Transcript Prescribing in nursing and pharmacy

Professions &
prescribing: insights from
nursing & pharmacy
Paul Bissell
Public Health
ScHARR
University of Sheffield
Background
Medical sociologist / worked in pharmacy for over 10 years
Numerous evaluations community pharmacy practice:
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Advice-giving in pharmacy
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Lay and professional perspectives on risk of non-prescription
medicines
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Pharmacy supply of emergency hormonal contraception (EHC)
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Public health and pharmacy
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Social capital, inequalities and pharmacy
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Ethical dilemmas in community pharmacy
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Medicines management in community pharmacy
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Evaluation of supplementary prescribing in nursing and
pharmacy
Overview
Nursing & pharmacy professions both
make claim to be rightful heirs to non
medical prescribing.
Provide contrasting & overlapping insights
into sociology of professions / continuing
dominance of medical profession around
medicines usage.
Context for non-medical prescribing:
power of medical profession
“Doctors have held a unique position of
power over prescribed medications for
some years, a role that has brought with it
the control of the scope of practice of other
health professionals. It is likely that some
will be reluctant to abandon it.” (Baird
2000: 454)
Context for non-medical prescribing:
power of medical profession
“The medical profession has an almost
exclusive right to prescribe medicines but
this right is being challenged by…other
health professions. It is argued that in
British General Practice, prescribing is a
battle ground on which the cause of
clinical autonomy is defended.” (Britten
2001:478)
Role of professions
Classic theme in medical sociology.
Friedson’s ‘Profession of Medicine’:
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medical power rests on autonomy over its
own work activities and
dominance / control over the work of others in
the health care division of labour.
Medical Dominance
“organised autonomy is not merely freedom from
the competition or regulation of other workers,
but in the case of such a profession as
medicine…it is also a freedom to regulate other
occupations. Where we find one occupation with
organised autonomy in a division of labour, it
dominates the others. Immune from legitimate
regulation or evaluation from other occupations,
it can legitimately evaluate the work of others.
By its position in the division of labour we can
designate it as a dominant profession”
(Friedson 1988:369).
Medical Dominance
Last 30 years various arguments about
decline of medical power:
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Proleterianization: clinical freedom under
threat from state / HMOs
Deprofessionalisation: rise of assertive
patients / narrowing of knowledge gap
Nancarrow & Borthwick (2005) discuss the
fluid nature of professional boundaries in
health care
Medical Dominance
A consensus that medical power is being challenged, but
not necessarily eroded:
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Internal stratification within medical profession
Cost awareness & containment: managerialism/ audit /
clinical governance
Greater scrutiny & regulation as a result of medical errors /
abuse
Consumerism / lay knowledge /greater assertiveness by
patients
Professionalisation and availability of CAM
Lay scepticism towards expert systems more generally
Boundary encroachment from other health professionals
(eg. prescribing and medicines management nursing and
pharmacy…)
Prescribing & medicines management in
nursing and pharmacy
General consensus about a challenge to, if not an
erosion of medical power.
How has the medical profession reacted to nurse and
pharmacist prescribing / medicines management roles?
Has this translated into enhanced status for nursing and
pharmacy as a result of involvement in prescribing /
medicines management tasks?
What are the implications for nursing and pharmacy
professions?
Nurse Prescribing - overview
Development & reaction to nurse
prescribing in the UK and US.
Different experiences and responses by
medical profession in UK and US.
Evidence of considerable concern from the
medical profession.
Nurse Prescribing
UK - able to carry out both Independent and
Supplementary prescribing.
Independent prescribing began in 1994 almost
opportunistically.
Roots in DN – diagnosis requiring ‘rubber stamp’ /
geographical distance from doctors require to sign
/ improvements in access.
Strong political support for prescribing role from
RCN – alliances with BMA & RPSGB / stressed
partnership model.
Push for private members bill (1992 Medicinal
Products: Prescription by Nurses etc Act).
Nurse Prescribing
Conservative government concerned about cost.
June Crown appointed to carry out review of non
medical prescribing.
Series of pilot sites set up – rise of independent
prescribing (from limited formulary)
Pace of change speeded up post Labour victory
Extended Independent Nurse Prescribing from
2001.
Dependent, renamed supplementary prescribing
(via Clinical Management Plan) implemented.
