This paper investigates the potential threat to medical dominance posed by the addition of pharmacists as prescribers in the UK. It explores the role of prescribing as an indicator of professional power, the legitimacy and status of new pharmacist prescribers and the forces influencing professional jurisdictional claims over the task of prescribing. It draws upon 23 interviews with pharmacist supplementary prescribers. Data suggest that the legitimacy of pharmacists as prescribers, as experienced in the workplace, has been aided by: (1) blurred definitions of prescribing; (2) the emphasis on new prescribers’ competence urging pharmacist prescribers to limit their areas of clinical practice; and (3) a team approach to patient management. Competence, self-limitation on practice and the benefits of team working as part of the ideology of patient safety were thus an important influence on pharmacists’ jurisdictional claim over prescribing. While pharmacists have successfully negotiated a role for themselves as prescribers, medicine has retained its high status, relative to other health professionals and with patients; it controls the knowledge base relevant for prescribing practice and has managed to develop an ‘overseer’ role over the process of prescribing. Prescribing, as an indicator of medicine's autonomy of control over their work and professional status, has changed. Yet the extent to which new prescribers have been able to threaten the professional dominance of medicine is debatable.
Hall, in his seminal 1980 work on prescribing as social exchange, noted the dual aspects of prescribing, as a phenomenon of interest at both the micro and a macro level (1980). At the micro level of the consultation, it is one aspect of doctor-patient interaction which can communicate the doctor's concern for the patient and willingness to help (Comaroff 1976). Giving a prescription is also a way of maintaining a relationship so the patient will continue to trust and return to the doctor for future visits (Harris 1980). The physical process of turning away from the patient and writing (or issuing) a prescription can also indicate that the consultation has finished and the patient should now leave (Hall 1980). The prescription has symbolic value, providing evidence of the doctor's ability to act (Bush 1983) and conveys the impression that the diagnosis and treatment of minor conditions is more precise than it actually is (Comaroff 1976). As discussed by Comaroff (1976), the prescription is a way of coping with clinical uncertainty; lengthy explanations, particularly in regard to vague or trivial symptoms, are foregone in favour of the simple ritual of providing a prescription.
At a macro level, the prescription provides epidemiological evidence of activity through computerised collation of prescription records which can be examined at locality, regional or national level. Indeed, the scale of prescribing is vast, with the total cost to the National Health Service (NHS) of medicines in 2005/6 in England being £10 billion or 12.7 per cent of total NHS expenditure (Department of Health 2007a). Traditionally, prescribing has also been an indicator of the clinical autonomy and professional power of doctors within the wider structure of society. As noted by Friedson (1994), doctors’ professional status is distinguished by their autonomy of control over their work, in part revealed by their professional monopoly over the prescribing process. The giving of a prescription grants access to treatment resources and shows that doctors have control over these resources (Stimson and Webb 1975). The closeness between doctors and the substance they prescribe is exemplified by the use of the word ‘medicine’ to describe both profession and drug (Britten 2001). Britten (2001) argues that, with pressures now coming from the State, patients and other health-care professionals, prescribing is the battleground where doctors’ clinical autonomy is defended in UK general practice.
Potential threats to the dominance of medicine are not new. Medical dominance can be defined as the power of doctors to control others through a cultural authority based upon the value accorded to their medical knowledge (Starr 1982). Friedson (1970) suggests that medicine's dominance is underwritten by the state that, at least until recently, had a common interest in maintaining the pre-eminent position of medicine in matters relating to health. Elston (1991) considered challenges to medicine within two principal theses, those of deprofessionalisation or proletarianisation. Deprofessionalisation can be described as the loss of their monopoly over knowledge due to the changing nature of professional-client relations and clients’ increasing access to medical knowledge (Haug 1973). Proletarianisation argues that medicine is losing control over its working conditions through deskilling, increasing salaried employment and other consequences of advanced capitalism (McKinlay and Arches 1985). Yet, at least up until the mid 1990s, authors have maintained that neither of these theses has resulted in significant threats to the dominance of medicine (Gabe, Kelleher and Williams 1994, Hunter 1994). More recently, Allsop (2006) reasons that while doctors’ clinical autonomy has been reduced, they still control a valued knowledge base, have significant social standing and are still able to command large salaries. In a 2006 review of his 1983 book Medical Dominance: the Division of Labour in Australian Health Care, Evan Willis weighed up the evidence for and against a decline in medical dominance, and concluded that there was ‘inevitably slippage between policies that seem to undermine the power of medicine but do not, in the end, have much control or influence’ (Willis 2006).
