RESEARCH ARTICLE

Pharmacist prescribing in Northern Ireland: a quantitativeassessment

Laura McCann • Sharon Haughey •

Carole Parsons • Fran Lloyd • Grainne Crealey •

Gerard J. Gormley • Carmel M. Hughes

Received: 21 April 2011 / Accepted: 25 July 2011 / Published online: 10 August 2011

� Springer Science+Business Media B.V. 2011

Abstract Objective Health care in the United Kingdom

(UK) has undergone a significant change in terms of the

range of professionals who are permitted to prescribe

medications. This study aimed to capture information on

pharmacist prescribing in Northern Ireland (NI). Setting

Primary and secondary care in NI. Method A structured

self-administered questionnaire was developed and sent to

all pharmacists who were identified as qualified prescribers

in NI (n = 105), although only 100 respondents provided

details of their prescribing status i.e. currently prescribing,

previous prescribers and those who had never prescribed.

Three versions of the questionnaire were developed to

accommodate each category of prescriber. The question-

naire, which sought information on clinical areas/practice

settings of prescribers, their working arrangements and

barriers to prescribing was distributed by mail on two

occasions to maximise response rates. Descriptive analyses

were used as appropriate, together with Chi-squared tests

or Fisher exact tests to evaluate associations between

responses and demographic information, with significance

set a priori at P \ 0.05. Qualitative data (from the free text

response section) were analysed for recurring themes using

content analysis. Results A response rate of 76.0%

(n = 76) was achieved. There were more female respon-

dents (73.7%) than males (26.3%). Nearly 50% of

respondents were currently prescribing (n = 36; 47.4%),

46.1% (n = 35) had never prescribed and 6.6% (n = 5)

had prescribed in the past. There were perceived benefits in

terms of patient care and perception of the pharmacist

within the health care team. A number of barriers to

pharmacist prescribing were reported. Independent pre-

scribing was viewed as the way forward, although phar-

macists expressed reluctance to prescribe without a

diagnosis or beyond the team setting. Conclusion Phar-

macy prescribing has yet to fully embedded in routine

practice. This study has shown that the number of qualified

prescribers in NI is relatively small and not all have taken

up prescribing responsibilities. Well recognised barriers

were reported as reasons as to why qualified prescribers

were unable to use their prescribing skills. Further research

should provide an in-depth understanding of pharmacy

prescribing in NI and examine patients’ experiences of this

form of practice.

Keywords Independent prescribing � Non-medical

prescribing � Northern Ireland � Pharmacist prescribing �Supplementary prescribing

