areas. We will continue to look at local needs where existing services are overloaded,” she says. “Prescribing can enable us as a business to do so much more for patients.”
Aim is universal coverage
The managing director of the M&D Green group is founder, Martin Green (pictured below with Numark chair Harry McQuillan), who has been chair of Community Pharmacy Scotland since 2006. So who better to ask about the future of pharmacist independent prescribing in Scotland when he popped into Kennyhill Pharmacy.
“The increase in pharmacist prescriber numbers across the network is going well,” he told me. “Training places continue to be oversubscribed each year, but there are significant numbers of pharmacists going through the programme.
“We’re probably close to around 30 per cent of the network having access to an IP. That figure will probably be not far off 50 per cent within the next 18 months.
“There is the added element of the pharmacist graduates coming out in 2026 able to prescribe, but none of us are sure exactly what they’re going to do from day one and where they will fit in the bigger picture,” he points out.
So is the ambition universal coverage – in other words, every community pharmacy in Scotland with a pharmacist prescriber? “I don’t see why not,” says Martin.
“We are certainly on that trajectory. If you’d asked me about this 10 years ago, I’d have said it was an aspiration, but it’s now within touching distance. In the next five years there will be a prescriber in every pharmacy in Scotland – and, in many pharmacies, more than one.”
How successful this will be in supporting the NHS depends to a large extent on further refining the service and having the right funding in place, says Martin.
“The system for prescribing, as originally set up, wasn’t hugely sophisticated. It had a purpose, which was to encourage pharmacists to become prescribers and remunerate them in a different way from how they were remunerated in the past, which was on a sessional basis through the health boards.
“If I’m being honest, with my commercial hat on, it simply doesn’t work. It was meant for those pharmacists who had a passion for prescribing to becoming prescribers. It wasn’t because it added any revenue commercially to the pharmacy,” he says.
“We took a view that if we could add value to community pharmacy businesses by having an independent prescriber there, then that would accelerate the [prescribing] roll-out – and it did.
“We now have to refine the system to change behaviours, and encourage pharmacists to engage with more patients and spend more time away from the dispensary and in the consultation room. I believe it is in our gift to do that.”
Successful approach
What Pharmacy First Plus has done in particular is enable community pharmacists to treat acute, typically self-limiting conditions and move the focus away from long-term conditions, which is where pharmacist prescribers have typically operated in the past, says Martin.
“This approach has been successful because, in terms of adding value to the wider NHS, it relieves a lot of pressure elsewhere in the system such as general practice and out-of-hours services.”
However, he sees several other potential avenues where pharmacist independent prescribers could be used to manage long-term conditions in the community.
“We’ve never quite managed to progress our Medicines Care and Review service, which puts patients onto serial prescriptions for their long-term conditions. Being an independent prescriber gives you an opportunity to better manage those conditions.
“I can see, within the next few years, less need to compartmentalise these services under Pharmacy First, Medicines Care and Review, for example, and bring them together under one broad heading, which is caring for the patient. So what we’re delivering in two or three years’ time might look quite different from today.
“A prescriber could be dealing with a whole host of different issues when seeing a patient.”
What about potential challenges? Martin is clear that the supporting infrastructure needs to improve – contractors are soon to start collecting data on the impact of IP services and prescribing activity to demonstrate the value to the Scottish Government – and the funding model re-examined.
“It needs to evolve to recognise things like pharmacies operating with multiple IPs and opening for extended hours.” The IT should enable direct communication with GPs and auditable consultations, he adds.
“The Scottish Government is very supportive of the service, which has been helpful, but actually hasn’t found any dedicated money to back prescribing, which is currently supported by repurposed money from within our contractual framework. If we are to get the service to where it needs to be, it will need some new investment.”
Central to practice
The overriding impression I took away from my day talking to community pharmacist prescribers in Glasgow was how central – even routine – prescribing has become in their practice, driven largely by the Pharmacy First Plus service.
It was also very apparent how rewarding the pharmacists, all at different stages of their careers, found using their prescribing skills and knowledge to benefit their patients.
