Prescribing the future

The Prescription for Excellence action plan was recently published by the Scottish Government. It sets out a vision for a new integrated role for pharmacists in Scotland. The plan complements the 2020 vision route map set out in 2011 which aims to put the patient at the centre of decision making through integrated services and more emphasis on prevention.

The new action plan will see pharmacists working more closely with GPs, having a greater role in prescribing and delivering more healthcare services directly to patients.

It will also see pharmacists having increased responsibility for prevention, minimising health inequalities and the pharmaceutical care of residents of care homes.

“Wow,” says Alex MacKinnon, the Royal Pharmaceutical Society’s director for Scotland. “It’s very ambitious. It’s evolutionary, and I think in a sense, it’s revolutionary as well, which is quite exciting.”

When the document was published, Health Secretary, Alex Neil, said: “This action plan will allow our pharmacists to achieve their own ambitions and use their knowledge to complement other healthcare professions – becoming an even more valued part of the NHS team.”

The ambitions referred to by Neil have been articulated most frequently by the RPS. MacKinnon describes it as a culmination of what he’s been campaigning for throughout his career. “Pharmacy, since 4,000 BC when the ancient Sumerians kicked it all off, has been involved in the sale and supply of medicines. It’s only in the last few decades that it’s really started to advance,” he explains.

The Right Medicine policy document, published in 2002, “changed the ballgame” for pharmacists “because it wasn’t a strategy for pharmacy, it was a strategy for pharmaceutical care of a patient.”

This gave pharmacists a role in the primary care of people in a more person-centred approach. The increased roles for pharmacists in public health made Scotland a world-leader in pharmaceutical care, according to MacKinnon: “Scotland led the way when we introduced the Right Medicine. It changed the focus toward person-centred care. I don’t think there’s any other country in the world which has enabled an opportunity for the role of the pharmacist.”

Prescription for Excellence takes the role further. One of its ambitions is to have all pharmacists as independent prescribers by 2023. “This new action plan is a great opportunity. It kind of takes it to the next level and builds on what’s gone before. The important thing is we’ve all got an expectation that it doesn’t unpick what’s gone before but builds on what’s already been delivered,” says MacKinnon.

Cross-party support was key to the success of Right Medicine, according to MacKinnon, and he calls for similar attitudes for this new plan: “We got full cross-party support for developing the clinical role of pharmacists. I think it’s really important that we get cross-party support for continuing that journey, because it just takes it to that next level.”

Even if there is no political objection, some doctors have been reticent about increasing the clinical role of pharmacists. Dr John Gillies, chair of the Royal College of General Practitioners in Scotland, admits that there has been some resistance among his profession: “My view is that primary care is so busy, and there is so much to be done, that the time is past when we should be arguing over having first point of access to everyone, because GPs do not have the capacity to do this. I think the important thing is to get the appropriate professional to the patient. That may well be the pharmacist, much of the time.”

The RCGP is already working on a project with the RPS in Scotland looking at joint working: “Fundamental things like what messages should we be giving out about self-care at pharmacies, because actually, giving out these messages is quite important in controlling demand. We need to think about how there are things people can look after without seeing either a pharmacist or a GP. That’s empowering for the individual as well. My personal view, and I think GPs are coming round to it, is that we should be working with pharmacists in this area,” says Gillies.

MacKinnon agrees: “Doctors are experts in diagnosis. Pharmacists are the experts in medicines, and their use. Both can be prescribers. That’s why the pharmaceutical care bit, after diagnosis is made, is very important. It’s a partnership between the GP, the patient and the pharmacist. Also the nurse, or the social care worker, whoever it is involved. I would love to see pharmacists and the whole team sitting down reviewing a patient from a caseload perspective, and looking at who needs to do what,” he says.

Objection could be the least obstructive factor for Prescription for Excellence.

Mark Feeney, policy and development pharmacist, Community Pharmacy Scotland, says there is a lack of clarity in how the plan would be enacted chronologically. He highlights three main fundamentals that need to be in place before the document’s aspirations can be met: IT, workforce planning and education.

IT has proved to be a major obstacle to integration when pharmacists, GPs, hospitals, and social work all use different systems. Patient records are separate.

“If you want pharmacy to take on a more involved role, and a further management role with chronic conditions, we’re going to need access to the information,” points out Feeney. Christina Wanscher of the Health Innovation Centre in Southern Denmark told the European Telemedicine Conference in Edinburgh recently that the Danes were piloting a shared care system in which GPs, hospitals, social care, pharmacists and the patient were able to access the patient records. “Sharing information builds trust,” she said.

Workforce planning would a bigger proposition, according to Feeney. An increase in volume of the dispensing service of 70 per cent over the last ten years and the development of other services such as smoking cessation, emergency hormonal contraception and public health promotion have seen workloads increase. About 350,000 Scots also now use their pharmacist for chronic medication, claims Feeney, which is “probably the start of the process of an increased role in managing chronic medication for patients with a long-term condition. What is the tipping point? The challenge for us is how do we do what we’re doing just now and all these new things?”

The Prescription for Excellence suggests health boards should be encouraged to carry out pharmaceutical needs assessments for every area of Scotland. This is a matter of urgency, says Feeney, “so we can identify rural areas and how we get in there. How many pharmacists do we need in inner-city Glasgow? We don’t at the moment know.”

The Prescription for Excellence indicates that patients should register with a named pharmacist, but Feeney believes that continuity of care is best realised with a patient registering with a pharmacy practice led by a generalised pharmacist, who can delegate to their team or refer the patient to specialist pharmacist or GP. “I think the strength of the generalist has to be recognised. There’s a real strength in having a generalist community pharmacist out there who can manage the majority of the patients and build a relationship.”

This would require training up the whole pharmacy team, says Feeney, including furthering the responsibilities of technicians. One of the suggestions in the action plan is that extra capacity workload could be performed by robot dispensers, which MacKinnon calls “scarily accurate.”

Feeney says: “We’re getting more and more volume in terms of the dispensing we’re doing, more services and responsibility. How do we find the efficiencies to deliver all these things?  Upskilling the team is absolutely critical, and probably a lot cheaper than having a robot.”

MacKinnon says robots are a long-term investment: “Robotics isn’t going to happen overnight, because it’s quite an intensive investment, but over a period of time it is a way of releasing pharmacists to be able to spend more time with patients.”

Time with patients is important, pharmacists agree, to have the interaction needed to play a greater role in prevention and inequalities. MacKinnon calls it the “Pharmaceutical care conversation”, and allows for “opportunistic interventions” such as pointing out the effect of smoking on blood pressure.

The regulator, the General Pharmaceutical Council, insists it is used to rapid change: “We’re used to working in an environment where requirements are constantly evolving and therefore having to look at our regulatory approach, and how we make sure that keeps pace with proposals for the future,” says Lynsey Cleland, GphC director for Scotland, “we’re really looking to work very closely with the Scottish Government with education and training providers around ensuring that our registrants have the necessary skills and knowledge to deliver these services safely.”

Education is the most pressing priority, according to Feeney. If all pharmacists are to be able to prescribe by 2023 then it’s a challenging timescale, he says: “Most pharmacists don’t have that qualification at the moment. That means you’ve got to get the degree changed in four or five years for the guys starting out.”