How pharmacist prescribing in the U.K. can inform American efforts
Unlike several other markets, the U.S. consumer healthcare system generally does not allow for the “third leg” of health care: pharmacists prescribing prescription medicines. The reasons are many and the debate continues as some states are allowing some level of pharmacist prescribing, but in general, it’s a key way the U.S. market differs. Is the grass greener and/or is the water bill higher with this model?
In the U.K., there are basic levels of pharmacy classification, defined services, training and supervision required, as well as some significant price controls and limits to the overall system. Overall, the numbers and results are impressive and have certainly contributed to a healthier U.K. population. The story is bigger than Superdrug providing Botox treatments or the myriad vaccinations available at Boots, including cholera, hepatitis A, hepatitis B, Japanese encephalitis, meningitis, rabies, tick-borne encephalitis, typhoid and yellow fever. The top U.K. drug chains can ensure that you can travel safely anywhere and look your best at the same time. On a more serious note, 12,500 high-risk asthma sufferers were identified at U.K. pharmacies last year.
The “third leg” of health care in the U.K. includes three basic classifications: drugs that can only be prescribed by a doctor, drugs that can only come from a pharmacist and drugs that are widely available to the public — OTC products. The number of prescriptions that come from pharmacists are impressive, with more than 1 million prescriptions written each year for the last two years. The “P” law is quite well defined: “Pharmacy medicines may not be sold, offered or exposed for sale by retail, or supplied in circumstances corresponding to retail sale in the course of a business carried on by any person, unless that person is, in respect of that business, a person lawfully conducting a retail pharmacy business, the product is sold, offered or exposed for sale, or supplied on premises that are a registered pharmacy … ” It’s far more expansive/inclusive than the saying “What happens in Vegas stays in Vegas.”
A U.K. pharmacy can be qualified as one of three general types in terms of the services it provides. The baseline or essential services are not surprising: dispensing, repeat dispensing, signposting, self-care, clinical governance, public health and medication waste disposal all make the initial cut. The next level, enhanced pharmacy services, include more active participation in a consumer’s wellness, including sexual health, care homes, intermediate care, domiciliary assessments, smoking cessation, needle exchange, supervised consumption, diabetes screening, weight management, healthy diet, health checks, alcohol interventions, palliative care, full clinical medication review, out of hours, shingles, and pneumococcal and meningitis. The highest level, unsurprisingly, is called advanced. This level has several components, the most complex and comprehensive of which include medicine use reviews and new medicine services.
The U.K. model centers on medicine use reviews and new medicine services. Both have broad usage, include fee caps and focus on specific conditions and/or patients. The medicine use reviews involve reviewing patients’ use of medication, ensuring they understand how their medicines should be used, making sure they understand why they have been prescribed, and identifying and addressing any problems. New medicine services are meant to support patients with newly prescribed medication for long-term conditions.
The U.K.’s experience with medicine use reviews is instructional on several levels. First, the scale is impressive. In the last year, about 3.4 million medicine use reviews were completed by more than 11,000 pharmacies. Second, there is a fee of 28 pounds — roughly $36. Third, there is a cap of 400 on how many MURs any pharmacy can handle. Fourth, there is a high degree of focus as 70% of medicine use reviews must address specific target groups and high-risk medicines: anticoagulants, antiplatelets, NSAIDs and diuretics. A focus on unintended side effects also exists with cardiovascular patients on four or more medicines, and those with respiratory conditions who are on two or more medicines.
The U.K.’s experience with new medicine services also is instructional. The scale is broad: almost 1 million new medicine services were carried out by over 10,000 pharmacies in the last year. As with medicine use reviews, a fee cap ranging from between 20 and 28 pounds exists. New medicine services also have a fairly narrow scope — pharmacist support for patients starting new therapies for asthma/COPD, Type 2 diabetes, antiplatelet/anticoagulant therapy and hypertension.
In 2016, the U.K. rolled out Healthy Living Pharmacies, an organizational development framework underpinned by three enablers: workforce development, dedicated consultation areas and community engagement.
The engagement area has thus far been the most ambitious with measured progress. Healthy Living Pharmacies provide a framework for commissioning public health services through three levels of increasing complexity, with pharmacies aspiring to get to the next level. Level 1 pharmacies promote health, well-being and self-care, and more than 8,300 pharmacies (over 70%) have progressed through the profession-led self-assessment process and registered with the Royal Society for Public Health to attain Level 1 status. It then proceeds to Level 2: prevention, in which pharmacies provide such services as medicine use reviews and new medicine services. Level 3: protection, with pharmacies in this group providing treatment.