Nurse Prescribing - responses
Numerous (HSR) studies, claiming nurse
prescribing viewed positively by patients, is cost
effective, is (viewed as) safe, improves access
and does not waste doctors time.
Jones - ‘irrefutable proof’ that nurse prescribing
was working on every criteria of safety, costs
and effectiveness.
By 2005 – prescribing from whole formulary was
announced (for both nurses and pharmacists) by
Sec of State.
Nurse prescribing – concerns from
within profession
Lack / absence of formal supervision for nurse prescribers.
Lack of incentives to assist with mentoring.
Concern that it is driven by medical shortages / to reduce junior
doctors hours / size of medical budget.
Many nurses not prescribing despite completing training.
Concern that nursing becomes medicalized / looses identity as a
‘caring profession’.
Aidroos (2002) – ‘offer and drug and depart’ service.
Will nurses be held to the same standards of care as other health
professionals?
Do nurses have choice about whether to prescribe – evidence
that employers alter job descriptions to include prescribing.
Considerable scope to develop a sociological research agenda in
these areas.
Nurse prescribing – concerns from
medical profession
BMA (2002) – ‘training nurses get is nothing like sufficient and will
not give them the clinical knowledge they need to prescribe these
drugs’.
Nurse prescribing - ‘a dangerous uncontrolled experiment’ (Horton
2002) - also refers to prescribing entailing a loss of nurses identity.
Criticism of nursing – seen through lens of professional attributes.
Others more cautiously optimistic about nurse prescribing (Avery
and Pringle 2005).
Concern about speed of change / availability of mentoring from GP /
doctor / availability of role.
Medical press (eg Pulse) maintaining pressure & surveillance over
nurse prescribing.
Numerous concerns about pharmacology & therapeutics training for
nurses.
Safety & nurse prescribing
Systematic review of safety of nurse (supplementary)
prescribing.
Most published papers not based on empirical research /
focus on adequacy of nurses training, knowledge &
skills.
Review shows that doctors believe that Clinical
Management Plan allows them to retain power / provides
a framework for guiding decisions.
Little empirical evidence that nurse prescribing is
‘unsafe’.
Concerns tempered by awareness of scope / scale of
nurse prescribing in England.
Overview of PACT data
Nurses
Year
Item volume
Net ingredient cost
2004
3.5 million
£52.2 million
2005
4 million
£58.9 million
2006
6.3 million
£79.3 million
2007 (to end of September)
6.8 million
£79.5 million
Pharmacists
Year
Item volume
Net ingredient cost
2004
2706
£25,348
2005
11,458
£96,846
2006
31,052
£278,634
2007 (to end of September)
44,318
£332,320
Nurse PACT Data
Nurse Prescribing 2004-2006
Nurse Prescribing 2006
7
Other 15%
6
5
2004
2005
2006
4
3
2
Appliances
7%
Obs, Gynae
and UTI 4%
Respiratory
6%
Skin 12%
Infections
10%
1
0
Item volume
(millions)
CNS 9%
Dressings
32%
Cardiovascular 5%
Nurse prescribing
UK - establishing prescribing rights for nurses has
involved some conflict with the medical profession.
Not clear that supp rx based around CMP enhances
status.
CMP provides reassurance for doctors.
Maintains status divisions between supp & independent
prescriber.
Indeterminacy / technicality ratio – supp rx based around
CMP / maintains status hierarchies.
Diagnosis / independent prescribing may result in rather
more conflict.
Different to situation in the US.
Nurse prescribing in US
Development of nurse prescribing resulted
in much more opposition in the US.
Nurse prescribing grew out of nurse
practitioner role in paediatrics / response
to ‘thin provision of care’ in rural areas.
Creation of ‘negative formularies’ for
nurses / negotiation of independent
prescribing in most states for NPs.
Nurse prescribing in US
Mundinger et al (2000) ‘combination of authority
to prescribe drugs, direct reimbursement from
most payers and hospital admitting privileges
creates a situation in which NPs and primary
care physicians can have equivalent
responsibilities’.
NPs reimbursed at same rate as physicians in
some states.
Fennell argues ‘inherent in the physician and
pharmacist opposition to nurse midwives
prescribing is…an interest in their own economic
survival.’
