Bruce Burnett
This is a hot topic right now. A bit of history to begin.
When supplementary prescribing (SP) became available to pharmacists, I jumped at the chance to expand my skill set and improve the patient experience.
I was an “early adopter”.
Independent prescribing (IP) became available and I could have converted but chose not to. The differences in the roles provided a reason to have both an IP and an SP in the same location. And, importantly, I struggled to get a defined role within the service I was involved in. Was I a laggard, or simply taking a realistic assessment of the pros and cons of converting? How might it affect patient care/experience? And there was no doubt that there was a lack of a plan to utilise this new skill.
As the differences between IP and SP narrowed my role had changed so converting to become a pharmacist IP (PIP) was not a priority. Moving to academia meant that my SP knowledge could inform my IP teaching. The nuance between IP and SP is something I still feel is useful in delivering patient care.
So now we come to the question of PIPs being a designated (medical) practitioner (DMP). There is a move to have PIPs acting as DMP for IP students. The General Pharmaceutical Council consultation in 2018 and The Royal Pharmaceutical Society Framework for Prescribing Supervisors from 2016 development support this move.
So here is my position:
Could a pharmacist IP be a DMP?
Yes (but see the next point).
What attributes should a pharmacist IP DMP have?
Same as a medic DMP.
Should pharmacist IPs be a DMP?
No (at least not at the moment).
Now let me explain why.
Let’s start with PIPs as DMPs. With the necessary skill set, experience etc., I see no reason why a PIP could not act as a DMP. Let’s consider what PIP students want from a DMP so that we can map ourselves against these. This is not as simple a task as it may sound. Most, if not all, institutions provide advice to students for choosing a DMP, and what they expect of a DMP. A quick google search (15 providers materials accessed) showed that all but one were explicit, and reference both GPhC advice to providers: Accreditation of independent prescribing programmes: guidance for providers 2018-19 and the slightly dated but still helpful National Prescribing Centre document from 2005 (no longer available online). These documents gave us a starting point.
Do we still need these criteria today?
Have they been useful, what do IP trainees think of their DMPs?
My experience was very positive, but I don’t know how representative that view might be 15 years later.
Paraphrasing from these documents we can pick out some important content to consider for DMP suitability:
- Has at least three years medical, treatment and prescribing responsibility for a group of patients/clients in the relevant field of practice.
- Within a GP practice, either vocationally trained or possess a certificate of equivalent experience from Joint Committee for Postgraduate training in General Practice.
OR
- Specialist registrar, clinical assistant or a consultant within an NHS Trust or other NHS employer.
- Has the support of the employing organisation or GP practice to act as the designated medical practitioner who will provide supervision, support and opportunities to develop competence in prescribing practice.
- Some experience or training in teaching and/or supervising in practice.
- DMP must fully understand the requirements of the GPhC for Pharmacist Independent prescribers.
Everyone will have their own view of what they feel is important from the above. For me, it is the practice experience (including mentoring / teaching), organisational support and teaching training/supervision in practice. To these points, I would personally add that the person needs to “want to do it”.
This is my line in the sand for a PIP to be considered as a DMP. There cannot be an abrogation of these basic points, no matter which profession is being considered for acting as DMP. The experience across diagnosis, clinical examination and clinical decision-making are, I feel, what a medical practitioner brings to the IP training. The breadth of prescribing experience is so important.
Do we still need this?
I think we do.
But are these the same as the attributes that make a good DMP? Can we define what these should be, and then provide evidence of meeting these as part of an accreditation process for pharmacist DMPs (PDMP). If we can define this and there are PIPs out there who meet these attributes, then they would appear to be a good fit for applying for DMP status. A detailed set of competencies for GP trainers has been published by Health Education England (HEE) which shows how difficult matching the current DMP skillset might be for PIPs.
Any other options?
What about the physician associate and enhanced/advanced clinical practitioner qualifications and roles that pharmacists are now undertaking? Is PDMP a role for them and are they a better fit than a PIP? Do they need teaching and mentoring recognition? Do we need some pharmacist equivalent to the Joint Committee for Postgraduate training in General Practice Certificate?
The fact that I can’t provide answers is telling.
Looking at just one of these attributes provides an insight into how difficult this might prove to be.
“Has at least three years medical, treatment and prescribing responsibility for a group of patients/clients in the relevant field of practice.”
If we look at the 2016 survey of PIPs by the General Pharmaceutical Council what is clear is that there is a huge variation in IP practice; where, what, how much, how often. Now, this is to be expected, after-all medics have varying amounts of “practice time”. However, this does leave us with a pertinent question. If we consider the practice element of medics and IPs, does the medic DMP experience compare with that of the PIP at three years post qualification? I’m not sure we can answer this definitively but if the survey results are to be generalised (accepting the low response rate), it looks unlikely except for a few individuals. Another question that I would like to have some insight to, is what proportion of PIPs have developed breadth to their area of practice, and to what extent. By the time medics are considered for DMP their experience breadth is likely to be significantly greater than our PIPs. There will be a few who have, but again, this is likely to be a minority.
That leaves us with should PIPs become DMPs?
There are two components to this in my view.
Do we need more DMPs and is there capacity for PIPs to do this?
What is the reason for the drive to have pharmacists as DMP?