L. McCann � S. Haughey � C. Parsons � C. M. Hughes (&)

School of Pharmacy, Queen’s University Belfast, 97 Lisburn

Road, Belfast BT9 7BL, Northern Ireland, UK

e-mail: c.hughes@qub.ac.uk

F. Lloyd

Northern Ireland Centre for Pharmacy Learning and

Development, Queen’s University Belfast, Belfast, Northern

Ireland, UK

e-mail: f.lloyd@qub.ac.uk

G. Crealey

Northern Ireland Clinical Research Support Centre, Belfast

Health and Social Care Trust, Belfast, Northern Ireland, UK

e-mail: Grainne.Crealey@crsc.n-i.nhs.uk

G. J. Gormley

Department of General Practice and Primary Care, School

of Medicine, Dentistry and Biomedical Sciences, Queen’s

University Belfast, Belfast, Northern Ireland, UK

e-mail: g.gormley@qub.ac.uk

123

Int J Clin Pharm (2011) 33:824–831

DOI 10.1007/s11096-011-9545-7

Impact statements

• Prescribing by pharmacists in Northern Ireland has yet

to be embedded within primary and secondary care

• Barriers have still to be overcome before the benefits of

pharmacist prescribing can be fully realised

Introduction

Health care in the United Kingdom (UK) has undergone

significant changes in terms of the roles and responsibilities

of the professionals who provide patient services. This has

been notable in relation to prescribing as a result of the

recommendations of the Crown Report, on the prescribing,

supply and administration of medicines [1], published in

1999. This report recommended extending prescribing

authority to non-medical professionals, including nurses

and pharmacists [1, 2]. In the context of this report, these

non-medical prescribers (NMPs) were described as

dependent prescribers (now called supplementary pre-

scribers) [SPs]. Supplementary prescribing is a partnership

between the independent prescriber (IP) and SP, who draw

up, with the patient’s agreement, an individual Clinical

Management Plan (CMP) for the patient’s condition before

supplementary prescribing begins, allowing a SP to man-

age the treatment of individual patients within identified

parameters [3, 4]. A SP may only prescribe medication

within a patient-specific CMP which may include authority

to alter doses or to stop medicines that are no longer needed

[5]. Further policy changes have taken place and NMPs

have gained independent prescribing rights [2]; an IP is

‘responsible for the assessment of patients with undiag-

nosed and diagnosed conditions and for decisions about the

clinical management required, including prescribing [6].

Provided the appropriate training has been successfully

completed and an IP is working within their competency,

an IP may prescribe almost any medicine deemed appro-

priate for a patient. Since 2006, any pharmacist who wishes

to become a prescriber must complete an accredited edu-

cation and training programme, comprising at least 26 days

of teaching, with an additional 12 days of learning in

practice supervised by a medical practitioner (mentor) [7].

A number of studies have evaluated nurse and phar-

macist supplementary prescribing [8–10], however there is

still a paucity of data relating to the impact of such pre-

scribing behaviour on clinical outcomes for patients and

patients’ views of the role of pharmacists in prescribing.

Early findings from a number of reports on pharmacist

prescribing largely mirror what has been reported from

nurse prescribing research. Benefits such as increased job

satisfaction, self-confidence, increased time with patients,

greater recognition of the role of the pharmacist, greater

level of medicines information provided and time-saving

have been reported [8–10], but this has been tempered by

financial and organisational problems, a lack of awareness

of the pharmacists’ prescribing role and restrictions

imposed by the CMP [8]. Research has also shown that

current levels of pharmacist prescribing in primary care

and community practice in England are extremely low,

equating to only 0.004% of all prescribing (in terms of

number of prescribed items) in this sector [11].

Aim of the study

This study aimed to capture information on pharmacist

prescribing in Northern Ireland (NI) [such as clinical areas/

practice settings of prescribers, their working arrangements

and barriers to prescribing] and was part of a larger study

evaluating pharmacist prescribing in NI.

Method

Ethical approval was granted from the Office for Research

Ethics Committee Northern Ireland (reference: 09/NIR03/

54). Governance approval was granted from the relevant

Health authorities. At the time of this study, 105 pharma-

cists had qualified as a SP and/or an IP in NI (representing

approximately 6% of all qualified pharmacists in NI). All

prescribers had been trained in conjunction with the

Northern Ireland Centre for Pharmacy Learning and

Development (NICPLD) and contact with pharmacist pre-

scribers was facilitated through this organisation. Contact

details were retrieved from the NICPLD database and

confirmed with the Pharmaceutical Society of Northern

Ireland (PSNI) which is responsible for maintaining a

register of all pharmacist prescribers. This approach

allowed the identification of other qualified pharmacist

prescribers who may not have trained via NICPLD, but

who now worked as a pharmacist prescriber in NI.

Three versions of a structured self-administered ques-

tionnaire were developed by referring to previous qualita-

tive findings [12, 13], and other relevant literature to

accommodate the current status of prescribing pharmacists:

i.e. those currently prescribing; those who had prescribed

in the past but who are not currently prescribing, and those

who were qualified as prescribers but had never prescribed.

