Is pharmacist prescribing the ‘holy grail’ for the profession?

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Pharmacist prescribing in Australia is nearly two decades behind that in the UK, but will doctors manage to retain medical dominance?

There is room for further acceptance of prescribing as a core part of the pharmacist’s role, argues Marjorie Weiss, Professor of Pharmacy Practice at Cardiff University in Wales, in a new journal article.

Pharmacist prescribing became possible in the UK under supplementary prescribing arrangements in 2003, explains Prof Weiss, and further legislation allowing pharmacists and nurses to become independent prescribers was introduced in 2006.

“This hallmark change meant nurse and pharmacist prescribers were on a par, at least in terms of legislative authority to prescribe, with doctors,” she says.

In the UK, ‘non-medical’ prescribers’ has now expanded to include physiotherapists, podiatrists, optometrists, chiropodists and therapeutic radiographers.

Pharmacist prescribing is also seen in some states and provinces of the US and Canada.

However Australia falls further behind, with pharmacist prescribing outside of S2 and S3 medicines not allowed under the current legislation.

Prof Weiss says pharmacists’ shift towards more clinical activities has in part been a way to counter the loss of a compounding role in making up medicines, but also to enhance the professional status of pharmacists through an association with more ‘doctor-like’ work.

“With the development of pharmacist prescribing in more recent years, pharmacist prescribers may have achieved the holy grail of professionalisation,” she said.

“Prescribing is an area where professionals are able to display their clinical autonomy; their control over the object of their work, the prescription, through autonomous decision-making and, by implication, the prescribing process and how medicines are used.”

However she says despite the extension of prescribing rights to non-doctors, “medicine has retained its dominance”.

Prof Weiss argues that doctors can be seen to have intellectual jurisdiction – where one profession retains control of the cognitive knowledge of an area but allows, or is forced to allow, practice by several competitors.

“Doctors have been forced, through legislation, to allow all pharmacists to prescribe but they still control the knowledge base of prescribing,” she says.

“Pharmacy’s ideology, involving medicines expertise and an emphasis on patient safety, is not enough to give pharmacist prescribers cultural authority over clinical knowledge, possibly because medicines expertise is viewed as a subset of clinical knowledge with doctors still retaining an overarching or oversight role.”

Prof Weiss asks whether doctors’ control over the cognitive knowledge base involved in prescribing and clinical decision making should be further eroded to a more advisory role.

While UK pharmacists have been able to independently prescribe for 14 years now, of some concern are recent reports coming out of the region where prescribing or advice given by GP pharmacists has been associated with serious incidents including cases of patient deaths.

The Pharmacists’ Defence Association (PDA) reported these incidents in November last year, adding that some of the cases were “linked in some way to pharmacists prescribing inappropriately or offering poor advice, often underpinned by an assumption of competence which was ill-founded”.

Further information about the details of these cases is yet to be published.

Meanwhile in Australia, a Queensland trial of pharmacy prescribing for antibiotic treatment of UTIs is on its way.

Doctors’ groups such as the RACGP and the AMA have strongly opposed the trial, as well as the push for pharmacist prescribing in general.

RACGP President Dr Harry Nespolon told newsGP last year that pharmacist prescribing is beyond the profession’s scope of practice and would fragment care.

“I know there are lots of other providers who would like to expand their role in the healthcare system, and we see providers working to the top of their practice as a goal for all healthcare providers,” said Dr Nespolon.

“But GPs are ideally placed to manage patients because we have comprehensive long-term care and oversight of the whole condition, instead of single episodes.”

Pharmacy groups such as the PSA have thrown their support behind pharmacist prescribing, particularly collaborative prescribing agreements.

Following the Pharmacy Board’s 2019 conclusion that there are no regulatory barriers in place for pharmacists to be able to prescribe collaboratively, PSA national president Chris Freeman said: “it is incumbent now upon state and territory jurisdictions with their medicines and poisons legislation to review their legislation to remove any unnecessary barriers to pharmacists ‘prescribing via a structured prescribing arrangement’ and ‘prescribing under supervision”.

Read Prof Weiss’ full article in Research in Social and Administrative Pharmacy here (login required)

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