Professions & prescribing: insights from nursing & pharmacy

1. Professions & prescribing: insights from nursing & pharmacy Paul Bissell Public Health ScHARR University of Sheffield

2. Background • Medical sociologist / worked in pharmacy for over 10 years • Numerous evaluations community pharmacy practice: • Advice-giving in pharmacy • Lay and professional perspectives on risk of non-prescription medicines • Pharmacy supply of emergency hormonal contraception (EHC) • Public health and pharmacy • Social capital, inequalities and pharmacy • Ethical dilemmas in community pharmacy • Medicines management in community pharmacy • Evaluation of supplementary prescribing in nursing and pharmacy

3. 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.

4. 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)

5. 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)

6. Role of professions • Classic theme in medical sociology. • Friedson’s ‘Profession of Medicine’: • 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.

7. 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).

8. Medical Dominance • Last 30 years various arguments about decline of medical power: • 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

9. Medical Dominance • A consensus that medical power is being challenged, but not necessarily eroded: • 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…)

10. 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?

11. 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.

12. 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).

13. 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.

14. 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.

15. 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.

16. 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.

17. 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.

18. Overview of PACT data

19. Nurse PACT Data

20. 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.

21. 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.

22. 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.’

23. 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’.

24. 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.

25. 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.

26. 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.

27. 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.”

28. 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).

29. Pharmacy & sociology of the professions • Denzin and Mettlin (1968) – pharmacy viewed as a case of ‘Incomplete professionalization’. • 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.

30. 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.

31. 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.

32. 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…

33. Re-professionalization project. • Continuing issues in community pharmacy’s re-professionalisation 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

34. 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: • University of Aberdeen • University of Nottingham • Keele University

35. The CPMMP

36. Results-% appropriateness

37. 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.

38. Pharmacists views about medicines management • Very positive about service: • “It’s wonderful to be able to talk to people” Better patient care: • “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: • “It certainly is an extension of our role and a very worthwhile one, actually using our clinical skills for a change.” (P16/FG4)

39. 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)

40. 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)

41. 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.

42. 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)

43. Pharmacists Changing Patients Medication • Concerns about whether it was appropriate for community pharmacists to change patient’s medication. • 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

44. 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.

45. 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”

46. Summary • Strong support for CPMMP in some areas, GPs highlighted many concerns: • 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.

47. 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.

48. 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.

49. 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)

50. 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.’