The three questionnaires had common sections on demo-

graphics, clinical area or intended clinical area of practice,

practice setting or intended practice setting, questions on

outcomes for pharmacists, patients and other healthcare

professionals, barriers to prescribing and the future of

pharmacist prescribing. Pharmacists were asked to provide

Int J Clin Pharm (2011) 33:824–831 825

123

any other comments regarding pharmacist prescribing (free

text section). Additional questions were included for cur-

rent prescribers and those who had prescribed in the past

(e.g. prescribing activities, drugs most commonly pre-

scribed (free text) extent of involvement in the multi-dis-

ciplinary team etc.). The questionnaire was piloted (current

prescriber version) with a random sample of prescribing

pharmacists (n = 30) from Scotland, ten of whom pro-

vided feedback on its content and ease of completion; it

was also reviewed by two colleagues in the School of

Pharmacy, Queen’s University Belfast.

Initially an email was drafted and sent to all qualified

pharmacist prescribers to ascertain their prescribing status

(n = 105). Pharmacists were asked to indicate their status

(by selecting one category) as previously outlined and

responding via email to the research fellow (LMC). Phar-

macist prescribers were also asked to provide their current

postal address. A cover letter was sent with the appropriate

questionnaire to explain the nature of the research project

and to reiterate the assurance of confidentiality. The first

mailing took place in October 2009; a second mailing was

carried out in November 2009. All returned questionnaires

were coded and data entered into SPSS� version 18 (SPSS

Inc., Illinois, USA) for analysis. Descriptive analyses were

used as appropriate, together with Chi-squared tests or

Fisher exact tests to test for associations between responses

and demographic information, with significance set a priori

at P \ 0.05. Qualitative data (from free response sections)

were analysed for recurring themes using content analysis.

Results

Of the 105 pharmacist prescribers contacted, 100 replied

(of whom 46 were current prescribers; 47 had never pre-

scribed and 7 had prescribed previously) to the initial email

correspondence providing details on prescribing status,

representing the denominator for the study. Following

distribution of the appropriate questionnaire (two mailings)

a 76.0% response rate (n = 76) was achieved. There were

more female respondents (73.7%) than males (26.3%).

Nearly 50% of respondents were currently prescribing

(47.4%, n = 36), 46.1% (n = 35) had never prescribed

(e.g. due to lack of funding, resources) and 6.6% (n = 5)

had prescribed in the past (e.g. due to a change in job). A

demographic profile of the study respondents is presented

in Table 1.

The dominant clinical areas for current and previous

prescribers were (1) hypercholesterolaemia (hyperlipida-

emia), (2) hypertension, (3) cardiovascular and diabetes

management and (4) anti-coagulation. The clinical areas in

which pharmacists who had never prescribed had intended

to prescribe were (1) respiratory e.g. asthma, chronic

obstructive pulmonary disease (COPD) etc., (2) hyperten-

sion, (3) haematology and (4) pain management. The four

classes of drugs (reported in free text section) most com-

monly prescribed by current and previous pharmacist pre-

scribers were (1) lipid-regulating drugs (13.3%) (2)

angiotensin-converting enzyme inhibitors/angiotensin-II

receptor antagonists (12.2%) (3) anti-coagulants (10%) and

(4) thiazides and diuretics (7.2%).

Barriers to implementing prescribing reported by those

who had never prescribed included inadequate resources to

cover other core services (n = 16; 45.7%); inadequate

funding (n = 10, 28.6%) and onerous paperwork associ-

ated with the CMP (n = 10, 28.6%). The main barriers

experienced by current prescribers when first qualified

included inadequate funding (n = 12; 33.3%); lack of

awareness of pharmacist prescribing by other healthcare

professionals (n = 12; 33.3%); inability of computers to

generate pharmacist prescriptions (n = 10; 27.8%) and

onerous paperwork associated with the CMP (n = 10;

27.8%).

Over 30% of current prescribers felt that they were

‘excellent’ at ‘opening the patient consultation’ (n = 11,

30.6%) and answering patient questions (n = 13; 36.1%).

