Independent Prescribing Research Articles

Investigating practice integration of independent prescribing by community pharmacists using normalization process theory: a cross-sectional survey.

Independent prescribing (IP) has not been extensively investigated in community pharmacy (CP). Normalization process theory (NPT) constructs help explain how interventions are integrated into practice and include: 'coherence' (understanding), 'cognitive participation' (what promotes engagement), 'collective action' (integration with existing systems), and'reflexive monitoring' (evaluation). To use NPT to investigate the integration of pharmacist IP in CP. NHS Scotland Pharmacy First Plus (PFP) is a community pharmacy IP service. Questionnaire items were developed using the NPT derived Normalisation MeAsure Development (NoMAD) tool for an online survey of all PFP IP pharmacists. Demographic data were analysed descriptively and scale scores (calculated from item scores for the 4 NPT constructs) were used for inferential analysis. There was a 73% (88/120) response rate. Greater than 90% 'strongly agreed'/'agreed' to NoMAD items relating to most NPT constructs. However, responses to 'collective action' items were diverse with more participants answering 'neither agree nor disagree' or 'disagree'. A statistically significant difference in NPT construct scale scores with significant p-values (ranging from p < 0.001 to p = 0.033) was shown on all the NPT constructs for the variable 'On average, how often do you consult with patients under the PFP service?'. This theory-based work offers perspectives on IP integration within CP. Despite its geographic focus this work offers insights relevant to wider contexts on IP integration. It shows 'collective action' focused 'organisation' and 'group process' challenges with a need for further work on staff training, resource availability and utilisation, working relationships, communication and management.

Exploring prescribing volume among pharmacist independent prescribers in community pharmacies across Wales

Abstract Introduction In a 2019 document titled ‘Delivering a Healthier Wales’, the Welsh Government presented a transformative vision for healthcare that emphasises a shift from hospital-centred healthcare to community-based care.[1] As part of this vision, independent prescribing (IP) is to be implemented in every community pharmacy by 2030.[1] Recently, the independent prescribing service (IPS) has allowed pharmacists to manage and treat patient conditions within the community pharmacy, offering a potential solution to the increasing demand for general practitioners (GPs). A substantial increase in IP consultations is evident, with 16,005 consultations recorded across 33 out of the 713 community pharmacies in Wales since 2016.[2] Aim This study aimed to explore, for the first time, the number of items prescribed by community pharmacists across Wales and in each of the seven local health boards (LHBs), as well as determining from which British National Formulary (BNF) chapter the medicines were prescribed. Methods A retrospective secondary data analysis of community pharmacy prescription data was conducted. Monthly prescription data of prescribed items were obtained from the Comparative Analysis System for Prescribing Audit (CASPA) from January 2020 to December 2022 and analysed on a three-monthly basis. To compare changes in prescribing volume across LHBs, the number of items per 100,000 population was calculated. The CASPA data were categorised into BNF chapters, and a Pareto analysis was performed to determine the most prescribed therapeutic areas. These accounted for 80% of total prescribing, which was used for further analysis. LHBs were coded as LHB1, LHB2, etc., to ensure anonymity. Results There were considerable variations in prescribed items across LHBs. Despite LHB 1 having the largest number of prescribed items in the overall population (n=13,982), it ranked third (n=1,988) in the number of prescribed items according to the number of items per 100,000 population, LHB 2 (n=2,542) and LHB 3 (n=2,659) ranked first and second, respectively. LHB 7 had the lowest number of prescribed items in the overall population (n=51) and per 100,000 (n=38). Based on the Pareto analysis, 80% of the items prescribed during the study period fell into the following six BNF chapters: Infection; Eye, Ear–Nose–Oropharynx; Skin; Obstetrics–Gynaecology–Urinary Tract Disorders; Appliances; and Central Nervous System. The infection chapter had the highest number of prescribed items (n=20,107), with most of the items being antibacterial (n=19,583, 96%). Nitrofurantoin was the most prescribed antibacterial agent (n=5,682). Conclusion This study explored the increase in prescribed items in community pharmacies across Wales, aligning with the 2030 vision for a healthier Wales. IPS plays a crucial role in pharmacist-led care for conditions such as urinary tract infections, potentially alleviating some of the burden facing GPs. While CASPA data captured prescribed and dispensed items specifically for community pharmacies, items prescribed but not dispensed are not accounted for in the data analyses. This study lacks information regarding the appropriateness of consultations. Further research is needed to examine prescribing appropriateness and patient outcomes.