In 2003, legislative changes were introduced in the UK which permitted prescribing by other health-care professionals such as nurses and pharmacists. These changes were informed by the Crown Report published in March 1999 which recommended that ‘the legal authority to prescribe should be extended beyond currently authorised prescribers’ (Department of Health 1999). The Crown Report's recommendations sought to modernise the NHS by providing more flexible arrangements on the prescribing, supply and administration of medicines in the NHS, to improve services to patients and to make better use of the skills of professional staff such as nurses and pharmacists. Initial legislative changes allowed pharmacists and nurses to prescribe under supplementary prescribing (SP) arrangements where pharmacist and nurse prescribers could act, with the patient's agreement, to implement a patient-specific clinical management plan (CMP) in partnership with a doctor or dentist. The aims of supplementary prescribing are to improve patients’ access to medicines, make better use of the clinical skills of eligible professionals and, in time, to decrease general practitioners’ workload so they could concentrate on more complicated cases (Department of Health 2005). In SP, a CMP must be in place before prescribing can occur and relates to a named patient with the specific clinical conditions which are to be managed by the supplementary prescriber (Department of Health 2005). The CMP contains information such as the types of medicines to be prescribed, restriction or limitations to the prescribing of the medicines, relevant warnings and the circumstances in which the supplementary prescriber should refer to, or seek the advice of, the doctor or dentist who is party to the plan. Further changes were made in 2006 to allow pharmacists and nurses to become independent prescribers, defined as ‘a practitioner responsible for the assessment of patients with undiagnosed or diagnosed conditions and for decisions about the clinical management required, including prescribing’ (Department of Health 2005). Pharmacist independent prescribers are able to prescribe any licensed medicine for any medical condition, with the exception of controlled drugs (Department of Health 2006a). While a CMP is no longer required to be used by pharmacist independent prescribers, pharmacists are likely to use disease- or treatment-based protocols, agreed at their practice base, when they prescribe.
Nancarrow and Borthwick (2005) describe this process as ‘vertical substitution’: where tasks are delegated or adopted across disciplinary boundaries without the level of training or expertise being equivalent between the two professional groups. Prescribing by nurses and pharmacists can fit within this paradigm. To underscore the difference between doctor prescribing and nurse, pharmacist or other allied health-care professional prescribing, prescribing by this latter group is called ‘non-medical’ prescribing. This distinction emphasises the difference, and by implication inferiority, of non-medical prescribing from doctors’ prescribing. Prescribing pharmacists and nurses are not financially rewarded to the same level nor do they acquire the same status as doctors, although they do have increased status within their own professional group (Nancarrow and Borthwick 2005, Weiss 1994).
Drawing upon Abbott's (1988) work on jurisdictional claims, prescribing can be seen as an area of jurisdiction, previously under full jurisdictional control of the medical profession, with recent actions by the state affecting professional control of that work. Abbott suggests that outcomes of contests for jurisdictional claims are mediated through interactions and negotiations at a public, legal or workplace level. Boundary encroachment or pharmacists negotiating with doctors in the hospital workplace for influence over prescribing decisions has been described previously (Weiss 1994). The research by Weiss (1994) took place before pharmacists were legally able to prescribe; yet, interestingly, it showed that some pharmacists sought to self-limit their scope of influence so that they did not have the possibility of conflicting with doctors in the area of prescribing.
Pharmacists’ increasing involvement in more clinical activities [e.g. taking patient medication histories, monitoring medication use on hospital wards and counselling patients on appropriate medicine use] such as prescribing can be seen as a professionalising strategy and a means of enhancing pharmacy's professional status (Eaton and Webb 1979). Mesler (1991) described the role of pharmacists as drug experts on medical teams in two North-eastern US hospitals. The potential for boundary conflicts between the pharmacists as drug experts and the doctors as the writers of prescriptions involved a slow process of encroachment and delegation. Doctors were left ‘in charge’ yet frequently welcomed the, sometimes unsolicited, advice on drugs provided by pharmacists as it was done in a tactful and non-threatening manner. As noted by Mesler (1991), ‘for some people [e.g. pharmacists] to obtain and deploy resources does not necessarily mean that others [e.g. doctors] have lost them’. Mesler's analysis mirrors the perspective of Abbott by suggesting that role boundaries between professional groups seeking control over specific tasks are constructed and maintained through social interactions within a specific workplace context.
