Pharmacist independent prescribers can make a significant contribution to antimicrobial stewardship

As the role of non-medical prescribers has become established, the number of pharmacists becoming qualified to prescribe has steadily increased. In the UK, there are currently 3,875 pharmacist independent prescribers, 382 pharmacist supplementary prescribers and 962 registrants who are both independent and supplementary prescribers^[1]
. In Wales, many of these prescribers were originally based in the secondary care setting — for example, in outpatient clinics prescribing for specialised areas such as rheumatoid arthritis^[2]
. Those based in primary care were likely to be prescribing for patients with chronic diseases — hypertension, for example.

From our involvement in the Cardiff University pharmacist independent prescribing programme, we have noticed, over the last two years, an increase in the number of pharmacists enrolled who are based in GP practices or GP clusters. This is a result of the Welsh government’s plan for primary care workforce, which sets out clear intentions for more pharmacists to work in GP practices in a clinical role. While many of these pharmacists on the prescribing programme choose a scope of practice related to a chronic condition (e.g. atrial fibrillation) there are more pharmacists considering prescribing for acute conditions — e.g. management of acute infections where an antibiotic may be considered, and expected by patients to be prescribed. This is one area that we believe is set to increase with the evolving role of pharmacist prescribers in Wales extending to triaging and working in ‘GP out-of-hours’.

Pharmacist prescribers are well placed to manage such patients. An increased presence of pharmacists within GP practices is supported by the RPS. One of the key campaigns of RPS Wales in 2017 is to promote the role of pharmacists in antimicrobial stewardship and the role of the pharmacy team within this important area is clearly indicated in the ‘Models of care for pharmacy within primary care clusters’, published in 2015 by RPS Wales and NHS Wales. The Welsh government also clearly recognises the role of pharmacists in tackling the public health agenda of antimicrobial resistance. Health boards within Wales have appointed antimicrobial pharmacists, many of whom are prescribers. These prescribers have a role in managing Clostridium difficile or MRSA infections, providing an educational programme for all healthcare staff, surveillance on antibiotic prescribing and enhancing antibiotic stewardship across both primary and secondary sectors. Nicholas Reide has been newly appointed as consultant pharmacist in the area of antimicrobials and this further illustrates the commitment of the health service in Wales to this important therapeutic area.

Research has shown that a high number of non-medical prescribers (nurses and pharmacists) prescribe for respiratory conditions^[3]
and infections^[4]
and are well positioned to educate the public on when antibiotics are required and that they are not needed for self-limiting respiratory tract infections, coughs, colds and sore throats.

Our recently published research, completed across the UK, explored patients’ expectations and experiences of nurse and pharmacist non-medical prescriber-led management of respiratory tract infections^[5]
. We found that the majority of patients were satisfied with the care they received. This is similar to other findings where patients have expressed satisfaction with the pharmacist consultation, and confidence in their extended role. While just under half of the 120 patients (43%) expected to receive an antibiotic, they were no more likely to receive one. The non-medical prescribers used a range of non-antibiotic patient-centred management strategies within the consultation, for example education, reassurance and physical examination. Importantly, the prescribers were not unduly influenced by patients’ expectations for an antibiotic. This is in contrast to findings from studies investigating influences on GP prescribing decisions, where patient pressure and expectations has played a part^[6]
,[7]
.

While there has been expansion and development of the pharmacist prescribing role, there still needs to be an ongoing strategic approach within all sectors to ensure that the role is used for maximum benefit. Recent unpublished research we have completed in Wales has identified that a clear organisational strategy helps to embed non-medical prescribing within practice.

These findings are currently being shared across the health boards. The importance of workforce planning, funding for training and study leave, clinical supervision and appropriate clinical governance systems need to be fully recognised by employers, commissioners and the Welsh government as these will support the sustainability of non-medical prescribing and allow its potential impact on patient care to be achieved. We envisage the RPS to have an important role in this agenda.