Pharmacist independent prescribers are a growing force for change: in PCNs, general practice, and in community pharmacy. Should more training places now be made available; and should commissioners be making greater use of this clinical expertise in primary care?
Pharmacists’ roles have evolved significantly in response to a growing demand in the NHS for clinical, patient-facing, accountable practitioners across all sectors.
One role expansion that has risen to meet this demand is that of Pharmacist Independent Prescribers (PIPs – also called IPs). But is the impact of the qualification being felt quickly enough, and should more prescribing pharmacists be trained?
Independent prescribing first evolved as an add-on qualification that pharmacists could undertake in their own time, often with their own money, but it is now a more widely funded qualification for pharmacists taking up new roles in general practice through the Additional Roles Reimbursement (ARRS) scheme.
In December 2020, the GPhC approved new standards for the initial education and training (IET) of pharmacists, which will make prescribing skills an integral part of pharmacists’ training and mean all MPharm graduates will be IPs from 2026.
In addition, in November 2021, HEE announced investment of up to £15.9m from NHS England and NHS Improvement to support the expansion of frontline pharmacy professionals in primary care over the next four years. This includes giving registered pharmacy professionals the opportunity to access further clinical training, such as independent prescribing skills.
This year, HEE invited eligible pharmacists in England to apply for one of 327 funded independent prescribing places on courses starting in the first half of this year, describing these developments as responding to ‘identified workforce need, and supporting the need for a flexible, integrated, multi-professional workforce, capable of confident, joined-up patient care’.
Meanwhile, the Welsh government has set aside £3m for pharmacy training for 2022/2023, with part of this for increased IP courses for the existing workforce.
And, last year, the Scottish Government launched a formal career pathway designed to boost independent prescriber numbers in community pharmacy, followed by the creation of a further 165 IP training places in the first three months of 2022 under the ‘National Clinical Skills for Pharmacists’ programme, in addition to 240 places that were due to have been provided in 2021.
Growing the number of training places
These initiatives are needed, according to many in the sector. As medication regimes become more specialised and complex, plans to expand the number of IPs across the UK over the coming years have been welcomed by the Royal Pharmaceutical Society (RPS).
The body has been clear about its wish for a greater use of IPs within the multi-disciplinary team to expand patient access to care, create capacity in the health care system and improve individual health outcomes.
‘Many pharmacists who trained as prescribers have been unable to use their qualification because opportunities to do so aren’t available…’, says Elen Jones, RPS director for Wales.
‘… So it’s vital that more patient-facing pharmacists have the opportunity to become prescribers too so that patients can get the care they need from a medicines expert, whether that’s in a specialist clinic in secondary care, in their local community pharmacy or even in their own home.’
PSNC, too, supports further development of the role, with Alastair Buxton, director of NHS services at PSNC, saying: ‘Independent prescribing will be at the heart of many future developments in community pharmacy services, so this is a welcome start to support community pharmacists to develop their skills, particularly those who were already planning to commence training early in 2022.’
HEE comments that the response to its initial offer of IP training places this year has been positive, and that it is working to secure a further round of funded IP training to be available from Autumn 2022.
‘We will share more information (including eligibility criteria) and how to apply, when these future offers are confirmed’, says a spokesperson, ‘and we would encourage pharmacists to prepare to apply for the [next] round of funded Independent Prescriber training.’
Arguing for faster annotation
To speed things up the meantime, responses to a recent GPhC consultation on independent prescribing have shown a willingness among sector stakeholders for pharmacists to not to need to practise for two years following registration, before being able to go on to train as independent prescribers.
In a report discussing the results of its eight-week consultation on independent prescribing, the regulator said that just over half of all 1,164 individual respondents (55%) – and 81% of the 47 organisations that responded – agreed that the two-year requirement for entry to free-standing pharmacist independent prescribing training should be removed to help increase the pace of development.
Respondents in favour of the proposal said that the five years of university training on the MPharm course gave pharmacists the necessary skills to prescribe as soon as they finish education, and that time spent working as a pharmacist was not an effective determinant of experience and skills.
But those concerned about the proposal of integrating IP training into MPharm training have said that the two additional years of experience in practice helps pharmacists gain confidence, and allows them to settle into their role before taking on the added responsibility of prescribing.
Time to train is currently an ‘obstacle’
Sunil Kochhar is a consultant pharmacist based in Kent, and who was annotated as a prescriber in November 2019 after doing an online course from Robert Gordon University in Aberdeen.
He says despite decades of experience in community pharmacy, he resisted training an IP for many years because finding the time to do the training was ‘an obstacle’. It had also been a long time since he’d studied formally, so ‘confidence was definitely a barrier’.
However, his experience helped him to see how ‘well-placed’ community was for helping with NHS workload.
‘I chose respiratory as my initial scope as I already had experience of running a smoking cessation clinic, but as I also operate an aesthetics clinic Robert Gordon allowed me to do a dual scope, which enabled me to do my practice hours some in private clinics as well as NHS - as long as my portfolio work was based around respiratory’, he says.
‘Alongside that, I spent a few days helping a PCN pharmacist run a blood pressure clinic in a local GP practice; sat in on COPD and asthma clinics; spent time with a specialist respiratory GP; and had two days in the respiratory clinic at the local hospital, which helped me see how well-placed community pharmacy is to help relieve the burden in all these sectors.’
Sanjay Ganvir is professional services director and superintendent pharmacist at Green Light Pharmacy, which pays for its pharmacists to undertake UCL’s enhanced clinical IP course.
He says that although a desire to do the course is important, there is more to consider.