Initial reaction from the medical profession with regard to the extension of prescribing rights to other health care professionals was unenthusiastic (Day 2005). The BMA (2005) described nurse and pharmacist prescribing as ‘irresponsible and dangerous’, citing concerns about patient safety and in-equivalence of training as key issues. While there may be valid underlying concerns (Avery 2005), this response could also be viewed, within a framework of challenges to medical dominance, as a logical reaction to the potential loss of professional status and doctors’ prescribing monopoly consequent with the addition of new prescribers.
This paper will focus on pharmacist prescribing, drawing upon data from interviews with pharmacists who have undergone the required training (25 days learning at an accredited higher education institution and 12 days learning in practice) to become supplementary prescribers. As noted by Tonna et al. (2007), pharmacists’ area of practice can be divided into three broad areas:
- • community pharmacy
- • primary care settings
- • secondary care settings
Community pharmacists are those whose main job is as an employee of a company owning a chain of pharmacies (e.g. Boots) and those who own, or are employed in, an independently owned pharmacy or ‘chemist shop’. Community pharmacists can work as a supplementary prescriber within their pharmacy or they may undertake sessional work (a ‘session’ usually equates to a half day) for one or more general practices. Primary care pharmacists are those whose main job is as an employee of a Primary Care Trust (PCT) or whose main job is working directly as a practice-based pharmacist in one or more general practices. Those working for a PCT may have a managerial role, for example monitoring prescribing across all general practices in the PCT, but also work on a sessional basis in individual general practices as a supplementary prescriber. Hospital pharmacists work within the secondary or tertiary care sector as a supplementary prescriber. This complexity in workplace arrangements for supplementary prescribing is likely to influence how supplementary prescribing has developed in the different settings.
This paper takes forward the perspective of Abbott and Mesler to explore how jurisdictional claims over prescribing have been negotiated in the workplace and the factors influencing the outcome of this negotiation. It will make the argument that the legitimacy of pharmacists as prescribers, as experienced in the workplace, has been aided by: (1) blurred or fragmented definitions of prescribing; (2) the emphasis on new prescribers’ competence urging pharmacist prescribers to limit their areas of clinical practice; and (3) a team approach to patient management. These act not only to mitigate the impact of new prescribers, but also limit the potential increased professional power and status of pharmacists as prescribers relative to that accorded to medical prescribers.
The research used a two-phase design, first with semi-structured interviews with pharmacist supplementary prescribers and secondly, using case studies at selected prescribing sites. This paper uses data from the pharmacist interviews only. Data were collected from January to June 2005. Ethical approval was obtained for both phases of the research.
Recruitment of participants
The sampling frame was all pharmacists registered with the Royal Pharmaceutical Society of Great Britain (RPSGB) as a supplementary prescriber. At the time of recruitment (November 2004), there were 237 eligible pharmacist supplementary prescribers with no pharmacist supplementary prescribers in Wales. To comply with research governance, the RPSGB asked pharmacists to supply details of their employing organisation so that Research and Development Management Approval could be obtained. Ninety organisations were contacted, with 76 giving approval. Ninety-six pharmacists were contacted from these 76 organisations. Potential respondents were sent an information sheet and a letter and, if they were willing to participate, they sent a reply slip to the project team.
Interviews with pharmacists investigated the following issues: (1) perceptions of their relationship with their medical Independent Prescriber; (2) pharmacists’ perceptions of their role and how it has changed over time; (3) the role of training in their development; and (4) environmental factors that enhanced or detracted from their role as a supplementary prescriber. This paper focuses on data describing their views on their current and potential future role as a prescriber.
All interviews were audio tape recorded and the tapes fully transcribed. The analytic process was both descriptive and explanatory (Strauss and Corbin 1998). Data were sorted and organised into categories. New and emerging categories of relevance to the research questions and grounded in the data were actively sought. The process of data analysis was used to inform data collection. The categories were further interrogated and grouped together in order to clarify the relationships between categories and to refine emerging ideas. Emerging explanations and ideas were investigated using deviant case analysis.
Results and discussion
Of the 96 letters sent out, 38 (39%) respondents expressed agreement to take part in the research. Eight of these had completed the training but were not yet prescribing. From these 38, 23 pharmacists were selected. Respondents were selected for their diversity with respect to the prescribing setting (PCT, community pharmacy or secondary care), breadth of clinical areas in which prescribing occurred (single or multiple prescribing areas) and pharmacist background (university affiliation where they undertook their prescribing training, age and gender). Twenty-three pharmacists (Table 1) were interviewed for Phase 1 representing approximately 10 per cent of the total number of pharmacists registered as supplementary prescribers at the time.
