Editorial: Non‐medical prescribing: where are we?

People with a chronic illness are often prescribed multiple medicines, so the quality use of medicines is important. Non-medical prescribing in the UK is one way that people with chronic illness have been able to access the right health professional who is able to prescribe medicines and give them the information and skills they need to make medicine decisions that are right for them. It was over 15 years ago since changes in legislation enabled appropriately qualified health visitors (HVs) and district nurses (DNs) in England to prescribe medicines (primarily wound dressings and over-the-counter products) from a restricted formulary. Prescribing rights were later extended in 2001 (DoH 2001) to include any appropriately qualified registered nurse and, in 2002, the first ‘independent extended’ nurse prescribers became qualified. These nurses were able to prescribe from a list of nearly 200 Prescription-Only-Medicines (POMs) for their associated conditions. Further extensions to prescribing rights to other groups of ‘non-medical’ healthcare professionals enabled pharmacists to prescribe in 2003 and allied health professionals (AHPs) (podiatrists/chiropodists, radiographers and physiotherapists) and optometrists to adopt this role in 2005 (DoH 2002). Following numerous changes to medicines legislation between 2002–2005, nurses and pharmacists were given the rights (DoH 2005) to prescribe any licensed medicine and some controlled drugs (CDs). These rights were the most extended worldwide for ‘non-medical’ healthcare professionals. In 2009, further changes [Medicines and Healthcare products Regulatory Agency (MHRA) 2009] provided nurses and pharmacists with the ability to prescribe unlicensed medicines and changes are currently awaited with regards to lifting the restrictions around CD prescribing [Home Office (HO) 2007]. Furthermore, recommendations have been made to extend prescribing to other groups of healthcare professionals (DoH 2009). Doctors were initially of the opinion that changes to legislation enabling nurses to prescribe medicines had occurred without adequate safeguards being put in place. They were concerned that nurses did not have the appropriate clinical skills, training in pharmacology, and would prescribe outside of their area of competence (Courtenay & Carey 2009). However, it has been four years since nurses were provided with virtually the same prescribing powers as doctors; evaluations have been positive and have reported these new prescribers to be safe. There have been no reports of poor prescribing and, only one case of inappropriate prescribing has been reported to the Nursing and Midwifery Council (NMC). The Chair of the British Medical Association (BMA) recently added his support for this role, saying, that nurse prescriber was both effective and invaluable (Lomas 2009). The prescribing programme, run at approximately 40 Higher Education Institutions (HEIs), is a national programme. Although there have been reports of variations across HEIs with regards to content and rigour of courses (Courtenay et al. 2009), programmes have been positively evaluated (Drennan et al. 2009). Pharmacists, nurses and AHPs are trained together at many of these institutions. Upon successful completion of the courses, nurses and pharmacists are awarded the dual qualification of both independent and supplementary prescriber. Allied health professionals are awarded the supplementary prescribing qualification. Like doctors, independent prescribers are able to assess, diagnose and prescribe medicines. By contrast, supplementary prescribing (which is more appropriate for use when treating patients with chronic conditions) involves working in partnership with doctors, the supplementary prescriber being able to prescribe any medicine listed on the patient’s clinical management plan (CMP). Both independent and supplementary prescribers must prescribe within their area of competence. The prescribing course is six months in duration and comprises 27 taught days (although some courses have a distance learning component) and 12 days in practice with a designated medical practitioner (DMP). The aim of the course is to provide students with the general principles that underpin prescribing. Topics include basic pharmacology, consultation skills, legal and ethical aspects of prescribing, prescribing in a team context, evidenced-based prescribing, calculation skills, medicines concordance, and prescribing from a public health perspective. Assessment is rigorous and comprises of the submission of a portfolio or a learning log (showing evidence of learning as applied to practice), examination, objective structured clinical examination (OSCE) and a calculations assessment. Candidates for the prescribing programme must be able to demonstrate a number of prerequisites including a minimum of 3 years experience as a qualified nurse (the year immediately preceding application to the programme must have been in the