Earlier this year, the Nuffield Trust published a report on the direction of independent prescribing across the UK. Many of our more striking findings related to community pharmacy, where there is a significant gap between ambition and reality.
Meanwhile, national ambitions for community pharmacy continue to expand. The Community Pharmacy Contractual Framework (CPCF) included a 10% uplift in funding, with the planned integration of the Pharmacy First budget into the framework, alongside a national independent prescribing offer from the autumn.
To support these changes, NHS England has published new guidance for integrated care boards (ICBs). As well as new commissioning guidance, the Professional Assurances Framework aims to support the safe implementation of the service.
But how far does this guidance go towards addressing the barriers we identified in our research?
Strengthened planning but challenges remain
The independent prescribing workforce has developed in a piecemeal way, with a lack of overall oversight and planning at both a local and national level. The commissioning guidance encourages ICBs to take a stronger approach to planning, considering how community pharmacy services integrate into the wider health system, while also addressing training and support needs.
Following the introduction of independent prescribing and pharmacy first into CPCF, it’s reasonable that demand for the independent prescribing qualification will increase. A significant challenge for pharmacists entering the prescribing course is access to a Designated Prescribing Practitioner (DPP). This is considerably harder in community pharmacy and remains an outstanding barrier to developing the workforce.
One solution could be allowing the integration of learning across services, including a system-wide approach to facilitate prescribers in training to move between organisations. Pharmacists often have to look outside community pharmacy for a DPP due to a limited number of prescribing pharmacists able to undertake the role.
There are some examples of good local initiatives to improve access to DPPs. Implementing these initiatives in practice can be challenging, however, with governance restrictions sometimes preventing prescribers from accessing DPPs from other organisations.
Assurance, supervision and continuing professional development
Establishing consistent and robust assurances will build public understanding and trust, allowing community pharmacy to be further embedded across the clinical pathway.
The assurances framework sets out to close the gap on professional assurance. Central to this is supervision. In our report, we drew out the lack of structured supervision in the community. The framework addresses this by outlining the responsibility of the employer, including regular access to a named supervisor, and ensuring time is allocated to complete a prescribing appraisal.
However, ICBs must go further to ensure supervision is effectively provided. Employers should be encouraged to implement structured supervision into job plans and provide protected time for regular supervision, not just appraisals.
Uncertainties remain as to whether community pharmacies have the workforce capacity to deliver robust enough clinical supervision to support the growing independent prescribing workforce. NHS England has commissioned a large portfolio of training to address continued professional development needs. However, access to this training will still require protected time and budget from employers.
A significant tension remains between ambitions to expand independent prescribing and equal access to a DPP required to support training
Tracking progress will be essential
No robust data is currently collected on how often independent prescribers in the community are using their qualification. Collecting this information will be essential to assess the integration of independent prescribing into community pharmacy. The commissioning guidance states that ICBs must ensure there is a process in place to actively collect and monitor clinical service and prescribing activity data.
Importantly, ICBs must consider de-prescribing. With a growing prevalence of long-term conditions and multi-morbidity, de-prescribing is an essential skill for prescribers. Only monitoring pharmacists based on how much they prescribe risks encouraging over-prescribing. Moreover, monitoring should include patterns of prescribing specifically for the new MPharm cohort – a particularly vulnerable group of prescribers.
Avoiding a postcode lottery
Overall, both documents align with several of the recommendations we make in our report. While there is a clear focus on strengthening governance, assurance and monitoring in community pharmacy, consistently implementing these changes across the country will be challenging.
There are also some notable gaps. A significant tension remains between ambitions to expand independent prescribing and equal access to a DPP required to support training.
Better planning for services and the workforce is a positive step forward, but ICBs must ensure these are developed based on local demand and population need.
This makes it all the more important that monitoring at a local level feeds into a national data collection, to help build a picture of service provision across the country and monitor inequalities in access.
