McCann et al (2012) note that although prescribing had long been the sole preserve of doctors, the Cumberlege Report of 1986 introduced the concept of non-medical prescribing, and a subsequent crown report recommended extending prescribing authority to non-medical professionals such as pharmacists. Interestingly, it was a decade ago that the findings of a Northern Irish study undertaken by McCann et al (2012) in the areas of hypertension cardiovascular/diabetes management and anticoagulation added further ‘to the evidence that pharmacist prescribing is widely accepted, and patients positively perceive pharmacist prescribing’.
More recently, in a Jordanian study, when Alhamad et al (2021) questioned 578 members of the public on their ‘perceptions about pharmacists' educational and prescribing role, and the medication delivery service provided during the COVID-19 outbreak’, they concluded that the public endorsed the positive impact of pharmacists during the pandemic. In a UK study that explored pharmacist prescribing for patients with chronic kidney disease, Alraiisi et al (2021) not only found enthusiasm among pharmacists ‘for the future development of prescribing practice including further establishment of clinics and taking responsibility for groups of patients’, but interviewees also indicated an awareness of systems for evaluating their prescribing activity.
As for physicians' perceptions of pharmacist prescribing, in a Canadian study, Faruquee et al (2020) reported that ‘physicians were more likely to accept prescribing activities of pharmacists with whom they worked in collaboration and had trust, collegial relationships, and high-quality communications.’
Given this context, the recent publication by the Royal Pharmaceutical Society (RPS, 2022) of new professional guidance for independent prescribers is an encouraging development. Although commissioned by the Welsh Government, the guidance is for the benefit of UK-wide prescribers, providing a useful tool ‘for prescribers wanting to expand their prescribing scope of practice.’ Further, the current post-pandemic state of flux in relation to patient access to GPs in the UK invites speculation that this initiative will be welcomed by a medical profession that appears keen to spread what it perceives to be an increasingly burdensome clinical load.
However, one aspect of the 29-page RPS (2022) guidance that merits reflection beyond the ‘nuts and bolts’ of technical implementation is that the word ‘ethical’ appears only twice, when the same sentence is repeated, advising the reader to ‘[l]ook at the specific legal or ethical considerations needed’. There are indeed ‘ethical considerations’ that deserve the attention of not only prescribers but might also arouse the interest of patients for whom medicines are prescribed. For example, when Rodwin (2012) considered physicians' conflicts of interest, he suggested that conflicts arise because although we expect physicians to act in their patients' interest, at the same time ‘financial incentives encourage physicians to practice medicine in ways that promote their own interests or those of third parties.’ Rodwin (2012) also raises the thought that when drug firms make substantial contributions to the costs of accredited continuing medical education (CME), they risk undermining the possibility of CME representing a source of unbiased information.
More explicitly, Fugh-Berman (2021) points out that sponsored CME can always be traced back to the sponsor's business; that industry-funded CME aims to create or expand markets for possibly unnecessary, inferior or overpriced products; and that industry-funded CME can affect medical discourse by ‘distorting doctors' understanding of diseases and treatments, and ultimately harms patients’ (Fugh-Berman, 2021). Fugh-Berman also reminds us that in June 2019, the European Federation of Pharmaceutical Industries and Associations were clear that its industry members could organise and provide input to CME activities and fund independent CME activities too. He also cites the fact that an ‘alliance between Mental Health Europe and organisations representing healthcare professionals and medical education stakeholders protested that “pharmaceutical companies must not be granted the right to influence the content of medical education”’ (Fugh-Berman, 2021).
Read more: Expanding the scope of prescribing practice
To be clear, both Rodwin and Fugh-Berman's thoughts were aimed primarily at the medical profession. However, one might infer that as the scope of prescribing widens among health professionals, diverse ethical challenges to prescribing practice not dissimilar to those flagged above are likely to arise. In this case, prescribers might usefully reflect on the importance of cultivating a heightened awareness of the range of influences that might wish to channel their prescribing practice behaviour in directions that may not always have patients' welfare at heart.