The dilemma
You are a pharmacist prescriber who runs a clinic for a local surgery, specialising in respiratory medicine. You carry out an annual review of a patient’s condition, and you have access to their medical notes so are aware of their co-morbidities and regular repeat medication. At the end of a consultation, as you are busy writing out the relevant prescription, the patient asks: “While I’m here, could you just prescribe me some of my water tablets?” The patient has been on furosemide 40mg OD for several months. What do you do?
The RPSGB advises that all pharmacist prescribers, whether supplementary or independent, must prescribe within their competencies and only medication appropriate for the patient.
You know the patient is already being prescribed the requested item by a GP, but it is for a condition you do not normally deal with.
Patients can put pressure on pharmacists and it would be easy to cave in. However, it is your signature on the prescription and you would be held to be legally responsible if anything were to go wrong – even if the item is normally prescribed by a GP. It would be difficult to defend your actions in a court of law if you could not demonstrate your expertise in a particular area.
In Scotland, pharmacists are able to prescribe on a community pharmacy urgent supply (CPUS) prescription any repeat medication that a patient gets for their usual quantity (generally up to two to three months), as long as the patient is registered with a Scottish GP. If the patient is from elsewhere in the UK, pharmacists have to make an emergency supply, as in England and Wales, and can only give up to 30 days plus levy a charge for the medication.
If the patient asks for something that I would normally be comfortable selling to them over the counter, such as emollients, antihistamines, or laxatives, I would not have a problem issuing them with their normal prescription. However, if they were asking for their usual medication for a more serious condition, such as heart failure or epilepsy, I would have to refuse as I do not have expertise in those areas.
Valerie Sillito is an independent prescriber working in the community for Alliance Boots in Aberdeen
What the law says
The July 2010 edition of the Society’s Medicines, Ethics and Practice (which will be replaced by a new code on September 27 when the General Pharmaceutical Council [GPhC] takes over pharmacist regulation) provides that “Pharmacist independent prescribers can prescribe any medicine (licensed or unlicensed) with the exception of controlled drugs for any clinical condition, but they must only prescribe within their professional and clinical competence”, and it is difficult to imagine that the GPhC will adopt a different approach.
Since a breach of the code of ethics may be evidence of misconduct, any pharmacist prescribing that falls outside of the pharmacist’s “professional and clinical competence” could lead to an investigation by the GPhC.
There could be other consequences of prescribing errors. For example, if a patient falls ill as a result of a prescription written by a pharmacist then, like a doctor, that pharmacist could be the subject of a claim for damages. If a patient were to die as a result of a prescription written by a pharmacist, that pharmacist could be investigated by the police for manslaughter.
In conclusion, given the consequences of an error, care should always be taken when prescribing. The pharmacist in this scenario (who refused to prescribe the item despite pressure from the patient) is adopting the wisest course of action.
Noel Wardle is a solicitor at Charles Russell LLP, specialists in pharmacy law
Tips for your CPD entry on prescribing ethics
Reflect What are your areas of clinical competence when prescribing?
Plan Consider what you would do if a patient asks you to prescribe.
Act Roleplay the consultation with a colleague to practise your skills.
Evaluate Are you confident in refusing a request to prescribe?