Supporting newly qualified pharmacists in transitioning to independent practice: a qualitative analysis of the role of supervision

Abstract Introduction Newly qualified pharmacists (NQPs) face a demanding and challenging work environment during their transition to independent practice.[1,2] They also face challenges related to the changing nature of pharmacy practice, with pharmacists playing an increasingly important clinical role in patient care, which can be daunting for NQPs. Supporting NQPs during this transition period is essential for ensuring the sustainable development of health services. In 2021, Health Education England introduced the Newly Qualified Pharmacist Pathway, which included access to the Royal Pharmaceutical Society (RPS) e-Portfolio, formal learning of clinical and other skills, and access to educational supervision. The learning programmes were delivered by different providers in different settings/sectors. In hospitals, the Pathway was intended to complement existing programmes. Those in community pharmacy, general practice, community health services, health and justice, and care homes had access to a 12-month structured programme. Aim To discuss how supervision works and its contribution to supporting NQPs during their transition to independent practice. Methods Semi-structured qualitative interviews with NQPs (n=7) and supervisors (n=14). Email invitations were sent via learning providers. Participants were selected to capture NQPs and supervisors from various learning programmes and settings/sectors. Interviews were analysed thematically. Results The transition to independent practitioners meant NQPs were required to work with a high degree of autonomy in their practice. Yet, NQPs reported a lack of confidence in this. Supervisors reported that being an independent practitioner also meant that NQPs needed to be accountable for their decisions, learn to prioritise in a high-pressure environment, lead more experienced colleagues and manage a team. Supervision was an important part of the Pathway. Both NQPs and supervisors reported that supervisors provided NQPs with guidance, support, and feedback during their transition period. Supervisors added that they conducted learning needs assessments to foster a learner-centred approach that aided NQPs in expanding their skills and knowledge. They also supported NQPs in developing reflective practice as part of their professional development and progression to advanced practice. How supervision was conducted in practice varied across different settings/sectors. NQPs and hospital supervisors described that NQPs had a clinical work-based supervisor and an educational supervisor. In community pharmacies where NQPs often lacked access to support and structured learning opportunities, NQPs and supervisors claimed that remote educational supervision offered through the Pathway provided a support system for NQPs who would otherwise have been without any support structure. Conclusion Our study highlights that both NQPs and supervisors noted the importance of the support provided by educational supervisors to address learning/support needs in the early year of practice. However, the extent to which NQPs received what they needed varied widely. This support will likely become increasingly important from 2026, when pharmacists will require support as they become independent prescribers. We need to develop processes and infrastructure to ensure high-quality supervision is available to NQPs in all settings/sectors. The strength of the study lies in the in-depth interviews that provided rich and insightful data, effectively addressing the limitation posed by the relatively small number of participating NQPs.