clinical field in which the applicant will prescribe). Students must be able to study at degree level (this is unlike some countries e.g. the States and Canada where candidates must have a masters degree), and have their manager’s support to undertake the course. Applicants must have the support of a doctor to mentor them through the 12 days learning in practice and, they must work in a role in which they will be required to prescribe. Candidates must also be competent in assessment and diagnosis, and many HEIs insist that nurses undertake a physical assessment and diagnostic module before they undertake the prescribing course. There are currently over 50 000 nurses across the UK who have a prescribing qualification. Approximately 32 000 of these nurses are community practitioner prescribers who are able to prescribe from the restricted Nurse Prescribers Formulary (NPF) for Community practitioners. More than 18 000 nurses are able to prescribe as both independent and supplementary prescribers and there are about 3000 pharmacist and several hundred AHP with a prescribing qualification. Most (over 80%) of nurses with the independent and supplementary prescribing qualification use independent prescribing and smaller numbers use supplementary prescribing (Courtenay & Carey 2008). There have been reports, that supplementary prescribing is sometimes used, for example in mental health (Jones et al. 2007), to increase nurses confidence to prescribe. Only about 50% of community practitioner prescribers prescribe. Reasons for this have been linked to confidence, and practical issues including accessing patient records (Hall et al. 2006). Most (over 60%) of independent/supplementary nurse prescribers are based in primary care and more than 40% work in General Practice. Chronic conditions including respiratory conditions, diabetes and cardiovascular conditions are areas in which large numbers of these nurses prescribe and pain is an area in which many use their prescribing skills in secondary care (Courtenay & Gordon 2009). The number of items prescribed by independent/supplementary nurse prescribers working in primary care is increasing year upon year. In the year ending March 2009, this totalled £33.0m (http://www.ic.nhs.uk). The benefits of nurse prescribing, as predicted by the Government, have been demonstrated. These benefits include improved and timely access to medicines, better use of health professionals’ skills, flexible working and improved team working (Bradley & Nolan 2007, Carey et al. 2009). In addition, patients say they are confident in the ability of nurses to prescribe (Berry et al. 2006). They like the continuity of care (Brooks et al. 2001, Harrison 2003), comprehensive information (Jones et al. 2007, Page et al. 2008) and holistic care (Harrison 2003, Jones et al. 2007, Page et al. 2008) that nurses are able to provide. Initial barriers to nurse prescribing included the inability to computer generate prescriptions and restrictions at a local level (i.e. waiting for prescription pads and organising prescribing budgets) (Courtenay & Carey 2008). Although these barriers have now been largely overcome, some barriers still remain particularly amongst community nurse prescribers (Hall et al. 2006) In addition, nurses working across broad practice areas, such as community matrons, have reported difficulties defining their area of prescribing competence and there have also been some reports of difficulties accessing continuing professional development at the appropriate level (Courtenay et al. 2009–2011). It is evident that for non-medical prescribing to be effectively implemented into service delivery, certain systems and processes need to be in place. This includes systems for ensuring that students and DMPs are aware of the expectations of the prescribing programme, that a prescribing role has been defined for students upon course completion, that criteria for the selection of individuals onto the prescribing course have been identified, and that support systems from appropriate clinicians and managers are in place. These support systems are particularly important directly following qualification as a prescriber. If they are not, nurses’ confidence to prescribe becomes reduced. Where these systems and processes are in place, and non-medical prescribing (NMP) is included in workforce planning, it has been reported to be rolling out smoothly into new areas of practice. Where they are not, this has been reported to act as a barrier to nurse prescribing. Many thousands of healthcare professionals in the UK now have prescribing rights. It is evident that these healthcare professionals are safe and, the predicted aims of this new role have been achieved. A future challenge for the UK is to ensure that primary care and hospital trusts have strategies in place for NMP and that it is fully integrated into service delivery. It is only when this occurs that the full benefits of NMP will be realised.

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