Having the right policy framework in place, carefully developed over a sustained period, is obviously helpful. As in Wales, health planners in Scotland identified gaps in primary care provision that could be plugged effectively by pharmacist independent prescribers – and the sector has risen to the challenge.
Contrast that to England, where it seems more a case of: ‘let’s make everyone a prescriber.... now what shall we do with them?’.
The learnings from the Pathfinder programme notwithstanding, it is far from clear how pharmacist prescribing will work in England.
As highlighted by the recent paper from Warner et al, there are complexities to resolve around the separation of dispensing and prescribing (and balancing commercial and clinical pressures), supervision and ongoing support for prescribers, funding, regulatory oversight, liability and scope of practice – to give just a few examples. How were some of these issues addressed in Scotland?
“Scotland recognised that for a period of time there would be, in effect, a two-tier service from community pharmacies whilst the current pharmacist workforce undertook postgraduate training,” says Harry McQuillan. “The impact of this would diminish over time as more existing pharmacists qualified and the pharmacy graduates entered the register.”
“What was also recognised was the need for two additional things – a service to be available to allow the prescribing skill to be deployed on qualification and the establishment of a support network for prescribers,” he adds.
The first issue was addressed through the establishment of the Pharmacy First Plus service allowing pharmacists to prescribe beyond the PGDs in place for Pharmacy First. This became a natural evolution to prescribing as the network had been intervening in care through the previous Minor Ailment Service and Pharmacy First services and its ability to provide advice, referral and appropriate treatment.
Secondly, a prescribing group was set up by Community Pharmacy Scotland and whilst I was there it was by far the group which saw the greatest engagement and debate. This would tend to support the view that ongoing support will be necessary, particularly in the early stages of prescribing deployment.”
The art of the possible
Scotland shows what’s possible in progressing the prescribing agenda. Harry McQuillan sums it up: “For community pharmacists, the future must be about the safety of medicines supply and ensuring patients get maximum benefit from their therapies. Prescribing is a key part of that.
“We must challenge ourselves to move towards a more clinical future by shifting the focus towards providing care through services.
“Independent prescribing is set to become a cornerstone of community pharmacy. With the right support, pharmacists can play a far greater role in managing chronic illness, treating common conditions and making public health interventions through prescribing”.
What I saw during my visit to Glasgow were pharmacists in Scotland grasping this opportunity in both hands, leading the way in what amounts to the most radical transformation of community pharmacy’s practice model in decades.
It was great to see.
Kennyhill Pharmacy is a Numark member. Click here to read the first article in the series.
First person: Michaela McEleney, pharmacist prescriber, Kennyhill Pharmacy
“I’ve been qualified as an independent prescriber for just under a year, so I’m still relatively new to it, but it’s great – I really enjoy it.
I prescribe for patients with common clinical conditions about three days a week when there is another pharmacist working with me in the pharmacy. This gives me the time to do the consultation and the second pharmacist clinically checks what I’m prescribing.
Having two pharmacists definitely takes the pressure off the operation of the pharmacy when I’m in the consultation room.
After I received my prescribing qualification, I got in touch with two of the local GP surgeries and sent them a list of my competencies and the conditions for which I intended to prescribe. Handling common clinical conditions makes so much sense for community pharmacy.
The doctors were really keen on the idea. I ask them to get patients to phone ahead, just to make sure I’m here and I’ve got the time to do it.
Each consultation takes a minimum 20 minutes, which gives me time to speak to the patient, record my notes and complete the paperwork. Most of the patients are grateful for the appointment and the opportunity to get our advice and support.
When some of them come in for the first time, and I’m checking their oxygen levels or using a stethoscope to listen to their chest, they say things like ‘I didn’t realise that a pharmacist could do this!’. When I explain to them that this is what pharmacists do these days, they appreciate how thorough we are and the time we can give them, especially if they’ve been unable to get a GP appointment.
Sometimes it’s hard to manage patient expectations – for instance, if they are expecting antibiotics for a sore throat. However, pharmacist prescribing makes so much sense for patients and the health service.
In a couple of years’ time, I think most community pharmacists will be based in consultation rooms providing clinical services and doing a lot more prescribing. For me, it’s been a very positive experience.”
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