Developing paediatric skills and knowledge in pharmacy education: an exploration of a novel work-based learning experience

Abstract Introduction Pharmacy education in the United Kingdom must adapt to produce independent prescribing pharmacists ready to join an evolving healthcare system. Current placement practices exclude approximately 21% of the population due to a lack of specific recommendations surrounding paediatric experience and knowledge within the MPharm programme.[1] In turn, students’ current experiences may be limited by lack of interaction with unique learning outcomes offered by some healthcare settings, such as paediatric hospitals.[2] To promote student exposure in an overlooked speciality, novel approaches to work-based learning can be utilised. Aim This study aimed to explore pharmacy students’ experiences of work-based learning in a paediatric hospital setting. Methods In October 2022, fourth-year MPharm students at one school of pharmacy were invited to undertake work-based learning sessions across one academic year. The sessions aimed to develop students’ paediatric consultations skills and knowledge. Sessions consisted of a briefing, ward activities, scaffolded consultations with children and carers, and debriefs with a clinical supervisor. Debriefs included students reporting clinical information, required action and learning outcomes. All debriefs provided by students were transcribed by a clinical supervisor using a spreadsheet which recorded the date, ward visited, patient details, student handover, follow-up (if required) and learning outcomes. Data was initially cleaned, quality checked, and underwent content analysis to identify patterns and key themes to describe student experiences. Results Seventy-four students took part in sessions and delivered 233 consultations covering the medical history of the patient (76%, n=177), with varied levels of completeness. Students were exposed to acute conditions (41%, n=96) and chronic conditions (33%, n=76), with 13% (n=30) still awaiting diagnosis. Forty-eight percent (n=81) of learning points related to the pathology, diagnosis and symptoms of conditions, 24% (n=41) to medicines, 15% (n=25) to patient care, 11% (n=18) to non-clinical experiences and 2% (n=4) to other outcomes. In addition to carrying out ward activities, students underwent the processing of experiences during post-session debriefs: “It’s uncomfortable seeing a child struggle to breathe” [P131]. The process of active reflection was also evidenced in debriefs: “I felt very anxious, like a tightness in the chest, to hear that a child had a short life expectancy” [P145]; “I realised they had zero cultural competence after seeing a patient from the Middle East with jaundice” [P233]. Conclusion The study demonstrates a proof of concept that students can be exposed to complex care needs and challenging consultations under indirect supervision, demonstrating the paediatric setting to be a suitable work-based learning host. However, findings are limited to a single cohort of students at a single site, meaning transferability may be limited. Future studies could focus on longitudinal educational and emotional outcomes of students by measuring clinical knowledge, competence and confidence. Utilising post-session debriefs with peers and supervisors created a space to share both pharmaceutical and emotional learning points, aiding in managing the cognitive load of students. This experience not only highlights the requirement of paediatric exposure in pharmacy education programmes to aid the students’ future practice, but the importance of supervised reflective activities following work-based learning experiences.

An umbrella review of pharmacist prescribing: stakeholders’ views and impact on patient outcomes

Abstract Introduction There is great geographical diversity in the degree of prescribing rights pharmacists have. In some countries such as the United Kingdom (UK), pharmacists have unrestricted prescribing rights following appropriate training; in other countries, pharmacists cannot legally prescribe. The impact of pharmacist prescribing (PP) has been studied in various qualitative and quantitative research studies, but this evidence has not been synthesised to support the development of PP internationally. Aim The aim of this umbrella review was to describe the international PP models, establish the impact of PP on patient outcomes and describe key stakeholders’ views of PP, by synthesising all the available systematic reviews (SRs). Methods Six databases (Embase, CINAHL, MEDLINE, Web of Science, Cochrane Library and PsycINFO) were searched, from January 2003 to June 2023, for key terms such as ‘pharmacist’, ‘prescribing’, ‘prescription’ and ‘systematic review’, ‘meta-analysis’, ‘meta-synthesis’. Systematic reviews that examined PP for any clinical condition, for patients of any age and in any healthcare setting were eligible for inclusion. SRs examining pharmacists’ interventions other than PP were excluded as were articles not published in English. Two researchers independently screened titles, abstracts and full texts for eligibility; discrepancies were resolved by discussion with a third reviewer. A data extraction tool was developed, piloted and refined prior to data extraction based on guidance from PRIOR[1] and the Joanna Briggs Institute (JBI).[2] Extracted information included: SR characteristics; inclusion and exclusion criteria; description of prescribing models, setting, clinical conditions, clinical and health service utilisation outcomes and key stakeholders’ views of PP. Data have been synthesised narratively due to the heterogeneity of included studies. Results A total of 6439 titles were retrieved from searches, with 917 duplicates removed. Following abstracts and full text screening (5522 and 129 respectively), 39 systematic reviews (8 qualitative; 19 quantitative and 12 mixed-methods) were included. The description of PP models varied within and between the SRs and demonstrated implementation of different PP models globally. Collaborative practice agreement with a physician, dependant prescribing by protocol and/or formularies were common in Canada and the United States, while supplementary prescribing and independent prescribing models were described in the UK. Prescribing activity was evident in all care settings and for a wide range of clinical conditions. SRs reporting on targeted clinical conditions, noted that patients of pharmacist prescribers had similar blood pressure control and depressive symptoms, better cholesterol and blood glucose control and reduced pain intensity when compared with patients of medical prescribers. SRs also suggests that pharmacist prescribers make fewer errors than non-pharmacists. Key stakeholders noted largely positive views towards PP, with a reduction in physician workload, an improvement in pharmacist job satisfaction, better utilisation of pharmacist knowledge and skills noted. Concerns over pharmacists’ diagnostic abilities, legal accountability for errors and appropriate implementation of PP models were noted. Conclusion A variety of PP models exist internationally. Careful examination of each model should be undertaken prior to adoption and implementation in countries where PP is currently not permitted.

