Non-Medical Prescribing

A Course Companion

Alison Pooler, Alison Pooler

• Publisher: Routledge
• Year: 2020
• ISBN:
  9781000317640
• Edition: 1
• Topic: Medicina
• Subtopic: Infermieristica

This accessible textbook provides a comprehensive resource for healthcare students and professional students studying non-medical prescribing, taking into account the Royal Pharmaceutical Society (RPS) competency framework for non-medical prescribing.

Non-Medical Prescribing: A Course Companion includes chapters on the context of non-medical prescribing; pharmacology; professional, legal and ethical issues; psychological influences; working in multidisciplinary teams; working with patients with complex conditions and co-morbidities; understanding antibiotics and resistances; prescription writing; and the role of non-medical prescribing leads. Each chapter acts as a self-contained study module, with key facts and areas highlighted, illustrative clinical cases to link learning to practice, and a self-test quiz.

Designed for professionals from a range of non-medical disciplines including nursing, midwifery, pharmacy, physiotherapy and occupational therapy, this book can be used at both pre- and post-registration level.

1 Introduction and development of non-medical prescribing

Alison Pooler

Introduction

Prescribing of medication is commonplace in the modern healthcare system for the treatment and management of conditions. Primarily only within the realm of doctor and dentists, over the past 25 years it has been expanded to other specially trained healthcare professionals to improve patient access to services and improved outcomes for patients.

This chapter gives an overview of the development of non-medical prescribing and the different modes within this concept of prescribing.

Learning objectives

By the end of this chapter, you should be able to

• Have an understanding of the development of non-medical prescribing.
• Appreciate the legislative processes which have occurred to provide the access of non-medical prescribing to the range of healthcare professionals that have permission today.
• Appreciate the impact that this development in access for non-medical prescribing across a range of healthcare professionals has had on patients.
• Understand the different modes of non-medical prescribing.
• Have an understanding of the Royal Pharmaceutical Society (RPS) prescribing framework and its central role in non-medical prescribing.

What is non-medical prescribing?

This is a term used to describe any prescribing of medications undertaken by a health professional, who is not a doctor or dentist. It concerns any medications prescribed by that healthcare professional for conditions and diseases within the field of expertise or that professional.

Why was non-medical prescribing introduced?

There have been significant advances in the United Kingdom over the past 25 years with regard to the prescribing of medications by nurses and other healthcare professionals, who are not doctors nor dentists. The concept of non-medical prescribing was first proposed in 1986 by the Cumberledge Report (DHSS, 1986), which was a review of the care given to people in their own homes by health visitors and district nurses. From this report, it was suggested that access to treatment could be enhanced for people if these community nurses could prescribe. It was also highlighted that use of resources would also be more efficient in terms of healthcare professionals time.

This proposed prescribing activity, however, was from a defined list of items, such as wound dressings and ointments, which were commonly required items for everyday nursing care. From this review, it was also disclosed that often general practitioners (GPs) were signing prescriptions for such items, despite the assessment being done by the community nurses. This not only resulted in wasted hours for both GPs and community nurses but was also not recommended prescribing practice, where assessment of the patient was not carried out by the professional signing the prescription (DH, 1989).

The recommendations from the Cumberledge Report (DHSS, 1986) were then reviewed and developed in the Crown Report in 1989 (DH, 1989). In 1992 legislation was passed to allow community nurses (district nurses and health visitors) to prescribe from an “Extended Formulary for Nurse Prescribers”, within the context of a care plan (DHSS, 1992). Pilot areas carried out this new initiative before it was rolled out across the United Kingdom.

In 1999 the second Crown Report (DH, 1999) was released following an extensive review of prescribing, supply and administration of medicines. This review highlighted the need for development of prescribing rights of nurses, due to changes in clinical practice and the developing roles of healthcare professionals from all disciplines. It was felt that there was a need for patients to become more involved in their treatment and to improve access to healthcare for them (DH, 1999). The outcome of this second Crown Report (DH, 1999) was that it recommended that other healthcare professionals would be able to undertake application for legislation to allow them to prescribe in specific clinical areas, which would improve access and effectiveness of healthcare to patients, whilst still ensuring standards of care and safety. The report also recommended the expansion of independent prescribing rights to other nurses to allow more flexibility and autonomy. This meant that nurses were able to prescribe all medicines not only from the original Extended Formulary but also from Pharmacy (P) and general sales (GS) lists, plus certain prescription-only medicines (POM). This was allowed to take place within a supervised framework of practice, which was originally called dependent prescribing, which was later changed to supplementary prescribing, which is a voluntary partnership between an independent and a supplementary prescriber, to implement an agreed patient-specific clinical management plan (CMP) (with the patient’s agreement) and to enable prescribing for a specific medical condition or health need affecting the patient (MCA, 2002).