Nearly 45% (n = 16; 44.4%) of current prescribers felt

they were ‘excellent’ at explaining information to patients

(5 point Likert scale). Over 20% (n = 8; 22.2%) of current

prescribers felt that they were ‘excellent’ at ‘setting aside

time to allow patients to ask any questions they may have’.

However, only 5% of current prescribers felt they were

‘excellent’ at ‘undertaking physical examination of

patients’ (n = 2; 5.6%) while half (n = 18; 50%) felt

‘adequate’ in undertaking this activity (Fig. 1).

Irrespective of prescribing status, most pharmacists

‘agreed’ or ‘strongly agreed’ that pharmacist prescribing

reduced the time-delay for patients between dose adjust-

ments [63/76 (82.9%)], increased continuity of care [62/76

(81.6%)], increased patient involvement in drug treatment

decisions [61/76 (80.3%)], increased patient compliance/

adherence [63/76 (82.9%)], increased monitoring of

patients’ drug therapy [70/76 (92.2%)], increased appropri-

ateness of drug therapy used [69/76 (90.8%)] and improved

patient safety [64/76 (84.3%)]. Over 70% of respondents

‘agreed’ or ‘strongly agreed’ that prescribing increased the

amount of time spent with patients during consultations

[71.1% (54/76)]. Current/previous prescribers were signifi-

cantly more likely to ‘strongly agree’ or ‘agree’ than those

who had never prescribed with the statement(s) that pre-

scribing had reduced the time-delay for patients between

dose adjustments (P = 0.01); and that prescribing had

increased patient compliance/adherence (P = 0.027).

Irrespective of prescribing status, most pharmacists

‘agreed’ or ‘strongly agreed’ that prescribing elevated the

professional status of the pharmacist [66/76 (86.8%)],

826 Int J Clin Pharm (2011) 33:824–831

123

Table 1 Demographic profile of pharmacist prescribers in NI who responded to the questionnaire (n = 76)

Currently

prescribing

Previously

prescribed

Never

prescribed

47.4% (n = 36) 6.6% (n = 5) 46.1% (n = 35)

Gender

Male 19.4% (n = 7) 20% (n = 1) 34.3% (n = 12)

Female 80.6% (n = 29) 80% (n = 4) 65.7% (n = 23)

Year of pharmacist registration

1979–1989 38.9% (n = 14) 60% (n = 3) 25.7% (n = 9)

1990–1999 50.0% (n = 18) 40% (n = 2) 62.9% (n = 22)

2000–2010 11.1% (n = 4) 0 11.4% (n = 4)

Type of prescribing undertaken

Supplementary prescribing 0 80% (n = 4) N/A

Independent prescribing 88.9% (n = 32) 0 N/A

Both supplementary and independent prescribing 11.1% (n = 4) 20% (n = 1) N/A

Prescribing setting**

Hospital inpatient 5.6% (n = 2) 20% (n = 1) 25.7% (n = 9)

Hospital outpatient 19.4% (n = 7) 20% (n = 1) 14.3% (n = 5)

Hospital inpatient and outpatient 25.0% (n = 9) 20% (n = 1) 20.0% (n = 7)

*GP surgery 47.2% (n = 17) 40% (n = 2) 17.1% (n = 6)

Community pharmacy 0 0 11.4% (n = 4)

GP surgery and community pharmacy 0 0 5.7% (n = 2)

Other (for e.g. private or prison) 0 0 5.7% (n = 2)

*GP general practitioner

**Missing data

Ability in opening the

patient consultation

Ability in explaining information

Ability in setting aside time to

allow patients to ask questions

Ability in answering questions

Ability in undertaking

physical examination

Ability in closing the patient

consultation

2.8% 5.6% 5.6%13.9%

8.3%

16.7%16.7%

50.0%

11.1%

52.8%

44.4%

55.6%

44.4%

25.0%

63.9%

30.6%

44.4%

22.2%

36.1%5.6%

16.7%

Poor Between poor and adequate Adequate Between adequate and excellent Excellent

Fig. 1 Pharmacists’ (current prescribers) abilities in a number of activities related to prescribing