Table 1. Interview participants
|1||F||Southwest||GP practiceFull time||Single clinical area or speciality||10 years|
|2||F||Southwest||GP Practice Full time||Multiple||15 years|
|3||F||Southwest||Hospital||Single clinical area or speciality||30 years|
|4||M||Midlands||GP practice PCT||Multiple||17 years|
|5||M||Midlands||Community GP practice||Not prescribing||26 years|
|6||M||Northwest||Hospital||Single clinical area or speciality||16 years|
|7||F||Midlands||GP practice PCT||Single clinical area or speciality||20 years|
|8||M||Northeast||Hospital||Single clinical area or speciality||20 years|
|9||F||Northeast||Hospital||Not prescribing||20 years|
|10||M||Northeast||Independent Community/GP practice part time||Multiple||15 years|
|11||M||London||Independent Community||Multiple||24 years|
|12||F||London||Hospital||Single clinical area or speciality||18 years|
|13||F||Scotland||Health Board* pharmacy advisor/GP practice part time||Single clinical area or speciality||19 years|
|14||F||Scotland||Health Board* pharmacy advisor||Not prescribing||17 years|
|15||F||Scotland||Hospital||Not prescribing||24 years|
|16||F||Midlands||GP practice part time/ PCT pharmacy advisor||Multiple||9 years|
|17||M||Midlands||PCT pharmacy advisor/GP practice part time||Multiple||29 years|
|18||F||Southwest||Hospital||Not prescribing||25 years|
|19||F||East Anglia||Hospital||Single clinical area or speciality||15 years|
|20||F||East Anglia||Hospital||Single clinical area or speciality||21 years|
|21||F||Southwest||Hospice||Single clinical area or speciality||25 years|
|22||M||London||Independent Community/GP practice part time||Multiple||20 years|
|23||M||Southwest||IndependentGP practice part time||Not prescribing||25 years|
Definitions of prescribing
The Oxford Dictionary defines to prescribe as ‘to advise or order the use of a medicine with directions for the manner of using it’ (Little, Fowler and Coulson 1982). As a physical task in the context of a consultation, prescribing has been conceptualised as a specific event where a medication is written down on a prescription, the prescriber signs the prescription and then gives this to the patient. Implicit within this event are the history-taking, clinical examination skills and diagnostic and therapeutic decision-making processes which precede it. Important to this procedure is the judgement of the professional writing the prescription: the process of drawing upon detailed scientific knowledge and applying this knowledge to an individual patient situation. Previous literature has noted that prescribing is an enduring sign of professional prowess (Schwartz, Avorn and Soumerai 1989). Indeed, comments from these respondents suggest that the actual writing of the prescription is key to their sense of professional self-worth and the associated status that comes with the act of prescribing:
Just making you think a little more about the accountability behind what you do and the consequences of what you do. It's actually quite frightening when you first write a prescription and you think, actually, I am responsible for this. I am not telling your doctor what to write, I am writing it and I am responsible. I am not standing there saying write this drug up and this dose, I am putting pen to paper (Interview 03).
I feel that they [doctors] treat us more like equals now (Interview 03).
Other pharmacists, however, felt that the actual writing of the prescription was not important; nor, by implication, was their sense of professional self-worth determined by the process of writing. Rather, it was the preceding decision-making processes which were significant:
The hospital pharmacists running their clinics were in effect prescribing already. It's just that they were telling the doctor what to put on the prescription and it wasn't their signature (Interview 05).
In contrast there were other pharmacists already able to prescribe who appeared uncomfortable with prescribing autonomously within the framework of supplementary prescribing:
But I don't write any prescription without speaking to the doctor. What I do is the doctor that is associated with it is in surgery when I'm in, so I’ll run in between patients and I’ll say ‘yesterday Mrs X – I gave him the date of birth – her blood pressure was high’ I said ‘she's not on aspirin. Do you want me to start her on aspirin?’ and he says yes, so that's fine (Interview 13).
The view taken by this individual supports the theoretical perspective put forward by Friedson (1994: 115): that medicine had been so successful at controlling the object of its work (the process of healing) that it was able to subordinate the labour of other occupational groups within that health-care setting. Previous research (Weiss 1994) has also suggested that pharmacists avoid encroachment into areas of prescribing where it is seen as the doctors’ domain. It is interesting to note that some pharmacists, even with the legal mandate to prescribe, may still see themselves as subordinates within a medically dominated hierarchy and feel the need to receive final approval from a medical colleague, even beyond what is needed within a supplementary prescribing framework.
