Non-medical who are distinct from medicine, nursing and pharmacy

Non-medical prescribers (NMPs) are healthcare
professionals who, despite not being doctors or dentists, are legally permitted
to prescribe medicines, dressings and appliances subsequent to attaining an
advanced level qualification in prescribing. The development of non-medical
prescribing within healthcare settings enables healthcare professionals to
enhance their roles and use their skills and competencies effectively, in order
to improve patient care in varied settings including the management of long
term conditions and medicines, emergency and palliative care, mental health
services and much more (Cope, et al., 2016). Non-medical prescribers can range from
roles such as nurses, pharmacists, optometrists, chiropodists or podiatrists,
radiographers and physiotherapists (Department of Health, 2017).

 

From an international perspective, only pharmacists
and nurses have been given prescribing rights outside of the United Kingdom and
not health care professionals who are distinct from medicine, nursing and
pharmacy (also known as Allied Health Professionals). In the United States of
America, independent pharmacists currently have the ability to prescribe from a
limited list of medications, however, this is only apparent in the state of Florida
(Cope, et al., 2016). Pharmacists can only prescribe
alongside doctors within Collaborative Drug Therapy Management Clinics (Drugs and Therapeutics Bulletin, 2006) in at least 16 states.
Other US states use dependent prescribing (supplementary prescribing) with the
use of a clinical management plan or independent prescribing using locally
agreed protocols, such as the Veterans’ Affairs Centres run by the Veterans
Health Administration (VHA) (Clause, et al., 2001).

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In terms of nurse prescribing in the USA, in order
to acquire ‘prescriptive authority’, nurses must additionally qualify as
Advanced Practice Registered Nurses at postgraduate level, and then specialise
as Nurse Practitioners, only to then further apply for additional prescriptive
authority credentials following board certification (Greenberg, et al., 2003). As the nursing
profession in the USA regulated by state, the extent of prescriptive authority
that nurses are given varies from state to state, depending on individual state
regulation.  However, 21 states and the
District of Columbia allow nurses to prescribe independently due to having
approved full practice status for nurse practitioners. This is a controversial
topic, as many states disagree with this and some still hold ‘restricted
practice regulations for nurse practitioners’ (Cope, et al., 2016). In a similar way to pharmacists, nurse
practitioners employed by the VHA who have prescriptive authority, may be
granted independent prescriber status whilst being a VHA employee (Konnor, 2007).

Other than in the UK, pharmacist prescribing
is currently not permitted anywhere else in Europe. However, countries such as Finland,
Ireland, Sweden, the Netherlands and Spain have introduced nurse prescribing
and the consequent legal restrictions on the types of nurses that may
prescribe, what they are legally permitted to prescribe and for whom, and
whether they are able to do so independently (Kroezen, et al., 2011). Pharmacists in
Canada with prescribing rights can prescribe independently or collaboratively
with a physician (American Pharmacists Association, 2014). Similarly, New
Zealand legislation has recently been introduced which allows qualified
pharmacists to prescribe (Parliamentary Counsel Office, 2013).

In Australia, the Health Workforce has
developed a national pathway for prescribing by other healthcare professionals
apart from doctors, dentists and nurses (Hale, et al., 2016). Nurse practitioners can currently
prescribe medications if they are endorsed by the Nursing and Midwifery Board
of Australia (NMBA), and medications are limited by the nurse practitioner’s
scope of practice, Medical Protection Society (MPS)/Pharmaceutical Benefits
Scheme (PBS) requirements and by hospital formularies or hospital prescribing measures
(South Australia Health, 2017). The Australian
Health Workforce Council has published a guidance document regarding developing
a case in order for Health Ministers to ‘consider
endorsing the prescribing of scheduled medicines for health professions that
currently do not have this endorsement, such as physiotherapy’, which will
allow the profession to consider whether it wants to pursue prescribing rights (Physiotherapy Board of Australia, 2017).

Non-medical prescribing has been in existence
in the UK since 1989 (Drugs and Therapeutics Bulletin, 2006), and played a
significant part in the Department of Health’s agenda since. The Cumberlege
Report (Department of Health and Social Security, 1986), indicated that
patient access to treatment could be enhanced, and patient care improved and
resources used more effectively if community nurses were able to prescribe as
part of their practices from a limited list of items. The recommendations from
the Cumberlege Report, (Department of Health and Social Security, 1986), were reviewed
by an advisory group chaired by Dr June Crown and the Crown Report (Department of Health , 1989) proposed several
benefits would occur with nurse prescribers – improved patient care, improved
use of nurses’ and patients’ time and communication between multidisciplinary
team members from clarification of professional responsibilities. It required a
further 3 years until primary legislation permitting nurses to prescribe was
passed in 1992 (Department of Health and Social Security, 1992).  