Int J Clin Pharm (2011) 33:824–831 827

123

increased their job satisfaction [69/76 (90.8%)], stream-

lined previous practice [65/76 (85.5%)], increased profes-

sional autonomy [70/76 (92.1%)] and resulted in better

utilisation of pharmacists’ clinical skills [75/76 (98.7%)].

No respondents ‘disagreed’ or ‘strongly disagreed’ with

any of the above statements. Most pharmacists either

‘disagreed’ or ‘strongly disagreed’ with the statement that

pharmacist prescribing increased the responsibility and

accountability of pharmacist prescribers in a negative way

[54/76 (71.1%)]. Current/previous prescribers were sig-

nificantly more likely to ‘strongly agree’ or ‘agree’ with the

statement(s) that prescribing had increased their job satis-

faction (P = 0.026) than those who had never prescribed;

and that pharmacist prescribing had legalised previous

practice e.g. writing prescriptions and getting doctors to

sign them (P= 0.031).

Table 2 indicates that eighty per cent of prescribers

[80.3%, (n = 61)] either ‘strongly agreed’ or ‘agreed’ with

the statement ‘‘I envisage the future as pharmacist Inde-

pendent Prescribing rather than pharmacist Supplementary

Prescribing’. Eighty per cent [80.3%, (n = 61)] of pre-

scribers either ‘strongly agreed’ or ‘agreed’ with the state-

ment ‘‘I would prefer to undertake pharmacist independent

prescribing after a diagnosis has been made by a doctor’’.

Over 50% of prescribers either ‘strongly agreed’ or ‘agreed’

with the statements that pharmacist supplementary pre-

scribing should only be undertaken in a team environment

[56.6%, (n = 43)] and pharmacist independent prescribing

should only be undertaken in a team environment [51.40%,

n = 39)]. Over fifty per cent of pharmacists (n = 41;

53.9%) either ‘disagreed’ or ‘strongly disagreed’ with the

statement ‘‘I am happy to undertake diagnosis in my role as

a pharmacist independent prescriber’’.

A number of recurrent themes were apparent from

the free text responses provided. These were summa-

rised under the themes of: issues relating to information

technology (e.g. need for shared patient records), lack

of funding and lack of awareness of the pharmacists’

role, (Table 3) and largely reinforced the quantitative

findings.

Table 2 Pharmacists’ responses on the development of pharmacist supplementary and independent prescribing

Strongly

agree/agree

Neither agree

or disagree

Disagree/strongly

disagree

Supplementary prescribing has no future as it usually

focuses on one clinical area only

19.7% (n = 15) 22.4% (n = 17) 57.9% (n = 44)

I envisage the future as pharmacist independent

prescribing rather than pharmacist supplementary prescribing

80.3% (n = 61) 13.2% (n = 10) 6.6% (n = 5)

Pharmacist independent prescribing is welcomed by all doctors 13.1% (n = 10) 39.5% (n = 30) 47.3% (n = 36)

Doctors perceive pharmacist independent prescribing

as handing over too much control

18.4% (n = 14) 48.7% (n = 37) 31.5% (n = 24)

I am happy to undertake diagnosis in my role as a

pharmacist independent prescriber

31.6% (n = 24) 14.5% (n = 11) 53.9% (n = 41)

I would prefer to undertake pharmacist independent prescribing

after a diagnosis has been made by a doctor

80.30% (n = 61) 13.20% (n = 10) 6.60% (n = 5)

Doctors with whom I work closely would be happy

for me to make diagnoses

35.2% (n = 26) 40.5% (n = 30) 24.4% (n = 18)

