United Kingdom and Canada point the way
U.S. pharmacy practice may be caught in the middle of a perfect storm. A shortage of primary care physicians, which stands to be exacerbated by droves of newly insured Americans this year, raises the question of whether other health care providers could pick up some of the slack. The Affordable Care Act (ACA) calls for the creation of accountable care organizations, which have the potential to engage pharmacists as full members of the health care team and allow them, and all other members of the team, to perform at the top of their skill sets and licenses. The HITECH Act is driving up use of electronic health records, which better situates pharmacists to collaborate with other members of the health care team.
Pharmacy practice is at a tipping point that could be the culmination of the profession’s efforts to gain provider status, prescribing authority, and overall expanded scope of practice, according to Rita Shane, PharmD, FASHP, FCSHP, Director of Pharmacy Services at Cedars–Sinai Medical Center in Los Angeles and Assistant Dean of Clinical Pharmacy Services at the University of California, San Francisco (UCSF) School of Pharmacy.
Pharmacists who are eager to see their profession move into this new territory can look to their colleagues who have already charted it abroad. In a panel at last year’s American Society of Health-System Pharmacists (ASHP) Midyear Clinical Meeting, pharmacists from the United Kingdom and Canada described the path to prescribing authority in their respective nations, while Shane highlighted strides the profession is making stateside.
United Kingdom
In the United Kingdom, physicians, nurses, pharmacists, and, most recently, podiatrists and physiotherapists can diagnosis and prescribe. But it does not mean that they all do.
Conditions. In 2000, pharmacists and nurses were given authority to dispense emergency contraception under a physician-signed prescribing protocol. This initiative led to supplementary prescribing, which allowed these clinicians to prescribe for a single disease state, but that wasn’t enough.
“Supplementary prescribing in pharmacy didn’t work very well because patients aren’t usually on just one medicine for a single condition,” said Claire Anderson, PhD, BSPharm, FRPharmS, FRSPH, FFRPS, Professor of Social Pharmacy at the University of Nottingham School of Pharmacy in the United Kingdom. “Pharmacists could treat the patient for asthma with a steroid inhaler. But if the patient [also had diabetes] and had chronic pain, neither of those conditions could be prescribed for.”
The flaws in supplementary prescribing revealed that prescribers needed the authority to address the whole patient. This helped further open the door to independent prescribing. Today, “a practitioner [can be] responsible for the assessment of patients with undiagnosed or diagnosed conditions and for decisions about the clinical management required, including prescribing,” according to the United Kingdom’s National Prescribing Centre, a division of the National Health Service.
Barriers. Nonphysician prescribing authority was met with strong opposition from the medical community. In a BBC story on nurses’ and pharmacists’ expanded scope of practice, a member of the British Medical Association called the reform an “irresponsible and dangerous move,” adding that “patients [would] suffer.”
“The World Medical Association was more bold,” Anderson said, “saying that certain tasks can only be performed by physicians and that prescribing is one of those things.”
Uptake, outcomes. In no small part due to the fierce opposition of the medical community, relatively few pharmacists have been certified to prescribe in the United Kingdom.
Certification requires a 26-day course and 12 days of practical experience under the supervision of a prescribing clinician. The course emphasizes prescriber responsibility, awareness of one’s own limitations, understanding how and when to refer or seek guidance, and relationship building with patients and members of the care team.
Only 2% to 3% of the pharmacist workforce was certified to prescribe in 2010, with 70% to 80% actively using the license, according to an assessment by the U.K. Department of Health Policy Research Programme (PRP). Certification uptake varies by region. In some hospitals, pharmacists write half the prescriptions; in others, none of the pharmacists prescribe.
Despite physician reaction, the prediction that patients would suffer has proven incorrect. The PRP found pharmacist and nurse prescribing safe overall in its 2010 study. And a pilot study examining pharmacist prescribing in the North of England found that pharmacists wrote 40% of prescriptions, with a 0.3% error rate.