Reports of lack of availability of DMPs, particularly in primary care exist. As a previous course leader, I can attest to the “do you know anybody willing to be a DMP” or “do you have a list of potential DMPs” questions which were not uncommon. It would even appear from some blogs that there is a DMP economy. One forum post related a £10,000 payment being made for a medic to act as DMP. Another post in the same blog, purporting to be from a group providing DMPs for “much less than that”, suggests that this is a real if unquantified issue.
Why might this be?
Well, it’s unlikely to be a single reason. So I don’t know if we need more DMPs or whether the DMP role needs to be more representative of an MDT in its composition?
There is an acceptance by staff and organisations that IPs have an important role in supporting service sustainability. Indeed, the drive for more primary care and GP practice-based prescribers, along with urgent care, is backed by money from Health Education England (HEE) as part of the Pharmacy Integration Fund.
So why isn’t there more use of existing PIPs?
The GPhC survey suggests there is IP capacity but it’s not being utilised. So why not? PIPs are a good thing, and there have been attempts to measure how good IP provision is, e.g. the Cochrane review published in 2017 which provided an insight into how well pharmacist and other independent prescribers “prescribe”. The Royal Pharmaceutical Society report in 2018 showcases pharmacist prescribers achievements in a range of situations. It’s pretty safe to say that pharmacist (and nurse) independent prescribing has been a success, using a range of measures. There is evidence of better blood pressure and diabetes control, but of course, assessing the impact on disease / patient outcome is much harder, if not impossible (overall care of the patient is multifaceted). Will we be able to prove that PIPs make the best prescribers?
I’m not sure, even if my gut feeling or personal experience told me otherwise.
I have been pointed to the medication error report from 2018 as evidence that pharmacists are safer prescribers. The authors make no such claims, in part due to methodology differences between studies included in the review, such as the definition of an error, but also that direct comparisons between prescribers are not possible, and if it were this would be a difficult comparison (my view).
If we need more IPs because the current prescribers are not prescribing, then surely we need to understand and tackle this. Could it be the training process, of which DMPs are part? Possibly, but it could also be that:
- Cost-effectiveness of PIPs is not competitive.
- Competition between different IP professions (nurse IP versus PIP).
- Competing and changing priorities of employer organisations.
The GPhC survey in 2016 provided a window to the situation at the time, although with a 17.4 % response rate we need to be careful with interpretation.
What did it find?
- Almost three-quarters of respondents didn’t have an issue with finding opportunities to prescribe.
- Only 41 % of respondents prescribe every day.
- Some qualified PIPs never prescribe.
Now, these findings are a bit contradictory to a notion that DMP availability is the driver behind a failure to optimise PIP utilisation. There are quite a few suggested reasons for this, from a lack of planning for roles in advance to a “cost” difference. Regardless of these reasons, it at least provides a basis for having a measure by which the utility of PIPs can be assessed and compared. Are nurse prescribers utilised more than PIPs, and if so why?
The questions that weren’t asked by the survey, but would have been useful are:
- Proportion of time spent in prescriber role (fraction of whole time equivalent).
- What did they “do”; diagnosis, repeat prescribing etc.
- When signing up for IP training, had they identified a prescribing role that was supported by the Trust/GP Practice etc. A defined role
This hints at the problem of IP capacity to perform a DMP role. Can they provide “a minimum” of 45 hours practice time, plus the inevitable discussions, review of progress etc. We already suspect that those who are likely to be most able to fit the DMP criteria are also likely to be the busiest, with less capacity.
Given all of this, before we can embrace PIPs as DMP, we need to decide:
- Do we want PIPs to be the main DMP responsible for sign-off?
- Should we mandate defined multiple DMP experiences for the 90 hours, of which PIPs have a component?
Personally, I think the answer to the first question is no, I don’t think that PIPs have the capacity and I’m unsure of how much clinical examination PIPs undertake on a regular basis. Requests for more clinical skills experience and earlier in the course are reported. Any move to allow DMPs with less clinical examination, diagnostic skills or mentoring/teaching experience would, I feel, be to the detriment of IP students.
The answer to the second question is maybe clearer and easier to answer. PIPs approach prescribing from a different perspective than medics or nurses. Not better, not worse, but different. I want the DMP input for IP students to be as broad as possible, to ensure that those 90 hours allows students to understand what clinical practice looks like, in all its’ variants, determine what their practice might look like, and importantly, what else they will need to do to feel confident in what their day go day practice and further develop their skills.
Understanding what and how each type of IP contributes to patient care is, in my opinion, the best way to ensure optimal use of PIPs. But let’s not kid ourselves, 90 hours does not produce a good diagnostician with excellent clinical examination skills etc.
This is just the start of the journey. In practice, patient care is holistic and includes multi-professional involvement so reflecting this in the DMP experience is not just reasonable, but actually key. A bonus of this could be a reduction in medic time for DMP role, potentially increasing access.
Having this debate via twitter is enlightening. It would be easy to suggest two opposing camps, but that’s not the case. How many of us have contributed to the GPhC consultation? How do we ensure that the desire to have pharmacists as DMP has the same positive outcome as our achievements in IP? The GPhC and RPS need our views and responses, and not simply from people like me (or those discussing on twitter) who have a strong view that they are willing and confident to share and defend.
Policy and resources need to be based on more than the 17.6 % survey response.
Bruce Burnett is a supplementary prescriber and currently a full-time PhD student. He declares that he is a pharmacist not currently working within a prescribing role or patient-facing practice. He is involved with an independent prescribing course in the North West of England and was previously a course leader for an IP programme.