Nurse prescribing in US
Byrne & Helman (2002) – anti-competitive
practices of health plans where consumers
are instructed to use mail order/internet
pharmacy services, many of which refuse
to accept NPs prescription.
Chen-Scarabelli (2002) – ‘various state
medical associations lobby against nurse
practitioners in a an attempt to maintain
monopoly over health care management’.
Nurse prescribing in US
Edgley et al – “federal state’s reactive
stance has opened the way for overt
conflict between the professions as they
fight it out over territory, rights and
responsibilities.”
Professions’ responses to threats &
opportunities depends on organisational
context.
Summary
Nurses successfully developed prescribing role.
Concerns from within nursing and from medical
profession.
Appears to be significantly more conflict in the
US than UK.
Medical profession able to mobilise arguments
about appropriateness of nurse training, despite
lack of evidence about risks / dangers /
inappropriate prescribing / consideration of type
of prescribing being undertaken.
Likely that IP will evoke more conflict than SP.
Pharmacists’ roles in medicines
management & prescribing
Pharmacy - very different history & response to
challenges of non medical prescribing.
Much slower engagement with prescribing agenda.
IP only just getting started / several years of SP.
Professional development shaped by commercial &
organisational environment (community) pharmacy
operates in.
Significant barriers to (community) pharmacists
developing role in this area.
Must overcome these barriers AND deal with potential
opposition from medical profession vis a vis IP and SP.
Pharmacist prescribing?
Eaton and Webb (1979) – interviewing
educators and policy makers:
“…I would draw the line at prescribing – the
pharmacist isn’t trained to prescribe
treatment.”
“Well really I think lines may be drawn in
terms of the medical degree…But they
(pharmacists) will never be involved in
prescribing, at least in Britain, unless they
have a medical degree. You can’t sign a
prescription which somebody will honour.”
Community Pharmacy – recent history
Up to mid C20th legitimacy based on expertise in
compounding / producing proprietary medicines.
Original pack dispensing from 1960s onwards forced
loss of role
 Pharmacy has long history of links with commerce /
‘petit bourgeoisie’.
 Ambiguous relationship with the NHS – private provider
in socialised system.
Community pharmacies seen as ‘dispensing’ factories –
considerable professional dissatisfaction.
Pharmacists ‘over qualified & under utilised’ (Eaton & Webb
1979) – de-skilled.
New roles for pharmacists – essentially a quest for survival
(Edmunds & Calnan 2001).
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Pharmacy & sociology of the
professions
Denzin and Mettlin (1968) – pharmacy
viewed as a case of ‘Incomplete
professionalization’.
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Pharmacy lacked control over the ‘social
object’ of practice - the medicine.
Pharmacists guided by commercial interests
at odds with the altruistic, service orientation
of a profession.
Essentially, a highly damaging critique /
retains potency.
Pharmacy & sociology of the
professions
Dingwall & Wilson (1995)
 Critique of Denzin & Mettlin (1968) position
 Other professions (e.g lawyers) associated with
commerce, does not undermine professional status.
 Pharmacists transform objects (drugs – medicines)
and have a (Foucauldian inspired) role in surveillance
around medicines usage.
 Hibbert et al (2002) – weak role over medicines
surveillance; protocol driven; role undermined by ‘lay
expertise’ / consumerism.
 Turner (1995) refers to pharmacy as tainted by ‘petite
bourgeoisie’ image.
Pharmacy & sociology of the
professions
Pharmacists increasingly ‘corporatised’ – increasingly
employees rather than independent practitioners.
Key decisions not taken by pharmacists (tensions
between superintendents & marketing departments) /
‘de-pharmacisation’ of chains / multiples.
Lack autonomy over work practises / boundary
encroachment from others.
Small profession (45 000 registered pharmacists – split
between hospital and community.
Considerable dissatisfaction with working practises in
community pharmacy.
Re-professionalization project.
Plethora of policy documents – PIANA, Choosing Health
Through Pharmacy, Pharmacy in the New NHS…
Some new roles identified:
 smoking cessation,
 PBNX
 supervised methadone
 minor ailments schemes
 Supplying emergency contraception
 Chlamydia screening
NHS contractual framework for pharmacy – essential,
advanced and enhanced.
Prescribing and medicines management…
Re-professionalization project.
