You are a recently qualified independent prescribing pharmacist trained in mental health, due to start a new role as a GP pharmacist. You are excited about your new role and venturing into a new sector — in particular, putting your expertise in mental health to use.
You have a weekend off and decide to go through your contract. You get to the section that describes what you are expected to do as part of your role and are a bit concerned about one of the tasks, which says “manage the repeat prescribing process by signing and reissuing repeat requests.”
While you are happy and feel competent to do most of the tasks, you are not sure about signing for repeat requests. You are unsure whether this is something that is usually expected of pharmacist prescribers in GP practices. What should you do?
“Discuss your concerns”
The management of the repeat prescribing process is fundamentally a core responsibility for any pharmacist. The caveat should always be around individual competency to carry out the task. Any concerns with the terms of the contract should always be discussed openly and honestly. Expectations from the practice and the pharmacist should always be explored. Considerations should be made to utilise the current workforce efficiently, encouraging networking with other service providers to ensure a robust process is adopted.
Working in general practice naturally lends itself to developing into a generalist; the initial chosen clinical specialty in prescribing forms a foundation to build confidence in prescribing and evidence-based medicine. Managing repeat prescriptions to ensure patient safety, optimisation of therapies and cost-effective prescribing is best placed among pharmacy professionals. The increasing burden of polypharmacy and the demands of managing complex comorbidity will continue with our ageing population. The skill base that a pharmacist can offer will add value to the management of medicines in general practice.
Helen Kilminster, GP pharmacist and independent prescriber
Source: Courtesy of Rahman Siddiqur
“Challenge the practice over batch signing of repeats”
I would raise this issue prior to starting the new role, so that both parties are clear on what the prescribing pharmacist can or cannot sign, depending on their scope of practice.
An expectation some general practices have is for all GP pharmacist prescribers to be batch signing acute and repeat prescriptions to take the burden away from the GP. During the non-medical prescribing course, it was mentioned numerous times that when signing a prescription you are fully accountable and responsible for that patient, so to absolutely satisfy yourself that you are signing for the best interests of the patient and that all monitoring, counselling and indication has been fully checked and documented, as you are essentially reconfirming their condition when you sign their prescription. This is extremely difficult to do if you do not have any direct involvement with the patient yourself and blindly batch-signing prescriptions goes against this principle.
Having protocols about batch-signing repeat prescriptions does not alleviate all of the accountability that the prescribing pharmacist will endure for that patient, as GP indemnity providers will ensure that the ultimate responsibility of the patient will fall on the prescribing pharmacist should any harm arise for that patient.
Ideally, signing a prescription should be done directly with the patient in front of you or by telephone and for the conditions that a pharmacist is competent in, which has been approved by all relevant parties, such as the local clinical commissioning group, GP mentor and the indemnity insurance provider.
If the practice insists that blindly batch-signing repeats is part of a GP pharmacist prescriber role, I would challenge this notion as one could say the GPs may be diverting the responsibility of their patients onto the prescribing pharmacist.
Rahman Siddiqur, GP pharmacist and independent prescriber
Source: Courtesy of Adeola Olukosi
“Explain your scope of competency”
In this scenario I would speak to my GP clinical lead or the lead partner and express my discomfort with this arrangement. I would explain I would only be willing to prescribe medicines within my clinical competency and scope.
The requirement to prescribe outside of my scope would call for the necessary training. I would further explain signing repeat prescriptions without reviewing the patient or for medicines outside my scope of competency ultimately risks patient care and patient safety.
I would explain what my scope of competency is and that I am happy to expand my scope with the appropriate development. I would be happy to sign repeat prescriptions for medicines I have shown clinical competence in, as well as only in patients I review.
I would hope the GP would understand and support me in my decision, as well as in my development as an independent prescriber.
Adeola Olukosi, primary care pharmacist and independent prescriber
Source: Courtesy of Tom Gregory
“‘Can’ does not mean ‘should'”
I have only just completed my independent prescribing qualification and am not even on the General Pharmaceutical Council register, so I’m yet to start thinking about signing my own prescriptions let alone someone else’s.
The independent prescriber qualification allows pharmacists to prescribe whatever they like (within reason); however, “can” does not mean “should” — we should still practice within the scope of our own competence. I would refuse to sign repeat prescriptions for anything other than items where I have reviewed or assessed the patient, and strictly within my scope of practice — which I accept is very narrow at the moment, and will stay like that until I am comfortable and competent to expand it.
I don’t think my answer would necessarily change whether I had signed the contract or not, but this does highlight the need to be fully aware of expectations when signing a contract. I would speak to the practice manager or one of the partners to discuss my concerns and have the clause relating to signing repeats removed. I think there’s a really clear role for pharmacists in GP practices to manage, streamline and support the repeat prescribing process (including improving the use of electronic repeat dispensing), but that responsibility cannot be extended to signing the prescriptions in all cases.
Tom Gregory, GP pharmacist and newly qualified independent prescriber
Yogeeta Bhupal (left) and Regina Ahmed are professional support pharmacists at RPS Professional Support
Advice from RPS Support
As with any prescriber, you would be responsible and accountable for each prescription you sign, so it is important to be aware of your own limits, skills, competence and confidence with the prescriptions you are signing for.
It is advised that you check with your own and your employer’s indemnity provider as to whether they would provide adequate cover for signing and reissuing repeats for independent prescribing pharmacists.
If you are unsure whether the tasks and responsibilities in your contract reflect those of other GP pharmacists, it may be useful for you to look at various job descriptions of independent prescribers working in general practice. An example GP pharmacist job description has been developed by the Royal Pharmaceutical Society (RPS) to provide an idea of what the day-to-day duties are for GP pharmacists. The RPS has a bank of case studies addressing potential scenarios that GP pharmacists may encounter on the job. You can also look at NHS Jobs to compare job descriptions of various other GP pharmacists.
You should seek further clarification from your future line manager/practice manager to establish exactly what your role will involve. It is important to ask whether you will be reviewing patients prior to signing any repeat prescriptions.
The prescribing competency framework discusses patient assessment. You need to consider if you are both comfortable and competent to assess, prescribe, safety-net, monitor and review patients outside your scope.
If you will be practising outside your scope, what training can the practice provide to assist you in developing competency in this area? Is it worth producing a formulary of the medicines you are competent to prescribe and discussing this with the practice GPs? Having a protocol in place, which includes when to refer patients, can also be helpful.
If you have already signed your contract and are unsure about your legal obligations, it is important that you determine whether you are appropriately indemnified for any work you decide to carry out. Discuss this with your indemnity providers and ensure you are covered to sign repeats.
If you are not comfortable signing repeat prescriptions without first reviewing patients, relay your concerns to your employers and discuss why you feel your skill set may not be best suited to this role, and explain it may be beneficial to the practice for you to work on other roles, such as setting up medication review clinics and prescribing for patients in your area of competence. You could have a discussion on how you could achieve this in the future, constructing a training plan or work shadowing to increase your competency.
Yogeeta Bhupal is a professional support pharmacist at RPS Professional Support. She also works part time as a GP pharmacist. Regina Ahmed is a professional support pharmacist at RPS Professional Support. She also has a background working in GP practice as an independent prescriber.
This professional dilemma is based on real enquiries made to the RPS Support Service. For further advice and support contact: RPS Professional Support Service: 020 7572 2737. The RPS professional support service is a confidential advice service that you can contact as part of your membership. It is a friendly team of pharmacists and pharmacist advisers who offer support and advice on careers, including starting a role as a practice-based pharmacist, the role of a practice-based pharmacist and working on your own professional development. You can get in touch with any questions, big or small.