Why pharmacist prescribing needs to be independent

Many jurisdictions are talking about and making the case for pharmacist prescribing. This is a good thing and a natural evolution of our practice from distributors of drugs to carers of patients. We have excellent evidence for the impact of pharmacist prescribing vs usual care, which includes improvements in blood pressure,¹ A1c,² lipids,³ cardiovascular risk,⁴ urinary tract infections,⁵ and so on, but also cost-savings^6,7 and, importantly, patient preferences.⁸

To prescribe is defined as “to designate or order the use of (a medicine, remedy, treatment, etc.).”⁹ Pharmacists already prescribe with every patient interaction when they make the decision to assess, treat, supply, refuse or refer. However, they tend to steer away from the term prescribe, preferring to state that they recommend—is this not just quibbling over semantics (like the use of the term diagnosis, from a previous editorial¹⁰)? Practically speaking, pharmacist prescribing is a spectrum of activities that include over- and behind-the-counter medications, refill authorization, therapeutic substitution, dosage adjustment, provision of emergency supplies, ordering and reviewing laboratory tests and de novo prescribing of Schedule I medications. With regard to the latter form of prescribing, this can be simply classified as independent or dependent prescribing.

Independent prescribing means that the decision on what to prescribe and who to prescribe it to is solely the decision of the pharmacist (this is the Alberta model). This doesn’t mean that other practitioners are not involved; far from it—they are kept in the loop (the pharmacist informs them of their actions and plans) and may be consulted, but the essential feature is that the decision lies with the pharmacist. Independent prescribing does not require permission or a prior agreement with another practitioner.

Dependent prescribing is when a pharmacist strikes an agreement with a physician. This agreement outlines which patients the pharmacist can prescribe for (usually it would be the patients under the care of that physician) and what the pharmacist can prescribe (e.g., metformin for patients with newly diagnosed type 2 diabetes). This is often called “collaborative prescribing.”

In our view, advocating for dependent prescribing is short-sighted, for the following reasons:

1. In a dependent model, you can only prescribe for those patients with a specific condition under that particular physician. What about those patients who need our care and intervention who are with another physician or (as is common nowadays) without a physician at all? In a previous editorial we highlighted that about one-third of patients cannot, will not or do not see a primary care physician.¹¹ Dependent prescribing will not help these vulnerable patients. Aren’t these physician-less patients the target audience for pharmacy interventions? Isn’t this where the public needs our help the most?

2. In a dependent model, often the physician must make the referral—“please prescribe for this patient’s hypertension.” Again, this helps very little with the public health problem. Figure 1 describes other patient populations that are left out in this model: What about the patients whose hypertension the physician has missed? They would not be referred for management. What about patients who can’t or won’t see their physician? They, too, will be missed in a dependent model.

3. Dependent models perpetuate the subservient relationship of pharmacists to physicians. Essentially, the pharmacist becomes an administrative clerk for the physician. Is that what we want? Are pharmacists not clinicians and health care practitioners in their own right? Again, how much does this really help patients?

4. Independent models provide equal collegial opportunities for patient-centred care—where the information flows in both directions. Dependent models rely on the unilateral flow of information from physician to pharmacist through a referral. Patient-centred care means all work together for the greater good of the patient—so why wouldn’t this apply in the community setting and include pharmacists?

5. The knowledge and skills required of pharmacists for both models are the same—there isn’t anything additionally required for pharmacists to independently prescribe. The ability to prescribe a treatment or medication for a patient is the same skill required to recommend the same treatment or medication to a physician for that patient—the only difference is who makes the final decision. Do pharmacists not share liability with physicians when supplying medications regardless of who makes the final decision?

6. Is there any evidence for a dependent prescribing model? As outlined above, we have good evidence for independent prescribing. Is there an evidence base for dependent prescribing?

Figure 1.

A closer look at a population of hypertensive patients within a dependent-prescribing model

The case is often presented that dependent prescribing is “a foot in the door” and the only way to “get” prescribing, or “isn’t some form of pharmacist prescribing better than none”? But where is the evidence to support the benefits of dependent prescribing? Is it in the patient’s best interest for pharmacists to push for this model? We could be so much more for our patients—why sell ourselves short?

Of course, physician groups will more likely oppose an independent prescribing model for pharmacists, but often for the wrong reasons (see our “Frequent Asinine Questions” editorial from July 2018¹²). We should not be afraid of this—we must put patients’ and the public’s needs first. That will take some courage. Pharmacist prescribing does not detract or take something away from physicians but, rather, enhances health care availability to patients.

While we are on the topic of prescribing, we have another little rant. In the recent context of the Australian bushfires, the provision of oral contraceptives and pharmacists’ ability to provide prescription medications under the new temporary emergency supply provisions have been framed as “now available from your pharmacist without a prescription.” This terminology makes it sound like pharmacists are being allowed to temporarily bypass regulations. While we understand that it may be mostly the media and government who are saying this, why aren’t pharmacists correcting them by saying, “Your pharmacist can assess and prescribe the need for ongoing medication supply during the bushfires”? The pharmacists have ultimately made the final decision to continue treatment.

In summary, the evidence is clear on independent prescribing by pharmacists, and as evidence-based health care providers, we should be advocating for this model of advanced scope of practice. Independent-prescribing models are part of a pharmacist’s full scope of practice.¹³ Pharmacists and pharmacy organizations need to have the courage to pursue their essential place as part of the health care team and should not be asking for permission to care for their patients.