Introduction  

Medication-related hospitalizations are frequent in the UK, estimated to account for around 10-16% of all hospitalizations in medical departments, most judged to be preventable [1]. Patient adherence to their medication regimen is lower than 50%. This suboptimal medication use is extremely costly for society, resulting in avoidable disease complications requiring treatment and reducing patients’ quality of life. Globally, pharmacist-led medication management is a recognized concept; however, it varies between countries. Almost all countries perform this function from hospital or community pharmacy facilities only. Still, Australia is an exception and is recognized as a world leader in providing these pharmacy-led services [1]. Sub-optimal medicine management is a key factor associated with unsafe care for care home residents, including medicines not being administered properly. This arises from inadequate knowledge of medicines and their adverse effects, record keeping and audits, and stock keeping and inventory management [2].

The profile and image of the pharmacist have rapidly changed over the last decade, with pharmacists under increased pressure to respond to patients’ clinical needs in the community [3]. This will continue to evolve due to a combination of factors such as oversupply of pharmacists within current roles, shortages of doctors, an aging population, and the global epidemic of non-communicable diseases, where following initial diagnosis, ongoing maintenance is medication-based. In the UK, National Health Service (NHS) pharmaceutical services provided through contracted privately owned community pharmacies [4]. Each day 1.6 million people in England access a community pharmacy, and for 89% of people, a pharmacy is  less than 20-minute’s walk from their address. In 2008, the UK government White Paper; ‘Pharmacy in England: building on strengths, delivering the future’ discussed a new vision for pharmacy, encouraging the sector to develop and increase the clinical services they offer, such as routine monitoring of long-term conditions, screening side effects, and adverse reactions, supporting better use of medicines, offering lifestyle advice and self-care support, and minor ailments services [5].

The national shortage of doctors in the UK has arisen through a combination of an aging population, budget cuts in services and training, an overall shortage of general practitioners (GPs), leading to more attendances at emergency departments [6]. In 2013, the Royal Pharmaceutical Society of Great Britain (RPS) advised that the government needed to utilize pharmacists’ skills better, moving beyond the focus on dispensing and supply of medication [7]. In the 2014 NHS ‘Five Year Forward View,’ the NHS and the Royal College of General Practitioners (RCGP) agreed and stated that community pharmacy is a ‘significant unexploited potential resource’ [8]. In the management of long-term conditions, they could provide an alternative triage point for common ailments to supplement out-of-hours services or accident and emergency departments.

Since 2006, to qualify as an independent prescribing pharmacist (IP), pharmacists must successfully complete a General Pharmaceutical Council (GPhC) accredited IP program delivered by an accredited training institution [9]. The places are increasing pressure for pharmacists to manage complex patients and expect they will be entering environments for which doctors have been specifically trained [3]. This was also reported to be a problem by the Chairman of the GPhC’ s fitness to practice committee, who warned that a pharmacist ‘…is not competent to undertake a physical examination which includes the touching of a patient’s body as part of a diagnostic procedure…’ after a case where a pharmacist physically examined a patient after complaining of back pain [10].

In 2016, the pharmacy integration fund was set up. It totaled £300 million to cover until 2021 [11]. The fund’s priorities were to deploy pharmacists into a wider range of clinical settings such as GP practices, NHS 111 services, care homes, and urgent care. Studies showed underutilization of community pharmacists’ clinical skills and the potential for utilizing those skills to alleviate the pressures on GPs and secondary care [11]. To support these changes, educational grants were provided for community pharmacists ‘to access postgraduate clinical pharmacy education, and training courses up to diploma level.’ The government recently announced £3.5 billion funding towards pharmacists servicing care homes following a pilot which showed that such roles reduce the risk of unplanned admissions into hospitals (Milmo, 2012). Since 2015, Health Education England (HEE) has been funding pharmacists to train to become advanced practitioners. The General Practice Pharmacist Training Pathway (GPPTP) was launched in 2016 and saw 500 independent prescribing pharmacists across England employed to work in general practices for 18 months [5]. Evaluation carried out on this pilot led to funding the deployment of 1500 pharmacists to work in general practice.

An independent evaluation report of ‘Community Pharmacist Independent Prescribers (CPIPs) working in a patient facing role in primary care, carried out by the University of Nottingham, concluded that pharmacists had a significant role in reducing the workload of doctors and that this could help reduce the pressure on general practices [5] especially for the management of patients diagnosed with chronic conditions such as hypertension, diabetes, and asthma. The report highlighted cases of pharmacists running triaging clinics where patients with minor ailments were given self-care advice or referred back to their community pharmacy. Those requiring further care were either dealt with by the CPIP or referred to the GP [5]. The report suggested a definite need for a clear pathway. All pharmacists can obtain a prescribing qualification and develop core principles around working and prescribing in primary care, such as clinical examination, assessment, and diagnosis. It further highlighted that there appeared to be a lack of support for GPs to help them understand the role of the pharmacists and the level of training they require to be integrated into general practice [5].

The National Pilot for Emergency Medicine 2016 (Pharmacists in Emergency Departments, 2016) was a multisite cross-sectional observational study that included 18,613 patients [12]. The study analyzed the impact of independent prescribing pharmacists in an Accident and Emergency setting and concluded they could autonomously manage 36% of patients. The major training areas identified were triaging skills and physical examination skills, including interpretation of blood tests and x-rays. The study did not investigate whether the pharmacists could have treated patients in their usual community pharmacy setting [12].