While some respondents felt prescribing increased their professional status, and while others felt it made no difference, respondents also expressed a range of views on what activities might constitute prescribing. This was a particularly dominant theme within the hospital setting where words used to describe the prescribing processes were subject to some semantic confusion:
The classic would be you might have a patient admitted to the Trust with a cardiovascular problem, their medicines are all prescribed but nobody has noticed that the patient has glaucoma and the patient has three different eye drops. So should the pharmacist then go back to the junior doctor who may no longer be on shift because they've stopped working and they were on overnight? To try and go up to a doctor that has never even seen the patient and say this patient actually has eye drops? Or should they just say well I know they’re on the drops, they seem reasonable or just add them to the prescription to facilitate continuation of medicines? And that raises the question ‘is that prescribing’ because within the hospital setting we don't have prescriptions. We might call and order a prescription but it's an authorisation to administer and an authorisation to supply which isn't necessarily a prescription. Which means all our forms are prescribing – or not . . . Some people may argue you don't need anything about that (continuing existing medication) . . . because that is just transcribing . . . just continuing . . . my understanding was it was enabling legislation but you shouldn't necessarily feel constrained by the fine details, as long as you understand the freedom of action (Interview 06).
Part of the confusion over what constitutes prescribing arises when documentation, different from a prescription, is used when medications are supplied or administered. It also arises when the person writing out (and signing) a prescription is different from the person making the clinical decision resulting in the (prescribed) drug treatment. What these quotes also suggest is that previous practice – with only doctors prescribing – was inefficient and potentially unsafe. Further, that this lack of safety under the old prescribing system could be used as a justification for the extension of prescribing to nurses and pharmacists. However, this lack of clarity on what constitutes prescribing was also extended to community pharmacists as well. Community pharmacists sell medicines over the counter to customers and may engage in a discussion with the customer about what medicine is most appropriate for them. An over-the-counter medicine is then selected and the customer purchases the product. These kinds of interactions could also be considered prescribing:
I don't see why community pharmacists couldn't take up independent prescribing without having to go through six months of hard work because largely they have the expertise for that because they do it all the time (Interview 17).
A further example was provided by a pharmacist explaining the work of pharmacist colleagues who adjust warfarin (an anticoagulant) doses in response to INR (blood tests which indicate blood clotting) findings. Warfarin tablets are available as 0.5, 1, 3 and 5 mg with patients frequently supplied with different strengths and told to adjust their dose in response to the INR findings:
If somebody is telling somebody that all your results are a bit low, rather than take 4 mg, take 5 mg and they are not actually writing a prescription because the patient already has got a supply of tablets, is that prescribing? It probably is prescribing (Interview 06).
Finally, if a key aspect of prescribing is the display and performance of professional judgement, it could be argued that pharmacists have had this all along:
Pharmacists are legally entitled to refuse to supply things that they don't think are appropriate and are able to make a professional judgement on things . . . we think of prescribing as something novel but it is something that we've always been developing and been part of (Interview 06).
Prescribing, instead of being seen as a single physical task at the end of a consultation, can be viewed as a complex series of processes with distinct tasks and decision points. This complexity means that prescribing can be fragmented into a number of parts which, potentially, can be performed by different health-care professionals. The multiple terms used to describe prescribing, the uncertainty as to whether dose adjustments constitute prescribing and whether the ability to be able to refuse to dispense an unsafe prescription is part of prescribing have helped to make prescribing by pharmacists that much more acceptable within the workplace as a ‘new’ innovation in practice, as they were engaged in some of these activities before the legislative changes occurred. In contrast to the general statements expressed by the British Medical Association noted earlier (Day 2005), the views of physician mentors involved in the training of prescribing pharmacists has indicated that they are broadly supportive of pharmacist prescribing within defined clinical boundaries (Lloyd and Hughes 2007, Buckley, Grime and Blenkinsopp 2006). Some pharmacists felt they gained professional standing through the act of prescribing; others felt unable to prescribe autonomously without support from a doctor. Finally, there were others who felt that being given the authority to prescribe was not a major change relative to their previous practice and a pharmacist prescriber was readily acceptable within their workplace.
