A variety of health workforce strategies are used internationally to improve access to and efficiency of health services. Demand for health services continues to increase due to population ageing and the growing prevalence of chronic disease. Countries have taken different approaches to alleviate these increasing demands and improve health system efficiency. One strategy adopted in multiple health systems is the expansion of pharmacists’ prescriptive authority. Pharmacists have formal training in pharmacology and medication management and are often already responsible for ensuring the safe and effective supply of medicines. Evidence shows that pharmacist prescribing could achieve clinical outcomes equivalent to medical prescribing, improve patient access to timely treatment, and reduce workload pressure on medical services.
Pharmacists’ scope of prescriptive authority varies internationally and has been broadly categorised into three models: independent prescribing, collaborative prescribing, and dependent prescribing. Independent prescribing, where pharmacists can prescribe autonomously within their scope of practice, is established in the UK, and parts of Canada. Collaborative prescribing, where pharmacists prescribe under a formal agreement with a doctor or healthcare team, is practiced more widely, with New Zealand and parts of the USA being notable examples. Dependent prescribing, where pharmacists are limited to prescribing according to protocols or formularies, is practiced in Singapore, Australia and Ireland. Australia is actively piloting expanded pharmacist prescribing in several states, while Ireland is considering broader reforms.
In July 2024, the Expert Taskforce to Support the Expansion of the Role of Pharmacy published its final report, which recommended developing a plan to enable pharmacists to independently prescribe medications. Given current policy aims to expand the role of pharmacists across diverse healthcare settings, the Department of Health requested an evidence review on the effectiveness, safety, and cost-effectiveness of pharmacist prescribing across primary, secondary, and tertiary healthcare settings.
We agreed three research questions to address in the review in collaboration with the Department of Health:
The scope of our evidence review was intentionally broad in order to provide evidence on pharmacist prescribing across a wide range of healthcare settings and healthcare populations. We developed two systematic searches to identify literature relevant to our research questions. The first systematic search focused on effectiveness and safety, the second systematic search focused on cost-effectiveness. Using this approach allowed us to target our literature searches at discipline specific literature databases, maximising the relevant articles identified by our searches.
Across the three research questions, our systematic searches identified 52 articles which met our inclusion criteria (12,187 were identified overall, with 271 studies receiving a full-text review). These studies looked at a variety of pharmacist prescribing models including collaborative practice agreements (25 studies), independent prescribing (18 studies), and dependent prescribing (9 studies).
The majority of included studies were based in the USA, with the remaining studies being conducted in Canada, the UK, Australia, and Singapore. These studies covered a wide range of healthcare setting including outpatient clinics, primary care, community pharmacy, hospitals, and long-term care settings. These studies covered 18 healthcare populations including diabetes, hypertension, coagulation disorders, urinary tract infection, and female contraceptive users.
Of the 52 included studies, 39 investigated effectiveness and/or safety in pharmacist prescribing compared with other prescribing healthcare professionals (mainly medical prescribers). These included 12 randomised control trials (RCTs) and 27 non-randomised studies. The remaining 13 studies were full economic evaluations which assessed cost-effectiveness. Ten were cost-utility studies, one was a cost-benefit study, and two were cost-minimisation analyses. These studies mainly assessed cost-effectiveness from a health system perspective, with time horizons ranging from one month to 50 years.
Across the 39 studies assessing effectiveness and safety, 167 outcomes were reported. Examples of effectiveness and safety outcomes included blood glucose, blood pressure, blood clotting, clinical cure, time to access care, adverse events, and hospitalisations. For 75 outcomes, there was no significant difference reported between prescribing groups, indicating equivalence of care between pharmacist prescribing and medical prescribing. For 51 outcomes, there was significant improvement in pharmacist prescribing compared with medical prescribing. Two outcomes reported significantly improved outcomes for medical prescribers compared with pharmacist prescribers. Inferential statistics were not reported for 39 outcomes, meaning we cannot comment on the statistical significance of these outcomes.
In relation to the cost-effectiveness outcomes, 12 studies projected pharmacist prescribing models to be dominant (i.e. lower treatment cost, more effective), or cost-saving (i.e. lower treatment cost, equally effective) when compared with medical prescribers. Only one study on chronic pain reported that medical prescribing was cost saving compared with pharmacist prescribing.
To our knowledge, this is the most comprehensive evidence review on pharmacist prescribing published to date. Across a range of healthcare settings and populations, pharmacist prescribing achieved effectiveness and safety outcomes equivalent to, or improved compared with, medical prescribing. Most of the cost-effectiveness studies projected pharmacist prescribing to be either cost-saving or cost-effective from a health system perspective. Expanding pharmacist prescribing in Ireland could be cost-effective while maintaining patient safety and treatment outcomes. Continued research and structured policy planning will support effective implementation.
Building on the findings of this evidence review we have identified areas for future research which in the Irish context would help to understand how pharmacist prescribing can be effectively integrated into existing healthcare structures. Research exploring barriers and facilitators for patients, healthcare professionals, and policymakers would help identify the supports required for implementation. International experiences may also offer useful insights into factors influencing successful adoption across different settings.
Our evidence review did not identify studies assessing pharmacist prescribing in children or adolescents. Including younger age groups in future primary research would address this gap. Limited research was also identified in specific clinical areas, including mental health, respiratory conditions, and infectious diseases. Conducting primary research in these populations would broaden understanding of pharmacist prescribing across different healthcare needs.
We identified common methodological limitations across the included studies. Future research could minimise these risks by strengthening study design, controlling for confounding factors, and providing transparent and comprehensive reporting.
This comprehensive systematic review shows effectiveness and safety outcomes in pharmacist prescribing were significantly improved, or equivalent to, outcomes achieved by medical prescribers across a range of healthcare populations and healthcare settings.
Internationally, economic evaluations have found pharmacist prescribing to be cost-effective compared with usual care.
The direction of evidence consistently supported pharmacist prescribing, with few outcomes favouring other prescribers. The evidence in this report will help inform the Department of Health’s next steps in expanding the role of pharmacists.
The full report is available on the HRB website at hrb.ie > Publications.
The HRB Evidence Centre conducts evidence syntheses to inform health policy and decision making. You can find out more about our work at hrb.ie > Data and Evidence > HRB Evidence Centre.
Dr Áine Teahan and Dr Melissa Sharp, HRB Evidence Centre
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