The U.K. also has created two basic routes for allowing pharmacist prescribing — independent and supplementary. The more advanced level is the independent prescriber who is responsible for the assessment of patients with undiagnosed or diagnosed conditions, who makes decisions about the clinical management required, and who ultimately draws up a treatment plan. The independent prescriber also has the authority to prescribe the medicines required as part of the treatment plan. An independent prescriber may prescribe autonomously for any condition within his or her clinical competence.
Supplementary prescribers are authorized to prescribe for patients whose condition had been diagnosed or assessed by an independent prescriber, within the parameters of an agreed treatment plan. Supplementary prescribers can prescribe any medicine, including controlled drugs, within the parameters of an agreed treatment plan.
By 2016, almost 4,000 pharmacist prescribers — roughly 8% of the total number of U.K. pharmacists — were active. About 2,500 were independent prescribers, more than 400 were supplementary prescribers and almost 100 were both. Almost three-quarters of qualified prescribers said they had prescribed at some point since qualifying, and over 60% had prescribed in the past 12 months.
So, who can apply to be a prescriber? There are the obvious requirements: current pharmacist registration with at least two years of U.K.-based post-registration experience. It’s the next level of requirements that are more challenging: support from the sponsoring organization with proven identified service need for this role extension and a named recognized medical practitioner who has agreed to supervise, support and assess the student during his or her clinical placement. Applicants must show basic clinical competence in the area they wish to prescribe, and, more importantly, have a training framework agreed upon with a doctor or dentist. The system has built-in checks and balances.
An accredited training course will typically cost between 2,000 pounds and 3,000 pounds ($2,600 and $3,900), usually run for six months and be delivered part-time through a combination of face-to-face and self-directed studies. After the course work, a pharmacist must complete at least 12 days of learning in a practice environment with designated medical practitioner mentoring. The designated medical practitioner, who directs and supervises the pharmacist during mentoring, also is responsible for assessing whether the materials have been learned and if the pharmacist has acquired certain competencies.
So, how do U.K. pharmacists decide which areas of prescribing they will pursue? Interestingly, the onus is on the pharmacist to be already clinically competent in the areas of interest, including up-to-date clinical, pharmacological and pharmaceutical knowledge. The course does not teach clinical competence, but rather allows pharmacists to demonstrate it. Ultimately, a pharmacist is restricted to prescribing in areas of clinical competency. The choices for the pharmacist are broad: working as a GP practice pharmacist; providing travel/flu vaccinations; focusing on such men’s health issues as erectile dysfunction, premature ejaculation and hair loss; managing such minor ailments as UTIs, sore throats or ear infections; or managing such long-term conditions as asthma, COPD, diabetes, hypertension or anticoagulation services, while linking with a local GP practice.
The U.K. system also goes one step further in identifying general areas of treatment, bypassing the traditional prescription from a medical practitioner or a pharmacist. A Patient Group Direction is a written instruction for the sale, supply and/or administration of medicines to groups of patients who may not be individually identified before presentation for treatment. They allow specified healthcare professionals to supply and/or administer a medicine directly to a patient with an identified clinical condition. There is no need to wait for a prescription or an instruction from a prescriber for such conditions as chlamydia, smoking cessation, asthma and erectile dysfunction, as long as the healthcare professional working within the patient group direction assumes responsibility for assessing that patients fit necessary criteria.
As with any new paradigm, there are challenges. Among the most significant are a general lack of awareness about what pharmacist prescribers can do, funding for pharmacist prescribers, a lack of financial incentive in taking on an enhanced role with the price caps, pharmacists not always confident in diagnosing as opportunities to develop physical assessment skills are limited, and finally, some competition between different prescriber roles, especially pharmacist and nurse prescribers.
The United States is dipping its toe in the waters of pharmacy prescribing in such rural states as Idaho, and even California and Washington, but it is not a national structure. Filling gaps in care through pharmacist prescribing would strengthen community pharmacy’s value proposition within the healthcare system.
The U.K. has learned a lot about pharmacist prescribing, some through trial and error, some through not. The vast majority of these efforts work and work well. At some point, the United States will determine if the grass is indeed greener on the other side of the Atlantic.
Ed Rowland is a Drug Store News Contributing Editor covering global issues. As the principal of Rowland Global LLC (www.rowland-global.com) he believes in the promise of global business and supports companies in their strategy, tactics and execution of international growth initiatives.
Trevor Gore is the Founder of the UK-based Maestro Consulting which he founded after 20 years at RB in Pharmacy education roles focusing on pharmacy soft skills, such as communication, team building, negotiating, leadership, engagement and motivation, and shopper psychology. The Royal Pharmaceutical Society of Great Britain awarded Trevor honorary membership in 2011. In February 2016 he was presented with a lifetime achievement award for ‘Outstanding contribution to the OTC Industry’ at the UK’s SMaRT awards.
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