Continuing issues in community pharmacy’s reprofessionalisation project:
 Commercial environment in which pharmacy is
practised
 Limited autonomy as employees
 Patient doubts about appropriateness of community
pharmacy as a site for advice / medicines
management / prescribing?
 Isolation from other professions / policy arena
 Subordination
Community Pharmacy Medicines
Management Project (CPMMP)
Project developed / implemented by the Pharmaceutical
Services Negotiating Committee (PSNC)
Funded by DoH (2001-2004)
Aim: to evaluate the introduction of a community
pharmacy led medicines management service for
patients with coronary heart disease (CHD)
Evaluated by independent research team using RCT &
qualitative research:
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University of Aberdeen
University of Nottingham
Keele University
The CPMMP
Study Protocol
9 localities picked to particpate:
Nantwich, Lichfield, Walsall
Poole, Portsmouth, Southwark,
Shipley, N. Tyneside, Salford
GP in each area
invited to participate
READ code search to
identify CHD patients
Pharmacists in each area
invited to participate
Have to complete
CHD training
Patients invited to
particpate from GP surgery
Randomised to intervention
or control group (2:1) ratio
Review pharmacist's
recommendations
& action if appropriate
Pharmacist receives
summary of clinical information
from audit clerk for
intervention patients
Control Group
receive medication
in usual way
Intervention Group
Receive medication review
from pharmacist & follow-up
during 12 months
Medication +/or lifestyle
recommendations made
Discussed with patient and GP
Results-% appropriateness
Intervention
Baseline
Intervention
Follow up
Control
Baselin
e
Control
Follow-up
P-value
Aspirin
82
80
76
78
*
Aspirin-related
95
94
91
93
0.24
Target
cholesterol
59
58
57
55
1.00
Statin
73
79
68
77
*
BP
47
49
43
47
0.49
Explanations…
Qualitative interviews and focus groups with
doctors, pharmacists and patients sheds
considerable light on ways in which the doctors
and pharmacists are working together?
Informs a sociology of pharmacy.
Pharmacists views about
medicines management
Very positive about service:
“It’s wonderful to be able to talk to people”
Better patient care:
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“We’re getting closer to some of the patients because
they think…feel that you’re taking more of an interest in
them rather than oh, another customer!” (P11/FG3)
Using clinical skills:
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“It certainly is an extension of our role and a very
worthwhile one, actually using our clinical skills for a
change.” (P16/FG4)
Pharmacists’ concerns: GPs’ perceptions
of their subordinate status
“We work as a team but they (GP) think they’re the
upper class; we are the lower class you know”
(P13/FG8)
“They sort of think of…they still think that a
pharmacist is a class down, like you know you
think of a shopkeeper.” (P14/FG7)
“Because they’re not used to having their judgement
questioned…Not by someone that they perceive
as being a shopkeeper.” (P12/FG4)
Pharmacists’ concerns: GPs feeling
threatened
“I think it’s because they feel threatened; it’s human
nature isn’t it? You are impinging on their territory.”
(P34/TI1)
“They might feel their opinion is being challenged, that
they are being checked upon, or whatever because I
suppose they are not used to it. It is a new thing for
them really to have someone who is looking at the
notes they have done themselves.” (P09/FG2)
Commerce & Pharmacy
GPs concerned that community pharmacists
advice influenced by commercial factors
“The difficulty I have really is trying to be certain
that their advice is not commercially related”
(GP19)
Resulted in GPs being suspicious of the
clinical advice they received from community
pharmacists.
Access to Medical Records
“ I think the whole area then that opens up is all
the areas of confidentiality and people who
are not actually part of the GP primary care
team, who have access to confidential
medical records, which may include so and
so is having an affair with so and so, who
might happen to be the pharmacists
neighbour you know. It may not, it’s a most
unlikely scenario but our duty first and
foremost is to all our patients is
confidentiality.” (GP15)
Pharmacists Changing Patients
Medication
Concerns about whether it was appropriate for
community pharmacists to change patient’s
medication.
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Do community pharmacists know patients well
enough to undertake this service?
