Targeting the new prescribers

pharmafile | April 26, 2004 | Feature | |   

This year will see increasing change to the pharmaceutical industry customer base as prescribing roles within the NHS continue to be expanded. With strong government backing, supplementary prescribing by nurses and pharmacists is giving the health service an additional level of prescribing decision-makers and is set to fundamentally change the traditional pharma-doctor-patient tripartite relationship. To this mix there needs to be added a new group of old prescribers, as numbers increase of GPs with a special clinical interest (GPwSI), who could well be a local authority in your therapy area.

The challenge for pharmaceutical companies will be in identifying which individuals make up these different groups of prescribers and tailoring their approach to the different prescribers' needs. Given that the number of prescribers is set to increase  - both in terms of individual prescribers and in terms of additional groups of healthcare professionals, who will be able to prescribe – there will be a serious need for new market intelligence.

Nurse prescribing

Although prescribing by nurses is not new, supplementary prescribing by nurses, which is still in its relative infant stages, should see the numbers of nurse prescribers substantially increase. As of April 2003, there are two types of nurse prescriber independent nurse prescribers and supplementary nurse prescribers. Independent nurse prescribing was first introduced in 1994 and there are now 25,525 nurses with district nurse or health visitor qualifications who have been trained to prescribe from a limited formulary of products.

Of course, the number of nurses trained to prescribe is not the same as the number of trained nurses actually using their training to prescribe. The formulary that these initial nurse prescribers use extends to appliances, dressings, some general sales list (GSL) and pharmacy (P) medicines and 13 prescription-only-medicines (POMs). This group of nurse prescribers is by now fairly used to the pharmaceutical industry coming to see them and consequently used to being targeted by the industry, according to Trudy Granby, assistant director of Non-Medical Prescribing Support at the National Prescribing Centre.

A second tier was added to independent nurse prescribing in 2001 when the government announced an extended formulary from which suitably qualified nurses could prescribe. The Nurse Prescribers' Extended Formulary (NPEF) contains all GSL, some 2,500 P and around 180 POM medicines – six of the latter being controlled drugs.

Training for extended formulary nurse prescribing began in spring 2002 and around 1,880 nurses have qualified for it with more in training. The NPEF extended independent nurse prescribing into a wider range of settings and medicines and allowed them to cover minor ailments, minor injuries, health promotion and palliative care. In total they can now treat around 80 conditions and the Committee on Safety of Medicines is considering extending NPEF to emergency care and first contact care.

Supplementary nurse prescribing

According to Ms Granby: "Nurse prescribing has been led by district nurses and health visitors, but nurses across the board have always influenced GP prescribing. Accordingly, the current drive behind nurse prescribing is about extended services and the profession."

Behind that current drive is the introduction of supplementary nurse prescribers, for which training began early last year. Their numbers also come from independent nurse prescribers who have qualified for the NPEF as they can 'top up' their training to become supplementary prescribers. From this group there are now around 1,180 nurse prescribers dually qualified.

One problem with nurse supplementary prescribing is that for nurses, the established route of getting medicines to patients has tended to be through Patient Group Directives so they are not yet used to supplementary prescribing. So far it seems that individual nurse prescribers are reluctant to prescribe overall.

Although they are not all reluctant to prescribe, the number of those that will prescribe have not yet met government expecations. "The indications are that it is the initial tranche of nurse prescribers that are reluctant," Ms Granby said.

Nevertheless, there was a six-fold increase in prescribing by both extended formulary and supplementary prescribers between December  2002-2003, when more than 30,000 items were prescribed. According to a report by the Prescription Pricing Authority on prescription volume and growth, total nurse prescribing also increased in the same period, showing 13% growth.

This occurred despite the disparity between government targets for supplementary prescribers which for nurses are several thousand by the end of this year and the actual numbers signed up.

"There are quite low numbers of supplementary prescribers and we're not meeting the targets at the moment that we expected," says Ms Granby, "but I think that we will do in the end."

Should nurse prescribing, and its extension through nurse supplementary prescribing, cause pharma eyes to light up as they will with the new GMS contract? It is unlikely. According to the National Prescribing Centre Prescribing Support Unit – which has tracked nurse prescribing since 1994 – less than 1% of all drugs prescribed were done by nurses, and in the areas where nurses were prescribing, GP prescribing actually decreased. They concluded that nurse prescribing was substitute prescribing rather than additional prescribing.

Ultimately however, independent and supplementary prescribing, together with the continued use of patient group directives (PGDs), have to be viewed within the context of the government pledge that by 2004, over half of all nurses will be able to supply medicines.

However, to find out who the new supplementary prescribers are will take a bit of investigational work on the part of pharma companies. Although there is a central register, it is unlikely to be shared with the industry and it looks like the best way of finding out who the nurse supplementary prescribers are in any particular territory will be to go to the PCT in that area.

Pharmacist prescribing

While nurses have nearly a decade of experience of prescribing in one form or another, for pharmacists it is less familiar. In fact the first ever pharmacist supplementary prescribers only qualified on March 18, 2004.