Over the following years up to 2002, supplementary prescribing rights were extended out to other healthcare professionals such as pharmacists (DH, 2001, 2005; MCA, 2002). This was followed in 2005 with the extension to physiotherapists and podiatrists (DH, 2005). In 2006, it was announced that any qualified Extended Formulary nurse prescribers would be able to prescribe any licensed medicine for any medical condition, plus some controlled drugs for specific conditions, as independent prescribers and the Extended Formulary would cease. In independent prescribing, the practitioner is responsible and accountable for the assessment of patients with undiagnosed or diagnosed conditions. If the practitioner is a doctor, then they are also responsible for decisions about the clinical management required, including prescribing (DH, 2005; MHRA, 2005).

The NMC (Nursing and Midwifery Council) also stated that these extended prescribing rights would always be within the individual nurses’ area of competence, to ensure parity with the NMC code of professional practice (NMC, 2018). Despite opposition from many within the medical profession, many nurses underwent the required training to undertake this clinical role. For many this formed part of an overall expansion and development of their clinical roles with nurses becoming more autonomous practitioners leading clinical services. Pharmacists quickly followed suit in this role development. Prescribing rights to other healthcare professionals started to cascade, and in 2005 the Department of Health permitted the introduction of supplementary prescribing for physiotherapists and podiatrists (DH, 2005). This was followed in 2007 by optometrists being able to become independent prescribers (DH, 2007) and then in 2013 by physiotherapists and podiatrists also being independent prescribers (DH, 2013). In 2016 NHS England announced new legislation which would allow therapeutic radiographers to become independent prescribers and dieticians to become supplementary prescribers (NHS England, 2016). So the expansion of prescribing rights to a range of healthcare professionals was expanding quickly. This followed ongoing development and expansion of health professional roles to increase autonomy and facilitate service development to meet the needs of a modern healthcare system in the United Kingdom. The most recent legislation (May, 2018) has now expanded these independent prescribing rights to paramedics who work at an autonomous level as a consultant paramedic, most of which work off the ambulances and in primary care and emergency centres.

Impact of non-medical prescribing

With any new development in the healthcare system, time is required for practices to be evaluated and thus allow the generation of evidence based to support practice Any initiative can also be evaluated from various perspectives to gain a holistic view; thus, in this instance it includes the non-medical prescribers (NMPs) themselves, stakeholders, other health professionals and patients.

Staff training to become prescribers felt, and still feel, that the programmes were challenging but provided them with the knowledge and skills to be able to prescribe safely, taking many perspectives into account during their patient encounters (Green et al., 2009; Latter et al., 2010; Meade et al., 2001). Once qualified NMPs have reported increased job satisfaction and self-confident, and being able to prescribe has enabled more effective use of their skills to improve patient outcomes as well as having a positive impact on the relationships they had with their patients and their families (Courtenay & Berry, 2007; George et al., 2007; Watterson et al., 2009). However, they have also reported the increased pressure and workload that prescribing duties brought (Watterson et al., 2009). NMPs and doctors across both primary and secondary care reported that they felt that patients accessing an NMP received higher quality care, with more choice and convenience, often due to increased accessibility and longer consulting times which were available (Courtenay & Berry, 2007; George et al., 2007; Latter et al., 2010; Stewart et al., 2009). Medical staff reported that working with NMPs also increased team working effectiveness, efficiency and positive relations within the team. Often it resulted in a reduction in their workload and freed up time to spend with more complex or acute cases (Stewart et al., 2009; Watterson et al., 2009). These effects were seen once time had been spent supporting the NMPs during their initial time following qualification, but it was felt to be time well spent with longer term gains for all (Hacking & Taylor, 2010; Watterson et al., 2009).

Patient feedback illustrated that they have more efficient access to healthcare with more flexibility to appointments. This was especially so in long-term conditions such as diabetes, asthma and dermatology. Patients reported improved continuity of care and appreciated consultations which were longer and perceived to be more caring (Courtenay et al., 2011; Stenner et.al., 2011). Patients also felt more in control of their conditions and understood their medications better since seeing the NMP (Latter et al., 2010). This positive feedback was all despite initial concerns from patients about seeing a nurse rather than a doctor (Latter et al., 2010; Stewart et al., 2008; Weeks et al., 2016).

Review of clinical practice has revealed that all nurse and pharmacist NMPs were making appropriate and safe decisions around their prescribing practice, despite initial concerns about the depth of pharmacological knowledge of nurses and physical assessment skills of pharmacis...