P087 Role of a physiotherapy independent prescriber in a Paediatric Rheumatology setting

Abstract Background/Aims To assess the benefit of having a Physiotherapy Independent Prescriber (PIP) within a Paediatric Rheumatology service at University Hospitals Southampton (UHS). Legislative change in the UK in 2013 enabled physiotherapists to independently prescribe certain drugs that assist in patient management. Independent prescribing by physiotherapists is a relatively contemporary development in role change and purpose. The clients seen by the paediatric rheumatology physiotherapists within our service frequently require medication prescription as part of their review and management. Having the ability to independently prescribe reduces the need for additional medical or nursing input, so improving efficiency and patient experience within the clinic. Methods In our Paediatric Rheumatology service within UHS, our PIP is able to assess and manage the repeat prescriptions for routine follow-up patients with Juvenile Idiopathic Arthritis (JIA), plus alter medication prescriptions in response to clinical findings. The medications the PIP can change/prescribe include Methotrexate, Oral steroids, Non-steroidal anti-inflammatory drugs, Folic Acid and proton-pump inhibitors. This facilitates a greater number of patients to be seen as they do not require appointments with multiple professionals at routine reviews. A satisfaction questionnaire was completed by patients who accessed this service over a 6-month period. Results Over a six-month period of 25 morning clinics, a total of 23 satisfaction questionnaires were completed by those who had medication prescribed by the PIP. Of these, 100% were satisfied with the service they received and the outcome of the appointment. In particular, highest scores were given for communication by the therapist and having knowledge and understanding of medications prescribed. Conclusion Having a PIP in our Paediatric Rheumatology Clinic is well-received by service users and improved patient-experience by limiting the need for multiple appointments and reducing time spent in clinic. Disclosure E. Bhullar: None.