‘Being keen is one thing but have they got the time to do it, and have they really thought what they want their speciality to be?’ he says.
‘Generally, they say diabetes or respiratory, but if you talk to them a bit more it turns out their passion is something a bit different, so before they start the course, we’ll have a conversation with them to find out what they really want to do, and where we can use those skills.’
In the past, some pharmacists have also found it hard to find medical practitioners to oversee them as part of their training.
But recent regulatory changes have enabled experienced independent prescribers to work as designated prescribing practitioners (DPPs) for the practice element of non-medical prescribing training – a role traditionally held only by medical prescribers (designated medical practitioners, or DMPs)
Green Light plans to use its own IPs as DPPs to oversee IP trainees, alongside the well-established GP DMPs it is already connected with.
This expansion improves access to prescribing opportunities for would-be IPs.
Still a lack of IPs across the country
While there are plans in place to create more IPs across the UK – and to make the process of becoming one easier - some pharmacists have told The Pharmacist there are a lack of them in their areas, which means they are not able to reap the benefits the role brings.
David Miller is an IP, and a clinical pharmacist in general practice in Yorkshire, supporting people to live well with diabetes.
He says that while ‘working together can never be a bad thing’, he’s ‘not aware of any [community pharmacist IPs] locally’.
This experience is shared by an anonymous PCN pharmacist who says: ‘If there are any community pharmacy IPs in our area then I am not aware of them.’
Recent high workloads may also mean that people with IP qualifications are not currently using their hard-won skills to help ease pressures across the rest of the NHS.
‘With pharmacies operating on reduced hours and not able to get locums, they are under so much pressure at the moment that just keeping the doors open is a victory. So I don’t think they’d even have time to be doing the work an IP should be doing right now,’ they say.
The finding that IP trained colleagues in community pharmacy appear few and far between, is mirrored by another pharmacist in general practice.
As an IP himself, as well as GP pharmacist partner at Orchard Family Practice, and lead for development and support for primary care pharmacists in Medway and Swale, Krish Patel has a broad view of the benefits of community pharmacy IPs.
But he also says that he has had only limited opportunities to work with IPs in community pharmacy.
‘There is an independent pharmacy a bit further away from our practice with an IP specialist in UTIs, so if we don’t have a nurse available or were fully booked, we can refer patients to their private clinic, and if she then needs access to further investigations, she documents everything and sends it back to us’, he says.
He argues that the Community Pharmacy Consultation Service (CPCS) should be offering a greater opportunity to work together as IPs. He says: ‘It would be good if more community pharmacists in the area were upskilled as IPs, especially now we’ve started with the GP CPCS.’
The system needs to change
Dr Dean Eggitt, a GP and chief medical officer of Doncaster LMC, has been training pharmacists as IPs for a decade. He has also employed a pharmacist in his surgery since before ‘general practice pharmacists’ were more widely instigated.
While he is a huge supporter of pharmacist IPs, he says that he does have reservations about the ‘system’ in place to ‘create’ them.
He says: ‘I got on board with IPs early on because my approach is that pharmacists are underutilised, and their jobs don’t allow them to work at the top of their intelligence - but the way IPs is being used at the moment is lip service’.
‘The system needs more people who can prescribe, and so it’s bringing in more prescribers from pharmacy land - but they are not equipped to do what they need to do, and this ends up making them look bad.’
Dr Eggitt is similarly critical of the new GPhC standards that are making prescribing skills an integral part of pharmacists’ training. Pharmacy students will automatically qualify as IPs from 2026.
He adds: ‘Yes, we need to be pushing more services to community pharmacy with independently minded community pharmacists who can prescribe without passing back to the other parts of the system, but to enable this we need support mechanisms in place to give them experience and competence.
He questions whether newly qualified pharmacists will have the prescribing skills required to practise safely.
‘I think those graduating with IP status will be ill-prepared to use it, without the ongoing support that they will need, and this will put them in a potentially dangerous situation.
‘Even when I help a pharmacist gain IP status, their work is not finished. They can stay with me overseeing them for as long as they need, so I can help them build a portfolio of confidence and knowledge in what they are doing – and this is the bit that is needed.’
There may still be enough time to iron out concerns such as Dr Eggitt’s before the first IP pharmacist graduates emerge.
But if IPs are going to be properly utilised to open up the future direction of pharmacy, and have a beneficial cumulative impact on primary care, then the issue of funding also needs to be addressed.
Pharmacists working in general practice may receive funding to achieve their qualification, but may community pharmacists are forced to self-fund, and then find it difficult to find a suitable role in which they are able to work as an independent prescriber.
Commissioning initiatives should enable primary care to make best use of the skills of IP-qualified pharmacists and recognise the new body of clinical expertise being created in its totality – in community pharmacy as well as in PCNs and in general practice - suggests Mr Ganvir.
‘The impact of IPs should be incredibly positive, but I do think the NHS need to start utilising the community pharmacy workforce properly…’, he says.
‘… by which I mean you have HEE spending a whole load of money training up community pharmacists to be IPs, and then you have, as far as I know, no NHS community pharmacy service commissioned that is using IPs.
‘There needs to be more joined-up thinking by the commissioners about how they are utilising this workforce they are building up.’
And seen by many as offering pharmacy a more visible seat at the primary care leadership ‘table’, the PCN pharmacist stresses that IPs are not the only key to the door of joint-working success.
Working more closely together as primary care professionals, including pharmacists, is key for the future, he argues.
He stresses: ‘There is always more potential to get pharmacy-led change going by working together. But it needs to involve all the pharmacy team - and not just pharmacists, IPs or not’.