All doctors would be happy for any pharmacist prescriber

to make diagnoses

0 (n = 0) 14.70% (n = 11) 85.30% (n = 64)

All doctors would prefer pharmacist independent prescribing

to take place following a diagnosis made by a doctor

44.7% (n = 34) 42.1% (n = 32) 13.1% (n = 10)

Pharmacist independent prescribing should be limited

to minor ailments and conditions for which treatments

are covered by a protocol

13.1% (n = 10) 7.9% (n = 6) 79.0% (n = 60)

Pharmacist supplementary prescribing should only

be undertaken in a team environment

56.6% (n = 43) 17.1% (n = 13) 26.3% (n = 20)

Pharmacist independent prescribing should only

be undertaken in a team environment

51.4% (n = 39) 11.8% (n = 9) 36.9% (n = 28)

Pharmacist prescribers should be managerially

accountable to a physician e.g. consultant/GP

38.2% (n = 29) 28.9% (n = 22) 32.8% (n = 25)

For pharmacist prescribing to be successful,

prescribing pharmacists must operate a

24 h-a-day, 7 days-a-week service

7.9% (n = 6) 18.4% (n = 14) 73.7% (n = 56)

828 Int J Clin Pharm (2011) 33:824–831

123

Discussion

A 76% response rate was achieved and of those who

responded, over 50% had either never prescribed or pre-

scribed in the past (e.g. no longer prescribing because of a

change in job); just over 50% of respondents are currently

prescribing in NI. This supports earlier work which found

that pharmacist prescribing has been accepted in practice

but is not widely prevalent [14, 15]. There were a higher

number of female respondents than males, reflecting the

overall demographic profile of pharmacists in NI (35.8%

male and 64.2% female) [NICPLD, 2011].

For those who were currently prescribing or had pre-

scribed previously, the dominant clinical areas were hy-

percholesterolaemia (hyperlipidaemia), hypertension,

cardiovascular and diabetes management and anti- coagu-

lation. This is similar to findings from other studies of

pharmacist prescribing. Over 35% of respondents in the

study by George et al. [8] were prescribing in the area of

cardiovascular medicine, and just over 7% were prescrib-

ing in respiratory medicine. The largest number of items

prescribed (according to British National Formulary cate-

gory [BNF]) in the study by Baqir et al. [15] were in the

cardiovascular, central nervous and gastro-intestinal areas.

Findings from this study have been positive in terms of

how pharmacists perceive this new method of practice.

Over 80% of pharmacists ‘agreed’ or ‘strongly agreed’ that

prescribing increased continuity of care and increased

patient compliance/adherence. This has been found previ-

ously in studies of non-medical prescribing [8, 13, 16]. In

this present study most pharmacists ‘disagreed’ or ‘strongly

disagreed’ that pharmacist prescribing increased responsi-

bility and accountability of a pharmacist prescriber in a

negative way; this suggests that pharmacists may be con-

fident in their abilities and eager to take on the extra

responsibility associated with prescribing. This appears to

support findings by Lloyd et al. [13] where it was reported

that pharmacists felt a greater level of responsibility and

accountability but welcomed and accepted this as part of

their professional progression, and there was greater rec-

ognition of their role in the health care team [13]. Phar-

macists already have experience in many aspects of clinical

Table 3 Free text responses reported by responding pharmacists

Themes Pharmacist quotes

Information

technology

‘‘This is an evolving role largely dependent on access to patient records if it is to progress but need also to continue tobuild relationships with medical practitioners’’ (CP, primary care)

‘‘I feel that pharmacy independent prescribing can only take place in a primary care setting, within GP practices. This isbecause we have no access to patient history and notes otherwise. This makes prescribing from elsewhere more difficultand possibly less effective’’ (CP, primary care)

‘‘I have seen no evidence that supplementary or independent prescribing will be implemented in community pharmacy. Ibelieve I will never use my qualification and that it was ‘mis-sold’ to me. I believe it was a waste of time and money. Itmay be useful in hospital or surgery settings but not in community pharmacy’’ (NP, primary care)