Further to the success and acceptability of community
nurse prescribing, the prescribing of medicines was reviewed (Department of Health, 1999) and it was recommended that prescribing authority should
be extended to other groups of professionals with training and expertise in
specialist areas. Thus, district nurses and health visitors
became legally able to prescribe independently from the renamed Nurse
Prescriber’s Formulary, and the range of medications nurses were able to
prescribe was increased. However, this was permitted only within a supervised
framework, which was termed ‘dependent prescribing’ (Department of Health, 1999) which was later
renamed as ‘supplementary prescribing’. The
original policy objectives for the development of non-medical prescribing were
set out in 2000, and were related to the principles in the National Health Plan
(Department of Health, 2000). These were improvements in patient care, choice and access,
patient safety, better use of health professionals’ skills and flexible team
working. In 2001, support was provided by the Government for the extension of
prescribing to nurses other than district nurses and from a wider selection of
medicines (Department of Health, 2001).

In November
2005, it was announced that qualified extended formulary nurse prescribers
would become able to prescribe any licensed medicine for any medical condition
(and some controlled drugs for specified conditions) as independent prescribers
in the following year, ending the existence of the Extended Formulary (Department of Health, 2005). Evaluation of
non-medical prescribing (Department of Health Policy Research Programme 2010)
indicated that nurse and pharmacist independent prescribing was becoming a
well-integrated and established means of managing patients’ conditions.

 

Specified
Allied Health Professionals such as podiatrists and physiotherapists were
granted rights to become Supplementary Prescribers (SPs) in 2005 (Statutory Instrument , 2005). Physiotherapists are ……….. definition
of physiotherapist

As supplementary
prescribers, physiotherapists would be able to prescribe a limited range of
medicines in partnership with a doctor, using an agreed patient specific
clinical management plan, as well as administer some medicines. Medications had
to be defined in writing within a Clinical Management Plan (CMP) and
appropriate to the needs of the patient (Chartered Society of Physiotherapy, 2016). Two years
later, in 2007, optometrists became able to act as independent prescribers (Department of Health, 2007). Proposals to
introduce independent prescribing by physiotherapists were put forward to the Department
of Health in 2012 to increase their quality of care, patient safety, experience
and effectiveness. Independent prescribing physiotherapists were predicted to
enhance patient care by improving access to medicines (Department of Health, 2012). They would reduce
the patient care pathway as a follow up appointment with a GP to obtain a
prescription would not be required. This was built on the white paper (Department of Health, 2010), which aimed to
ensure patients had increased access to timely treatment by liberating
frontline healthcare staff to maximise the benefit they can offer to patient.
In 2013 for England and 2014 for the rest of the UK, physiotherapist and
podiatrist prescribing was widened to include the independent prescribing
status (Department of Health, 2013). Early last year, NHS England announced new legislation
permitting independent prescribing by therapeutic radiographers and
supplementary prescribing by dieticians (National Health Service England, 2016).

 

Non-medical
prescribing has taken many years of planning, review, and discussion, and it
has been a long-fought and hard-won battle to reach today’s current status where
not only nurses and pharmacists have the ability to prescribe in the UK, but
allied health professionals do also. In regard to physiotherapists, non-medical
prescribing is viewed as an essential component of expanding their scope of practice
(Morris and Grimmer 2014), however current statistics indicate that out of
54,980 registered physiotherapists with the profession’s regulatory body, the
Health and Care Professions Council (HCPC), only 1.4% (n=784) are supplementary
prescribers and 1.25 (n-659) are independent prescribers.  What are the reasons for these modest and
somewhat disappointing numbers, given that the UK is at the global forefront of
providing allied health professionals such as physiotherapists with prescribing
rights. Physiotherapy prescribing has been recognised as producing a more consistent,
transferable and recognised workforce (Atkins 2003) yet Robertson et al 2016
indicated that a lack of published evidence on the effectiveness of
physiotherapists prescribing exists and more studies have been undertaken on
other extended scope of practice roles such as orthopaedic triage (Kersten et
al, 2007). This study proposes to provide insight into the conundrum of the
lack of published literature regarding any changes that physiotherapist
prescribing rights has brought to the profession through the exploration of the
attitudes and feelings physiotherapists have towards prescribing. Understanding
the reasons, whether they be barriers or reluctance (if any) that
physiotherapists have towards becoming prescribers, as well as their general
attitudes towards pharmacotherapy will allow for the development of future
interventions which may allow more physiotherapists to utilise their right to
prescribe and become prescribers, whether supplementary or independent.