The emphasis on prescribers’ competence
The National Patient Safety Agency was established in 2001 as a Special Health Authority in the NHS. Its remit is to promote patient safety wherever the NHS provides care by identifying issues relating to patient safety, and to find appropriate solutions. Since the late 1990s, the Department of Health has published a range of reports related to improving patient safety such as Building a Safer NHS for Patients – Implementing an Organisation with a Memory (Department of Health 2001), Design for Patient Safety (Department of Health 2004), Safety First: a Report for Patients, Clinicians and Healthcare Managers (Department of Health 2006b) and Coding for Success: Simple Technology for Safer Patient Care (Department of Health 2007b). The theme of safety has come to dominate health-care services. It is not that safety was not on the agenda earlier, but rather that it has become an overarching and pervasive theme in all aspects of health care. The neutrality in the collection of patient safety data has however been questioned. Researchers have raised concerns about the use of patient safety data (e.g. medical error reporting) as a mechanism for regulating doctors’ performance which may obscure problems while giving a spurious appearance of objectivity (Lloyd-Bostock and Hutter 2008). Safety too has pervaded discussions on prescribing; both as a rationale for the need for new prescribers and also as a mechanism for containing, or constraining, new prescribers through its emphasis on competence. Traditional practices with regard to doctor prescribing in a secondary care setting were described as unsafe:
Independent prescribing would address a lot of the other issues which as a hospital pharmacist we have to deal with day in, day out. A lot of problems with drug histories being incorrect and you are not able – even having spoken to the patient – there is nothing you can do to change that mistake without going back to the prescriber which is always back and forward and back and forward when you are obviously aware of the mistake and the prescriber who took the drug history in the first place has not noticed the mistake. Such is life (Interview 15).
There was an issue about legalising current practice, when the doctor wasn't there and the nurses would just write something up and wait for the doctor to come and sign it which was maybe in a few days. We had issues about faxed orders and verbal orders and all that and clearly that is not ‘Safe Prescribing Practice’. So I felt that if we had more people that could prescribe and when you’re talking about chronic conditions that is totally appropriate . . . I felt that it would [also] improve patients’ access to care because, the nurse and myself are there more often than the doctors (Interview 12).
In this second quote, the addition of new prescribers would improve safety and access by ensuring that prescribing decisions were documented, and taken responsibility for, by a prescriber who was available in a timely manner. One respondent also highlighted that doctors were not necessarily the best persons to prescribe, given their rather relaxed approach to safe prescribing:
It certainly is a silly situation where, the person with the most knowledge of medicines [a pharmacist] isn't allowed to prescribe. With no disrespect to doctors and nurses, I find sometimes they are a bit blasé about medicines and they don't take into account the negative effects enough. So all the iatrogenic diseases will come into play there . . . I think GPs and unfortunately nurses, who shadow GPs to learn how to prescribe, develop the GP's very blasé attitude to medicines . . . when they only have 10 minute consultations and they are pushed, then they tend to be quite, you know, cavalier about what they prescribe (Interview 02).
What is conveyed in these quotes is that pharmacists feel they have a singular expertise on medicines, superior to other health-care professionals and, further, that they can use this to argue that they are the best person to prescribe, given the need to engage in safe prescribing practice. Previous research reinforces this respondent's view where individuals who refrain from risky behaviours perceive themselves to be more responsible and rational than those who engage in more risk-taking behaviours (O’Bryne 2008). Within a wider political context, the discourse on risk and the need to improve patient safety serves the purpose of encouraging individuals to police themselves (Foucault 1977).
Fifteen to 20 years ago, a doctor's competence as a prescriber was taken for granted; implicit within the act of prescribing. The competence of doctors as prescribers rarely merited discussion as a topic in its own right. Prior to the mid-1990s, the clinical autonomy of doctors, embedded within their right to prescribe, meant that general practitioners would be unlikely, at least overtly within their practice setting, to limit the range of chronic conditions in which they prescribe (and in which generalists would normally be expected to prescribe) because of a perceived lack of competence. Prescribing has been described as the battleground where general practitioners’ clinical autonomy is defended (Britten 2001); for a general practitioner within routine generalist areas of prescribing, self-limitation on prescribing would be anathema to this core professional prerogative. Indeed, historically, general practitioners have resisted external attempts to limit the scope of their prescribing, raising concerns about the introduction of clinical guidelines (Woolf et al. 1999), use of medical audit (Black and Thompson 1993) or practical applications of handheld computers (McAlearney, Schweikert and Medow 2004), and their potential to reduce their clinical autonomy. However, the more recent emphasis on a culture of safety not only provides a rationale for extending prescribing to non-medical prescribers but it also provides a forum for the explicit discussion of the competence of pharmacists (and all other) prescribers. This also now includes explicit discussions of the competence of doctors as prescribers (Aronson et al. 2006). For new prescribers, the emphasis is on circumscribing their areas of clinical practice; of self-limiting your own prescribing to areas in which you are competent. A culture of safety puts forward self-limitation and constraint on prescribing as an aspiration, and a new core professional ideal, for all new prescribers:
Well, if you’re prescribing, you should be able to justify why you’re choosing that drug and to do that you might need to know the evidence base. You might need to know why you’re using it. So I think that is going to be the trick . . . they’ll (new prescribers) have to justify why they are prescribing, otherwise, like as a pharmacist, we could end up with the same problem that we get with GP prescribing . . . the variation in prescribing (Interview 04).