Inadequate funding ‘‘Supplementary prescribing was a missed opportunity on the part of the board. A completely unrealistic pay suggestionjust made it impossible for me to leave my business and work in surgeries which until records are shared was the onlysafe method’’ (NP, primary care)

‘‘Hospital pharmacists have not been remunerated for taking on these additional roles and responsibilities. Paid as Band7’s*, same band as many nurses and other pharmacists who have not taken on additional roles’’ (CP, secondary care)

‘‘Although I have qualified as a supplementary prescriber, I have not used this qualification and do not see this changing.Funding and access to clinical notes are the main barriers. With an increasing workload in my dispensary, providingadditional services such as minor ailments, smoking cessation and weight management, it does not pay me to leave mypharmacy to run a clinic in a GP surgery’’ (NP, primary care)

‘‘Funding issues-it is not financially viable to work with independent prescribing qualification’’ (NP, primary care)

Lack of awareness ‘‘I feel that GPs are not ready to hand over any of their prescribing yet to pharmacists. I think GPs are trainingpharmacists as supplementary and independent prescribers but are not fully aware of the role they are training us for.Many GPs feel that the idea of pharmacists prescribing is very contentious and feel there is a conflict of interest betweenpharmacists prescribing and dispensing’’ (NP, primary care)

‘‘Once GPs understand the supplementary prescribing/independent prescribing role they feel more comfortable-

particularly if you can work in an area (such as benzodiazepine reduction) which can involve a lot of time’’ (CP, primary

care)

‘‘I feel that pharmacist prescribing has been hindered by the development of clinical nurse specialists. The nurses are inmore contact with the medical teams and therefore have a greater ability to expand their roles. There are also a greaternumber of nurses and they get more publicity. Pharmacy management not particularly supportive of pharmacistprescribers or clinical pharmacist roles’’ (NP, secondary care)

CP currently prescribing, NP never prescribed

*Pay scale: secondary care setting

Int J Clin Pharm (2011) 33:824–831 829

123

practice [17] therefore taking on responsibilities for pre-

scribing and monitoring therapy can be seen as a natural

extension of a pharmacist’s existing role [17].

In this current study, over 80% of pharmacists ‘agreed’

or ‘strongly agreed’ that prescribing improved patient

safety. This has been found elsewhere [19]; this may be

because pharmacists are particularly well placed to make

an impact on patient safety due to their high risk aversion/

safety focus [17]. Respondents in a study by Weiss and

Sutton [20] felt that 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. It

has been argued that recognising levels of competency is

crucial in managing prescribing decisions for all health

care professionals (HCPs). HCPs are accountable for their

acts and omissions and must work within their skills,

knowledge and competence [17]. It is particularly impor-

tant that pharmacists develop a culture of safety, do not

prescribe outside their areas of competency and are sup-

ported in their prescribing role, rigorous and robust gov-

ernance procedures should be in place where pharmacist

prescribers operate [18].

A number of barriers to implementing pharmacist pre-

scribing were noted such as inadequate funding, inadequate

resources to cover other core services and onerous paper-

work associated with the Clinical Management Plan

(CMP). Most of those who had never prescribed reported

experiencing such barriers to prescribing which would

suggest that these issues played a significant part in phar-

macists not beginning prescribing practice. Logistical

barriers to implementation identified such as information

technology issues (lack of access to patient notes in pri-

mary care), the CMP, funding and lack of resources have

all been reported previously [8, 13, 15]. It may also be

possible that doctors are not happy with shared access to

patient notes and wish to retain this control. In this present

study, onerous paperwork associated with the CMP was

cited as a barrier when pharmacists first qualified; in the

past CMPs (supplementary prescribing only) were con-

sidered restrictive, time consuming and unsuitable in get-

ting agreement from the IP [8]. This appears to be no

longer an issue as the introduction of independent pre-

scribing rights for pharmacists means generic treatment

plans are now used and CMPs are no longer required. Other

research (mainly UK) has cited similar barriers; financial

pressures, both organisational and personal (e.g. cost of

indemnity insurance) as barriers to expanding the services

offered by prescribing pharmacists [15].

