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Pharmacists Outside U.S. Inch Toward Independent Prescribing

Kate Traynor

Pharmacists in the United Kingdom (UK) could gain independent prescribing status as an extension of a policy this year that grants so-called supplementary prescribing privileges to the profession.

In the UK, supplementary prescribing is part of the "vision for pharmacy" announced last year by the Department of Health.1 The department described supplementary prescribing as part of a movement "towards full independent prescribing" by pharmacists and stated that the National Health Service (NHS), which provides health care in the UK, would work with health professions and patient organizations this year to develop a framework for independent prescribing.

Supplementary prescribing requires an agreement between a pharmacist and a physician or other health care professional who has full prescribing privileges. The patient receives a diagnosis from the physician and begins treatment under the physician's care. If the patient agrees, subsequent monitoring and adjustment of treatment is the responsibility of the supplementary prescriber, who consults the responsible physician when necessary.

The arrangement is akin to collaborative drug therapy management agreements through which pharmacists in 40 states in the United States can gain the right to direct medication therapy under a physician's guidance.

Nurses are also candidates for supplementary prescribing in the UK, which already grants limited prescribing authority to qualified nurses.

A slow start. Proposals to move forward with supplementary prescribing were developed in 1999 by a committee of experts and announced in April 2002 by Junior Health Minister Lord Philip Hunt. The legislative underpinning for the proposals was the Health and Social Care Act of 2001.

The Health Department had initially predicted that pharmacists would begin training as supplementary prescribers early in 2003 and begin prescribing soon after. Hunt stated in November 2002 that the goal was "to have up to 1,000 pharmacists and up to 10,000 nurses trained by the end of 2004."

To become a supplementary prescriber, a pharmacist must receive 25 days of classroom training plus 12 additional days of training in a practice setting under the supervision of a physician. After completing the training, the pharmacist must register with and pay a fee to the Royal Pharmaceutical Society of Great Britain, which regulates pharmacy practice in England, Scotland, and Wales.

Regulatory issues delayed the start of pharmacist training until last fall, and the first pharmacists qualified as supplementary prescribers in February of this year. By May, about 100 pharmacists and 1400 nurses in the UK had completed training and registered as supplementary prescribers, according to NHS.

Pharmacist Lorna Davies on May 7 became the first member of her profession to write a supplementary prescription, according to Health Minister Rosie Winterton.

DotPharmacy, a Web site operated by Chemist & Druggist magazine, reported that Davies wrote her first prescriptions, for amlodipine and lisinopril, at a hypertension management clinic. Davies was hired to operate two half-day clinics per week at a medical practice in the city of Derby after completing her training as a supplementary prescriber, according to the report.

More to come? Pharmacists and nurses who register as supplementary prescribers are not currently authorized to prescribe controlled substances. Proposed amendments to NHS regulations could lift that barrier later this year.

NHS announced in May that plans are afoot to extend supplementary prescribing privileges to physiotherapists, radiographers, podiatrists, and optometrists.

The Health Department announced in June that it had awarded contracts designed to increase pharmacists' role in public health.

"We would like pharmacists to do even more and get involved in aspects of care such as checking people's blood pressure and even measuring blood glucose levels," Winterton said in a statement.

Beyond the UK. The Alberta College of Pharmacists (ACP) and the Pharmacists Association of Alberta launched a public campaign in 2002 to draft regulations that would allow prescribing by qualified pharmacists in the Canadian province. Although most prescribing would be done through collaborative agreements with physicians, the pharmacy groups have proposed limited independent prescribing in certain circumstances.

These circumstances would include emergency situations, refills for long-term therapy, the provision of smoking-cessation products and emergency contraceptives, and prescribing of therapeutic alternatives for reasons of cost, adverse events, or formulary issues.

ACP announced in its May/June 2004 newsletter that legislative support exists for the proposed changes and that the regulatory changes needed to implement them could take place this year. In its 2003–04 annual report, the pharmacy group emphasized that pharmacists in Alberta "are already performing many of the activities proposed within the expanded scope of practice." ACP stated that the proposed regulatory changes would legitimize these practices.

In Manitoba, British Columbia, and Quebec, pharmacists can have limited prescribing authority through delegation from licensed prescribers. In Quebec, British Columbia, and Saskatchewan, pharmacists can receive training that entitles them to prescribe emergency contraception. Of note, Health Canada in May proposed making emergency contraception available without a prescription.

Pharmacists in Australia and New Zealand are also authorized, after receiving training, to provide emergency contraception without a physician's prescription.

1. United Kingdom Department of Health, 2003. A vision for pharmacy in the new NHS. (accessed 2004 Jun 17).