I think they [doctors] did feel threatened. They did feel we’re taking over their roles, we were trying to be mini-doctors . . . and there was a very telling comment made to me by the consultant ‘if you were a maverick, you could be really dangerous with these clinical management plans’. The subtext of what he was saying was actually the clinical management plans give a huge amount of freedom and it is up to us to limit that freedom according to knowing what we know and what we don't know and practising what we do want to do and stopping when we don't feel we’re capable of practising (Interview 12).
While there may be theoretical concerns about the competence of non-medical prescribers (BMA 2005), evidence from nurse prescribers suggests that nurses do prescribe appropriately and within their areas of competence (Latter et al. 2005). A culture of safety and the need to be competent within your area of practice, both provides a rationale for, and facilitates, prescribing by new prescribers, but also constrains and delimits what pharmacists are able to do.
Prescribing as a team activity
A culture of safety, an emphasis on competence and blurred definitions of what constitutes prescribing underpin the notion of prescribing as a team activity. At one level, working within a team could suggest an inherently safer system: an activity would be broken down into its constituent tasks, and different but uniquely competent professionals would undertake specific tasks within that activity and, to some extent, act as checks and balances on each others’ activities. Equally, such an approach could bring greater risks unless there were efficient systems for communication between those involved in the process. Applying this team approach to prescribing, the process can be broken down into parts which are then undertaken by the most appropriate and competent health-care professional in that area.
If I'm honest the whole prescribing issue . . . has been a team thing. If I write the words in or the doctor writes the words, it was a team decision. It wasn't ‘I'm the doctor, I'm going to tell you what to do’ or ‘I'm the pharmacist, I'm going to recommend to you what to do’. It was a team decision (Interview 12).
All newly diagnosed hypertensives go through the healthcare system to get their BP checked according to BHS [British Hypertension Society guidelines], then they go to the nurse practitioner who will work them up and get their ECGs done and work with the doctors around a titration of the medicines. And then once that's settled they will come to me for medication review and then I would take them over from there. So it feels a nicer way forward because it uses all the different skills that are there (Interview 02).
In the second pharmacist's description, nurses were responsible for specific task-based activities such as doing the patient's ECG, the doctor established initial doses of medication and the pharmacist monitored the patient's long-term medication. Whereas in the past, the doctor might have done all these activities, it is now appropriate for the process to be fragmented and conducted as a team activity:
I would see a situation where the doctor identifies a patient with a particular condition and then passes it on to a pharmacist for prescribing, without the need for a clinical management plan. It may be a case of, the GP would say, I will pass you on to the pharmacist for your hypertension to be treated (Interview 05).
In particular, there were two aspects of this process where pharmacists felt the least competent: conducting clinical examinations and making initial diagnostic decisions. Under supplementary prescribing arrangements, and at the time of these interviews, pharmacists would be unlikely to be involved in diagnosing new conditions. Most of these respondents, however, saw themselves as becoming independent prescribers in the future, where a role in diagnosis would not be prohibited [provided it was within their competence]:
If you were working in a role where you had to examine patients, you know, the hands on stuff, if you were working with say a respiratory patient, if you've got to check their chest, you know all the tapping on the back and percussion sounds and all that kind of stuff, pharmacists don't touch patients . . . we went into pharmacy because we didn't want to get our hands dirty, and now we might have to (Interview 09).
We’re not really going to lay hands on patients in hospitals because that is somebody else's job. It is somebody else's job to diagnose in hospitals . . . we won't diagnose, it's not our job. Doctors diagnose (Interview 08).
I think my concern with independent prescribing is that you’re then assessing patients, you’re making a diagnosis and I'm not totally 100 per cent convinced in my head I'm actually going to be competent enough as a pharmacist to diagnose, because I can see the difficulties that doctors have diagnosing and I think that we have to be careful as pharmacists that we don't go into a field that we’re not really trained for (Interview 04).
The model of a nurse conducting clinical examinations, the doctor diagnosing and the pharmacist monitoring and adjusting a patient's subsequent drug therapy was a model which particularly found favour. Each professional doing a specific aspect of patient management in which they were competent:
Nurses maybe think that we’re encroaching a little bit on their territory and wonder how it's all going to work together. But then I've seen some of the fantastic models where a nurse and a pharmacist run a clinic together. And the nurse does the physical exams and the pharmacist does the dose titrations (Interview 07).