Implicit within a prescribing consultation are history-

taking, clinical examination skills and the diagnostic and

therapeutic decision-making processes [20]. In this present

study there was a general view that pharmacists were least

confident at undertaking physical examination of patients.

Eighty percent of pharmacists preferred to undertake

pharmacist independent prescribing after a diagnosis had

been made by a doctor. It appears that whilst pharmacists

have taken on the role of prescriber, they have less desire to

take on the role of diagnostician and would prefer to pre-

scribe within a team context. Indeed, in most cases, the

initial diagnosis is made by the doctor. This mirrors what

has been reported in earlier studies of pharmacist pre-

scribing; Lloyd et al. [13] reported that there were major

concerns voiced over pharmacist involvement in diagnosis

as doctors considered this their defining role and appreci-

ated that pharmacists themselves would be uncomfortable

with diagnosis. Similarly, were two aspects of the pre-

scribing process where pharmacists felt the least compe-

tent: conducting clinical examinations and making initial

diagnostic decisions [20]. Pharmacists in this study [20]

conveyed that they were not used to carrying out physical

examinations of patients and many had selected pharmacy

as a profession because they did not want ‘to get their

hands dirty’ [20].

A number of recurrent themes were reported by pre-

scribers in the final section for free text responses. Essential

to effective prescribing was the need for shared patient

records. Inadequate funding and lack of support and

awareness of pharmacist prescribing from other HCPs were

cited as significant barriers. Again, these issues have been

reported elsewhere [8, 12]. Some of these barriers may help

explain why community pharmacists as yet cannot pre-

scribe from their own pharmacy.

In this current study, over 80% of respondents either

‘strongly agreed’ or ‘agreed’ with the statement ‘I envisage

the future as pharmacist independent prescribing rather

than pharmacist supplementary prescribing’. This could

potentially be attributed to the onerous paperwork associ-

ated with the CMP and reflects the findings of Lloyd et al.

[13]. Provided pharmacists have successfully completed

the appropriate training and are working within their

competency, independent prescribing allows pharmacists

to prescribe almost any medicine believed to be appropriate

for the patient although there are some limitations [5]. It is

advantageous that a CMP is no longer required to be used

by pharmacist IPs. Independent prescribing is clearly the

future model of practice although pharmacist prescribers

will continue to work under appropriate guidelines, often

using generic treatment plans which indicate the scope and

extent of prescribing practice.

The role of response bias must not be overlooked; the

extent to which non-response bias plays a part in this study

is unknown. The intrinsic motivation of the respondent is

critical to who responded; those pharmacists who were

particularly interested in the area of pharmacist prescribing

may have been most likely to respond.

830 Int J Clin Pharm (2011) 33:824–831

123

Conclusion

This study has shown that the number of qualified pre-

scribers in NI is relatively small (in comparison to the rest

of the UK) and not all have taken up prescribing respon-

sibilities. Well recognised barriers were reported as reasons

as to why qualified prescribers were unable to use their

prescribing skills. Independent prescribing was viewed as

the way forward, however, respondents considered that the

role of diagnostician should remain with a doctor as they

have overall responsibility for a patient’s care. Further

research should provide an in-depth understanding of

pharmacy prescribing in NI and examine patients’ experi-

ences of this form of practice.

Acknowledgments The authors would like to thank all pharmacist

prescribers who completed the questionnaire. A copy of the ques-

tionnaire can be made available to the reader on request.

Funding This work was supported by Health and Social Care

Research and Development (HSC R and D) Northern Ireland.

Conflicts of interest None.

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