Pharmacists involvement could cause fragmentation
over patient care & responsibility
Patients could become confused if more than one
person had responsibility for medication
Pharmacists lack access to medical records when
undertaking medicines management role
Pharmacists Changing Patients
Medication
“ I mean I think getting medication right is
quite complicated and it depends on
quite a lot of medical historical
information and unless they have got
the whole set of notes and they are
sitting down with the patient and got to
know them over a period of time they
can’t do that” (GP15)
Likely to be highly relevant to prescribing.
Reasons for GPs’ Concerns
“Professional boundaries”
“Threatening…challenging management
and criticism”
“The whole area opens up areas of
confidentiality and people who are not
actually part of the primary care team”
Summary
Strong support for CPMMP in some areas,
GPs highlighted many concerns:
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Community pharmacist’s links with commerce
Some resistance to pharmacists undertaking new
roles & boundary encroachment
Some resistance to community pharmacists
having access to patient’s medical records
Distance from patients - concerns that
pharmacists do not possess a detailed knowledge
of the patient & clinical histories
Isolation from medical / nursing professions and
primary care more generally.
Medicines Management: A challenge
to medical dominance?
Issues identified by Denzin & Mettlin (1968) still relevant –
commerce / altruism / motivation.
Strong discourse around community pharmacy’s subordinate
position in health care division of labour.
Distance from patients ‘everyday’ care.
GPs able to mobilise powerful arguments against pharmacists
involvement. Eg commerce, access to records, confidentiality,
knowledge of patient.
Able to name / identify roles for pharmacists eg. compliance /
repeat dispensing but NOT changing medication.
Pharmacists collude to re-produce and sustain their own
subordinate status. Eg. reference to ‘shops’; deference to GPs.
Medicines Management: patients views
Patients’ views similar to GPs assessments of
pharmacists involved.
Cautiously welcoming ‘talking to pharmacists’
But anxious about them making recommendations
about treatment / changing medication.
Concerns about the commercial environment / strong
awareness of subordinate position of pharmacy.
Medicines Management: patients views
Commercial influences:
“I’m just not sure I’m happy about it at all. I enjoyed
talking to him, that wasn’t the problem. It’s just at the
back of your mind, is it me, or is it a bit daft, you
wonder about, well, you wonder about the drugs
companies and all that, and all those promotions in
the shop…I came home from it, and we were talking,
I said, is it the kind of place they should be doing this
kind of thing?” (R5)
Medicines Management: patients views
Subordinate position:
“The pharmacists don’t diagnose, don’t they? The
doctors do that. They put you on the treatment and
the pharmacist just gives you it.”
‘Because you look at most prescriptions…It says if
you develop any of the following consult your GP.
And this is from the chemical company. They don’t
say go to the pharmacist. They say go to the doctor.’
Subordination & isolation
Cooper’s research around ethical loneliness of
pharmacists.
Draws on qualitative research with pharmacists:
Subordinate position:
“I tend to feel that when I get a prescription, coming
back to your point, that it’s the doctors responsibility
ultimately and that I’m just a tool of the doctor really.
I’m not happy with it, I’m passing the buck and not
accepting the responsibility that I should be taking.”
Subordination & isolation
Isolation:
“In a way we are isolated as pharmacists and we
haven’t got anyone to chat to, to ask about things, to
find out what other pharmacists think”.
“We’re all islands and we’re all competing against
each other […] The only time when you come into
contact with another pharmacist is when there’s a
conflict with something or when you want to borrow
something.”
Habermas / Mead (discourse ethics) – loneliness /
isolation may be ethically problematic for
pharmacists.
A sociologically informed research
agenda for pharmacy
Commerce, altruism, isolation, subordination
retain some force.
Nancarrow & Borthwick (2005) – not clear
that taking on new roles results in enhanced
status.
Moreover – ‘no examples of role changes
that have removed the attributes that are
associated with the professional labels.’
Community pharmacy remains a site tainted
by commerce, isolation, subordination.
To develop, pharmacists leave the
commercial environment / undertake
professional journeys / narratives of change.
Prescribing & medical dominance?
Britten (2001:478): Prescribing and the defence of
clinical autonomy:
“The medical profession has an almost exclusive
right to prescribe medicines, but this right is being
challenged by the State, patients and other health
care professionals…These changes do not yet
support the thesis of proletarianization [or
deprofessionalization] as the medical profession
continues to dominate the clinical agenda and
responsibilities of other health care workers.”