Evaluating trends in pharmacist e-prescribing: 2019–2022

BackgroundPharmacists have some prescriptive authority in all fifty states through dependent and independent prescribing. Data describing the volume and characteristics of pharmacist prescribing are not widely available, and these insights are critical to gauge the impact of regulations supporting pharmacist prescriptive authority. ObjectiveTo identify trends in pharmacist prescribing and compare them to primary care provider (PCP) prescribing trends by analyzing e-prescriptions initiated from electronic health records systems from 2019 through 2022. MethodsThis cross-sectional study used e-prescriptions from a national health information network to identify e-prescriptions ordered by pharmacists and PCPs from January 7, 2019, to January 1, 2023. E-prescriptions ordered by pharmacists and PCPs were analyzed to identify annual volume by prescriber type and most prescribed therapeutic classes. States with the highest volume of e-prescriptions ordered by pharmacists were identified. ResultsThe number of e-prescriptions prescribed by a pharmacist increased 47% from 2019 (n = 814,726) to 2022 (n = 1,199,601). The number of pharmacists prescribing in 2019 was 1650, and this increased by 122% to 3664 in 2022. The number of e-prescriptions prescribed by PCPs increased by 4% from 2019 (n = 927,890,123) to 2022 (n = 965,803,376) while the number of PCPs prescribing increased by 8% from 2019 (n = 364,995) to 2022 (n = 394,753). ConclusionPharmacist e-prescribing increased across the 4 years studied while PCP e-prescribing modestly increased. Factors like access to technology, such as electronic health records, state regulations, and reimbursement impact a pharmacist’s ability to prescribe.

Safe prescribing of oral alendronic acid following hip fracture

In the UK, physiotherapists can train as independent prescribers and are working in increasing numbers as advanced clinical practitioners. This case study examines the safe prescribing of oral bisphosphonates following a fragility fracture of the hip and considers this process in the context of the Royal Pharmaceutical Society's competencies (2021) , which were adopted by the Health and Care Professions Council in 2016. Despite these medications being around since the 1960s, their utilisation in the treatment of osteoporosis remains limited, and low levels of patient adherence continues to present a problem. This case study will look at the ways in which these issues can be addressed and identifies areas for future development. It will also describe the process of bone health assessment, offering non-pharmacological approaches as a way to reduce fracture and falls risks. The shared care nature of osteoporosis management will also be considered, with communication and partnership between primary care and secondary care being key in the provision of this treatment.

Holistic health and social care outreach for people experiencing homelessness with recent non-fatal overdose in Glasgow, Scotland: the Pharmacist and third sector Homeless charity worker Outreach Engagement Non-medical Independent prescriber Rx (PHOENIx) pilot randomised controlled trial

ObjectivesTo examine randomised controlled trial (RCT) progression criteria including emergency department (ED) attendance and non-fatal overdose, from a holistic, integrated health and social care outreach intervention (PHOENIx), for people experiencing...

Management of stress urinary incontinence associated with perimenopause

Pelvic health physiotherapy is recommended as first-line treatment for those with lower urinary tract symptoms and pelvic floor dysfunction. Pelvic health physiotherapists treat a number of genitourinary conditions conservatively, including stress urinary incontinence, overactive bladder, pelvic organ prolapse and vaginal atrophy. When physiotherapy management alone does not fully resolve symptoms, medication may be required. Independent prescribing enables the physiotherapist to maintain continuity of care, allowing a smoother, more effective patient journey. This offers quicker access to medicines and helps avoid delays in commencing appropriate treatment, reducing waiting times across other services. In this article, the role of the pelvic health physiotherapy independent prescriber is detailed in a case study of a patient referred with symptoms of stress urinary incontinence associated with impaired pelvic floor function and episodic constipation, in addition to perimenopausal vaginal dryness causing dyspareunia.

Development of prescribing indicators related to opioid-related harm in patients with chronic pain in primary care—a modified e-Delphi study