Indeed, recognising the changing nature of the prescribing process, from a situation of one individual (a doctor) doing all activities associated with the process of prescribing to this model where several individuals might undertake this process, this pharmacist further notes:
I know that doctors are very worried about their loss of power, if you like, letting go of prescribing is quite hard for doctors. They've had a monopoly on that for so long. But I think as other professions come in and take on different bits of prescribing, it's only logical for the pharmacist to be in there really (Interview 07).
The ideas expressed in this paper were derived from qualitative interview data with pharmacist prescribers. While the hypothesis is that these ideas have relevance to all pharmacist prescribers and potentially all new nurse prescribers, the extent to which these ideas are generalisable to all new prescribers is not known. The study was also conducted early in the implementation of supplementary prescribing and the pharmacists who agreed to participate may be atypical of pharmacist prescribers in that they are likely to have a more pioneering approach to expanding pharmacists’ roles. This was a small sample of pharmacists and while we tried to select participants who were diverse with respect to geographical area, years of experience and clinical area of practice, the extent to which we were able to achieve the complete range of views on prescribing issues is not known. Hypotheses and ideas expressed in this paper need further investigation in a larger sample group and across a range of prescribers.
In today's world of increasing information and multi-professional working, evidence from this research has explored conceptions of prescribing and theories of professional power. It suggests that the functions of a prescription at the micro level of the consultation, as a sign of professional power or as tangible evidence of the prescriber's ability to act, are likely to be as relevant today in the traditional consultation setting when other (non-medical) health-care professionals write out a prescription. Some pharmacists did feel they gained status, within their professional group and more widely with doctors, through the act of prescribing. However Nancarrow and Borthwick's (2005) thesis on vertical substitution suggests that pharmacist prescribers are unlikely to obtain the same financial rewards or status as doctors. While the status and financial rewards for pharmacists do appear to be improving, they are yet to approach those of doctors.
Abbott (1988) argues that the best way to examine change in professions is to investigate its work, not its organisation; to analyse the forces that affect the content and control of that work. In the example of pharmacist prescribing, the State has mandated a change in who has the authority to prescribe. The ideology of safety is also a key force on pharmacists’ jurisdictional claim over prescribing. This exhorts an emphasis on competence, self-limitation on practice and the benefits of team working. At a state, professional and workplace level, pharmacists can argue their unique competence as a prescriber, given their background drug knowledge, attention to prescribing detail and, when dispensing medication, their role as clinical checker or ‘safety net’ on prescriptions.
The fragmentation of the prescribing process into the separate aspects of history-taking, clinical examination, diagnostic decision making, treatment decision making and long-term monitoring for chronic conditions lends itself to improved patient safety through a team approach: each aspect having a health professional competent within that specialist area. While a doctor's competence as a prescriber has traditionally been taken for granted (e.g. a general practitioner would refuse to prescribe an intravenous cancer drug), the rhetoric of safety as an ideology has exhorted new prescribers to identify and self-impose limitations on their prescribing and to work within teams where each professional has their respective area of competence. New prescribers might limit themselves with regard to their range of clinical areas (e.g. cardiovascular disease) or clinical processes (e.g. clinical examinations and not drug product selection or vice versa), as well as being limited by the structure of their workplace.
What is also evident within these pharmacists’ accounts is Mesler's (1991) concept of negotiated order where concepts of social power are fluid, and that doctors do not need to ‘lose’ power for pharmacists to gain it. Pharmacists’ status as legitimate prescribers was largely unquestioned within the workplace. Eaton and Webb (1979) argued that clinical pharmacy activities offered little threat of territory encroachment, as doctors delegated tasks such as patient counselling and monitoring of side effects to pharmacists, yet retained overall control of patient management. While the delegation of prescribing activities to pharmacists was not explicitly expressed within these interviews, the medical profession has still influenced the outcome of legislation allowing pharmacist prescribers. As noted by Allsop (2006), medicine has accommodated to change rather than being annihilated by legislative changes allowing multiple professionals to prescribe. Medicine has retained its high status, relative to other health professionals and with patients; it still controls the knowledge base relevant for prescribing practice and has managed to develop an ‘overseer’ role over the process of prescribing. Prescribing, as an indicator of medicine's autonomy of control over their work and their professional status within society, has changed. The dominance of medicine has not. Has prescribing by other health-care professionals threatened the professional dominance of medicine? The evidence to date suggests not.