So far the numbers remain small – just 27 from a pharmacist population of 20,000 have graduated from the course. But whilst this may be less of a first wave and more a trickle, the government is determined to make more use of pharmacists, a group it sees as being an underused resource within the NHS in the past.

According to the Department of Health, the most obvious types of pharmacists to be trained as supplementary prescribers are those who already have close links with doctors, because of the close partnership required between them. This means that the pharmacists the pharma industry will want to speak to will be those located in health centres or GP practices, or who are hospital pharmacists.

Another group of pharmacists to target will be community pharmacists who do sessional work at GP surgeries. Indeed, Gul Root, Principal Pharmaceutical Officer, Medicines, Pharmacy and Industry at the DH, noted at the Prescriber conference that "the [Health] Minister is extremely keen for community pharmacists to become supplementary prescribers".

The moves are part of the government's overall plans to transform the role of the pharmacy. "We want pharmacy to be an integral part of the NHS, not a shop on the high street," Ms Root said.

As to which pharmacists will go on the course, the DH says it will be for the NHS to locally determine who is trained. Although there was a government target for up to 1,000 pharmacists to be trained as supplementary prescribers by the end of 2004, this has been revised. "We had said 1,000, but we recognise that we may not meet this so it is not a government target but an expectation," Ms Root said.

But who exactly will pass the training to become pharmacist supplementary prescribers? Whilst there are no guidelines for pharma on access to the names of pharmacist supplementary prescribers, Ms Root suggests that, as with finding out who nurse supplementary prescribers are, companies will have to go through PCTs to obtain this information.

She said that the RSPGB would annotate its register to show which pharmacists were also supplementary prescribers, but that the society was unlikely to give that information out to the industry. She added that the names might appear on the RSPGB website (www.rpsgb.org.uk), but that access to that has been not decided on.

Michael Sobanja, chief executive of the NHS Alliance and a board director at HealthGain Solutions, said: "There is no substitute for local intelligence and that means getting out and about in PCTs, picking up the details of this through community pharmacies, etc, and identifying who is going on the training courses.

GP with special clinical interest

The idea of GPwSI was first introduced in the NHS Plan in 2000, which called for 1,000 new GP and nurse 'specialists' (as they were then termed). The idea behind their creation was that it would help combat workforce pressures and encourage people to stay in the profession by creating new, exciting roles for them to hold. Although GPs with a particular interest in a clinical area have always existed, the difference now is that there is the political will to corral them together with a title and create accreditation and training programmes for them.

There are currently around 12,000 GPwSIs that, although they range across a number of specialities, have high numbers in dermatology and orthopaedics.

As to what impact they will have, Dr Clare Gerada, a GP with a special clinical interest in drug misuse, told the Prescriber conference that she expects GPwSIs to be as influential as the leaders who innovate will allow them to be.

"I suspect that if a primary care organisation has an innovative leader then  you will get a lot of change, but if the chief executive is a Luddite and frightened then you won't," she said.

"I think they [GPsSIs] will be very influential, because I think they are going to be the primary care leaders in particular areas. There is so much noise at the moment around the system that [the industry] has difficulty in understanding it all."

She suggested that there could be situations where, for example, practices within a primary care organisation were led on diabetes by a pharmacist with a special clinical interest in the condition – something the industry should clearly be concentrating on.

Indeed, there is a resource on the The National Primary and Care Trust Development Programme website (www.natpact.nhs.uk/survey.php) dedicated not to GPwSIs, but PwSIs and lists a number of the 'practitioners' involved, from ophthalmologists to midwifes, physiotherapists to health visitors, and even GPs. Although the register is not exhaustive, it will give a good indication of which specialties PwSIs currently cover and where they are based.

Working with the new prescribers

IIt will therefore be possible to locate the new groups of prescribers, but some are going to need more detective work than others. But once you have identified them, how should you approach them?

Mr Sobanja said it would be a mistake to think that their motivations and requirements are identical to those of traditional prescribers. "We've got to think about what works for nurses, pharmacists and physiotherapists and so on," he said. "Nurses will be far more guideline and protocol driven than GPs are and were and we need to respond to that.There will also be issues about whether the new prescribers will even want to work with the pharmaceutical industry or not."

Mr Sobanja suggests that they are more likely to be sensitive to working with the industry than GPs. heye going to want things in a box,he says. heye going to want things done properly and theye going to want things like probity agreements signed off, I think, more rigorously than GPs.The new groups of prescribers should also not be viewed in isolation. They will not replace GPs as customers, but will instead fragment the industry customer base into different groups that will all probably need a different approach.

The prescribing base of the NHS is evolving and the pace of change looks set to continue unabated over the next few years. Even as the first wave of nurse and pharmacist supplementary prescribers emerged there are plans to push the changes even further in the next couple of years.

The DH has been working with representatives of the Allied Health

Professions and Optometrists to introduce supplementary prescribing for physiotherapists, radiographers, podiatrists and chiropodists and optometrists by the end of 2004.

Indeed, such healthcare professionals may already be PwSIs and therefore people that the industry should be talking to.

In conclusion, however pharma copes with these changes, there is still no substitute for gathering local knowledge and using it to tailor the message accordingly.