Canada
In Canada, pharmacists can prescribe drugs for minor self-diagnosed or self-limiting ailments; monitor and authorize refills of existing prescriptions; modify and adapt a prescription to alter dose, formulation, regimen, or duration; complete missing information on the prescription; and provide emergency supplies of a prescribed medication to a patient. Pharmacists can also provide a therapeutic alternative; prescribe independently or in collaboration with a physician when a diagnosis is provided; and provide comprehensive medication therapy management (MTM).
Conditions. Not unlike the United States, Canada faces a shortage of family physicians. In 2002, a report of the Royal Commission on the Future of Health Care in Canada shifted national attention to the importance of primary care. In examining how to make sure patients saw the right health care provider with the right skills at the right time, policy makers were forced to consider the role that pharmacists could play in this mission.
In the report, former Premier of Saskatchewan Roy Romanow wrote, “Pharmacists can play an increasingly important role [on] the health care team, working with patients to ensure they are using medications appropriately. … In the future there may also be a role for [non–community pharmacists] to prescribe certain drugs under specific limited conditions.”
Ten years later, the Council of the Federation—a meeting of the premiers of each of Canada’s 13 provinces and territories, one of whom is a pharmacist—established as a priority increasing “the important role paramedics and pharmacists play in the provision of frontline services.”
Today, most provinces have laws that expand pharmacists’ scope of practice to include some form of prescribing authority, said Janet Cooper, BSc, ACPR, Senior Director of Professional and Membership Affairs for the Canadian Pharmacists Association. Extent of authority varies by province.
Barriers. Like pharmacists in the United Kingdom, Canadian pharmacists also faced severe opposition to their prescribing authority by physicians.
However, other barriers to gaining prescribing authority, which is regulated by province, are significantly lower in Canada. For example, in Alberta, the first province to authorize pharmacist prescribing, all licensed pharmacists get basic prescribing authority after attending an orientation. Pharmacists who meet additional requirements, including 1 year of full-time experience in direct patient care, can earn additional prescribing authority.
Basic prescribing authority allows pharmacists to adapt prescriptions, renew them, and prescribe in an emergency. Canada has already seen the benefits of emergency prescribing. In 2013, community pharmacists prescribed for flood victims in Calgary who had to evacuate their town in the middle of the night and leave without their medications.
Uptake, outcomes. About 10% of pharmacists in Alberta have additional prescribing authority. While physician response was initially extremely negative, attitudes have softened. Patients, on the other hand, were only disappointed that pharmacists could not do more.
“The public thought they could go to the pharmacist and never had to see the doctor again,” Cooper said. “Pharmacists weren’t allowed to prescribe as much as the public wanted.”
While the number of pharmacists with additional prescribing authority in Canada is relatively low, as in the United Kingdom, Cooper doesn’t attribute that to physician resistance.
“I think the biggest issue is confidence,” she said. “Pharmacists: it’s holding us back.”
Where we stand
Pharmacy practice in the United Kingdom and Canada might not seem completely foreign to the U.S. practitioner, Rita Shane of UCSF noted in her presentation at last year’s ASHP Midyear Clinical Meeting. Forty-seven states and the District of Columbia allow collaborative drug therapy management. The extent of authority, which varies by state, may include initiating MTM, ordering and interpreting lab tests, and discontinuing or modifying drug therapy.
Shane points to a confluence of events that show promise for the future of pharmacy in the United States. The primary care physician shortage will require other clinicians to step in. ACA encourages team-based care, MTM, care coordination for the chronically ill, and reduction of readmissions—all areas to which pharmacists would bring useful skills and expertise. California became the first state to grant provider status to its pharmacists late last year—a sign of changing times for the profession. And pharmacy residency applications currently outnumber open slots, she said.
None of these events, however, is as important as the evidence of the improved outcomes brought about by pharmacists’ care.
“I really do think we are at tipping point,” Shane said. “I also believe that we are beginning to see patients demanding pharmacy services. And that’s our overarching goal—that patients come into our health care settings and say, ‘Where is my pharmacist?’”
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