Materials and Methods

Two activities were undertaken:

1. Explore the extent of the independent prescribing pharmacists’ current employability in Wolverhampton.
2. Explore the opinion of pharmacists who are not qualified as independent prescribers on the skills and knowledge they believe they lack and should master before becoming prescribers using an online survey.

Local employability

There are currently 58,225 registered pharmacists in the UK, with 6192 (10%) are registered as independent prescribers. There are currently 211 clinical commissioning groups (CCGs) in the UK. Using the CCG list for GP’s based in Wolverhampton, each surgery was individually contacted to determine whether the surgery employed an independent prescriber pharmacist (IP). If so, the number of IPs employed is measured as Full-time Equivalent (FTE). The information was used to ascertain the number of IPs employed in a prescribing role compared to qualified and registered. Increasing the number of IP responsible for providing primary care may improve patient access to healthcare; however, only 21 out of 57 surgeries (37%) in Wolverhampton CCG employed an IP. With only 7 out of 57 (12%) surgeries employing an IP on an FTE basis, the remaining employed IP mainly on a part-time (PT) basis. There were 70 IPs employed a total of 50.2 FTE.

Pharmacists’ opinions survey

Community pharmacists were asked to complete a questionnaire around extending prescribing services into the community and the skills and knowledge required to achieve that. The anonymous, one attempt per person survey was composed online using Survey Monkey™. The link was sent to all pharmacists in Wolverhampton and Birmingham who were not qualified independent prescribers, using the public online email contacts for their pharmacies (n=70 in Wolverhampton; n=285 in Birmingham, a total of 355 pharmacists). Using the Survey Monkey™ data analysis utility to review the responses.

Results and Discussion

Only 52 responses were returned (15%); 65% males and 35% females. There were 59% married, 39% single, and 2% did not disclose. The majority (48%) were 31-40 years of age, followed by 22-30 years old (39%), 41-50 years old (12%), and 1% did not wish to disclose. Out of the total respondents, there were 77% from an Asian background, 14% white, and 9% from a Black background. The majority (75%) of respondents worked FTE, and the remainder worked PT. There was 96% first degree qualified in the UK, 2% from an EU country, and 2% from non-EU overseas. Additionally, 69% already had a postgraduate qualification, and the remainder held only their first degree. Most of those who had postgraduate degrees were employed in hospitals (25%), general practice (45%), or academia (22%), where their postgraduate qualification was an employment requirement. There were 42% worked in two sectors of those three. The other 28% worked in community pharmacies and did not have postgraduate qualifications. There were only 2 respondents had Doctor of Philosophy, 6 had Master degrees and 8 had Clinical Diploma.

When participants were asked in which sector they would like to work in the future as IP, the majority (37%) selected general practice, followed by urgent care (21.6%), community pharmacy (14%), private clinic (12%) and care homes (10%). Participants were then asked to nominate the sector where they spend most of their time. The majority (71%) nominated community pharmacies. When participants were asked their special area of interest, diabetes (30%), minor ailments (20%), and respiratory care (18%) were the most listed (Table 1).

Participants were then asked about their clinical knowledge and their confidence level in applying this knowledge (Table 2). The most selected areas as highly confident were ‘I am aware and able to apply public health issues into my Practice’ at 19.6%, followed by pharmacology and routine biochemistry equally at 17.65% compared to all other clinical areas. 23.5% reported not being confident in interpreting highly specialized diagnostics, followed by anatomy at 18%. The most selected as the first option of course of future studies was 1-2 days continuous professional development (CPD) by 42.55%, where all longer courses were selected as 5^th (53%), 6^th (63%), and 7^th (72%) options indicating that the majority prefer a maximum of 6 month PT studies (Table 3).

Participants were then asked about their preferred learning method; most participants (55%) selected ‘mix of work-based and attendance learning, followed by full-time university at 30.6% (Table 4).

Participants were asked if they would like to see the provision of independent prescribing as part of everyday practice in community pharmacies; 90% answered yes. One participant commented, “It depends what it is being used for, so as I couldn’t say yes for everything as a generalist as there is not sufficient clinical support to mentor and close working. However, I think yes, there are roles for prescribing, with public health options such as smoking cessation or vaccination clinics good for patients.”

Participants were asked if they would like to perform prescribing activities during normal GP hours or only after hours and in an emergency; most (60%) selected both during and after the normal GP opening hours (Table 5).

Participants were then asked about the barriers regarding the provision of prescribing by pharmacists from community pharmacies, and participants made the following comments:

“I am not allowed to start prescribing until I have been practicing for 2 years and can find a DMP. This is unnecessary because my knowledge was at its highest when I first graduated, and I also became a prescriber after graduating. So the GPhC is the biggest barrier. The second barrier is the doctors themselves. They ask for money to supervise you, and nobody funds us to do the course, but the government keeps saying they want to ease the pressure off doctors.”

“I feel there would be a total conflict of interest. If I owned a pharmacy, it would be in my favor to prescribe more medications to get my script numbers up.”

“There is no structure in place to allow this. I don’t think the CCGs would welcome it. Patients might not want their data shared with the pharmacist. There isn’t a proper consultation room and space in most pharmacies. The pharmacist is not adequately trained.”

Participants suggested some barriers and solutions, where the main themes were financial restriction, high workload, and need for training and infrastructures (Table 6).

Finally, participants were asked to add further comments (Table 7). The major theme was pharmacists, the NHS, the GPhC, higher education, and confidence in practice. However, surprisingly, there was no mention of how patients may react to having their community pharmacist as their first point of call for healthcare provision in conjunction with their GPs.