BackgroundLong-term opioid use is associated with dependency, addiction, and serious adverse events. Although a framework to reduce inappropriate opioid prescribing exists, there is no consensus on prescribing indicators for preventable opioid-related problems in patients with chronic pain in primary care in the UK. This study aimed to identify opioid prescription scenarios for developing indicators for prescribing opioids to patients with chronic pain in primary care.MethodsScenarios of opioid prescribing indicators were identified from a literature review, guidelines, and government reports. Twenty-one indicators were identified and presented in various opioid scenarios concerning opioid-related harm and adverse effects, drug-drug interactions, and drug-disease interactions in certain disease conditions. After receiving ethics approval, two rounds of electronic Delphi panel technique surveys were conducted with 24 expert panellists from the UK (clinicians, pharmacists, and independent prescribers) from August 2020 to February 2021. Each indicator was rated on a 1–9 scale from inappropriate to appropriate. The score’s median, 30th and 70th percentiles, and disagreement index were calculated.ResultsThe panel unanimously agreed that 15 out of the 21 opioid prescribing scenarios were inappropriate, primarily due to their potential for causing harm to patients. This consensus was reflected in the low appropriateness scores (median ranging from 1 to 3). There were no scenarios with a high consensus that prescribing was appropriate. The indicators were considered inappropriate due to drug-disease interactions (n = 8), drug-drug interactions (n = 2), adverse effects (n = 3), and prescribed dose and duration (n = 2). Examples included prescribing opioids during pregnancy, concurrently with benzodiazepines, long-term without a laxative prescription and prescribing > 120-mg morphine milligram equivalent per day or long-term duration over 3 months after surgery.ConclusionsThe high agreement on opioid prescribing indicators indicates that these potentially hazardous consequences are relevant and concerning to healthcare practitioners. Future research is needed to evaluate the feasibility and implementation of these indicators within primary care settings. This research will provide valuable insights and evidence to support opioid prescribing and deprescribing strategies. Moreover, the findings will be crucial in informing primary care practitioners and shaping quality outcome frameworks and other initiatives to enhance the safety and quality of care in primary care settings.

NHS England to fund additional 3,000 independent prescriber places for 2024/2025

NHS England to fund additional 3,000 independent prescriber places for 2024/2025

IT system for independent prescribing pathfinder programme ready for rollout, says NHS England

IT system for independent prescribing pathfinder programme ready for rollout, says NHS England

The path to independent prescribing

The path to independent prescribing

Workforce development in community pharmacies in England: Opportunities and tensions for a private sector provider of NHS services.

The intention to more effectively mobilise and integrate the capabilities of the community pharmacy workforce within primary care is clearly stated within National Health Service (NHS) England policy. The Pharmacy Integration Fund (PhIF) was established in 2016 to support the development of clinical pharmacy practice in a range of primary care settings, including community pharmacy. This study sought to determine how PhIF funded learning pathways for post-registration pharmacists and accuracy checking pharmacy technicians enabled community pharmacy workforce transformation, in what circumstances, and why. Realist evaluation. We identified two main programme theories underpinning the PhIF programme and tested these theories against data collected through 41 semi-structured qualitative interviews with community pharmacist and pharmacy technician learners, educational supervisors, and community pharmacy employers. The data supported the initial programme theories and indicated that the learning pathway for post-registration pharmacists had also provided opportunity for pharmacists to develop and consolidate their clinical skills before pursuing an independent prescribing qualification. Employer support was a key factor influencing learner participation, whilst employer engagement was mediated by perceptions of value expectancy and clarity of purpose. The study also highlights the influence of contextual factors within the community pharmacy setting on opportunities for the application of learning in practice. When designing and implementing workforce transformation plans and funded service opportunities that require the engagement of a diverse range of private, for-profit businesses within a mixed economy setting, policymakers should consider the contextual factors and mechanisms influencing participation of all stakeholder groups.

Number of independent prescribers rose by 37% in 2023, reveals NHS workforce survey

Number of independent prescribers rose by 37% in 2023, reveals NHS workforce survey

‘Pay it forward’: enticing independent prescribers to mentor the next generation

‘Pay it forward’: enticing independent prescribers to mentor the next generation

Foundation trainees to train in limited clinical areas for independent prescribing

Foundation trainees to train in limited clinical areas for independent prescribing

Pilot scheme explores value of protected learning time for pharmacist independent prescribers

Pilot scheme explores value of protected learning time for pharmacist independent prescribers

Government to 'accelerate' roll-out of independent prescribing in pharmacies, says prime minister

Government to 'accelerate' roll-out of independent prescribing in pharmacies, says prime minister