The UK has more than 50,000 non-medical prescribers, but are they improving care?
In this article…
- An overview of non-medical prescribing in the UK
- How non-medical prescribing can improve the quality of patient care and maximise resources
- The impact of nurse prescribing on patient safety and patient-centred care
- Patients’ and health professionals’ views of nurse prescribing
Nicola Carey is senior research fellow; Karen Stenner is research fellow; both at the Division of Health and Social Care, University of Surrey.
Carey N, Stenner K (2011) Does non-medical prescribing make a difference to patients? Nursing Times;107: early online publication.
This article examines the literature on non-medical prescribing to establish its impact on UK healthcare. It discusses how better access to medication through non-medical prescribing can improve patient safety and patient-centred care, and how nurse prescribing can help ensure quality of care in the NHS during the current financial crisis.
Key points: Non-medical prescribing, Nurse prescriber, Medication
- This article has been double-blind peer reviewed
5 key points
- Prescribing allows non-medical prescribers (NMPs) to work more independently, increasing the convenience and speed with which patients receive their medicines
- NMPs take responsibility for their prescribing decisions. This means doctors do not sign prescriptions for patients they have not assessed, which improves patient safety
- There have been no reports of poor prescribing by nurses. Evidence suggests the standard of care provided by nurse prescribers (NPs) is as high as traditional models of care
- Health professionals consider NPs more approachable than doctors, better at communicating, and more likely to involve patients in discussions about their healthcare
- Patients report high levels of satisfaction with, and confidence in, NPs due to their level of specialist knowledge, experience with specific treatments, and recognition of their own limitations
Many countries have introduced non-medical prescribing to improve efficiency and access to medication, particularly where access to doctors can be difficult (Ball, 2009; Miles et al, 2006). UK policy on the prescription of medicines by nurses, pharmacists and allied health professionals (AHPs) has evolved in recent years, and the UK now has the most extended non-medical prescribing rights in the world (Department of Health, 2006; 2003; 2002; Avery and Pringle, 2005) – non-medical prescribers (NMPs) prescribe more than 12 million items a year (NHS Prescription Service, 2010).
There are more than 50,000 NMPs in the UK; of these, over 30,000 are community practitioners who prescribe from a restricted formulary consisting mainly of over-the-counter products, medicines and wound dressings. Around 19,000 nurses and almost 2,000 pharmacists are qualified as independent and/or supplementary prescribers, as are several hundred AHPs, including podiatrists, radiographers and physiotherapists (Culley, 2010). As independent prescribers, nurses and pharmacists can prescribe any licensed medicine, and some controlled drugs, provided they are within their areas of competence. Supplementary prescribers can prescribe any medicine stated in a patient-specific clinical management plan once the patient has been diagnosed by a doctor (DH, 2006).
The DH is also considering extending prescribing rights to paramedics (DH, 2010); it is therefore timely and appropriate to reflect on the evidence to date, and consider whether non-medical prescribing does make a difference to patients.
This article examines the literature on non-medical prescribing and its impact on UK healthcare. While important, it is beyond the scope of the article to review barriers and facilitators to non-medical prescribing. Where available, evidence relating to pharmacist and AHP prescribing is referenced, but most current evidence pertains to nurse prescribing.
Access and efficiency
The DH expected that non-medical prescribing would improve access to medicines and patient care without compromising safety, and increase patient choice in accessing medication (DH, 2006; 2002). Improved speed and convenience of access to medicines have been consistently reported as key benefits of non-medical prescribing by patients and health professionals (Ball, 2009; Drennan et al, 2009). The evidence suggests greater autonomy over prescribing enables NMPs to overcome inadequacies in the traditional healthcare system, such as the need to discuss each patient with a doctor before starting medication. As that approach depends on the availability of a doctor and they are not always available in the clinical setting, it can be problematic (Royal College of Physicians, 2005).
According to key stakeholders, prescribing enables NMPs to work more independently, increasing the convenience and speed with which patients receive their medicines (Jones et al, 2010; Oldknow et al, 2010). Involving fewer people in patients’ care also reduces waiting times and increases the efficiency of appointments (Courtenay et al, 2011; 2010; Page et al, 2008). Prescribing also allows NMPs to make more effective use of their know-ledge and skills, improves continuity of care and enables them to complete consultations with fewer interruptions (Courtenay et al, 2009a; Watterson et al, 2009; Stenner and Courtenay, 2008).
Increasing the number of health professionals who prescribe has improved the way patients can access services. It has increased the number and flexibility of appointments and the availability of telephone advice, and supported the provision of nurse and pharmacist-led services (Carey et al, 2010a; Bissell et al, 2008). As a result, doctors can also make better use of their time and concentrate on patients with more complex disease pathologies (Carey et al, 2010b; Daughtry and Hayter, 2010). While there is anecdotal evidence of these efficiency changes, there is little published outcome data other than individual case reports (Dawoud et al, 2010; McCulloch, 2010).
Evidence also suggests multiple factors can affect the impact of non-medical prescribing, such as the extent of autonomy to prescribe, role expectations, the appropriateness of supplementary prescribing, and the configuration of pre-existing services (Dawoud et al, 2010; Jones et al, 2010; Courtenay et al, 2009a).
As NMPs take responsibility for their prescribing decisions, and doctors do not have to sign prescriptions for patients they have not assessed, patient safety has reportedly improved (Carey et al, 2009a; Courtenay et al, 2009a). Patients are also said to be highly satisfied with, and confident in, NPs’ abilities, inspired by their level of specialist knowledge, experience with specific treatments and the belief that nurses know their own limitations (Courtenay et al, 2011; 2010).
The continuity of care that NPs provide – especially in areas with a high turnover of junior doctors – has had a positive effect on the quality of care; clinically inappropriate prescribing is avoided or corrected by specialist nurses who have adopted the prescribing role in their area of practice (Carey et al, 2009a; Courtenay et al, 2009a).
While questions have been raised over whether NPs have adequate knowledge to prescribe safely (Offredy et al, 2008), there have been no reports of poor prescribing, and only one case of inappropriate prescribing reported to the Nursing and Midwifery Council (Courtenay, 2010). Importantly, evidence suggests the care provided by NPs is of an equally high standard as traditional models of care (Jones et al, 2010; Carey et al, 2009b; Courtenay and Carey, 2008). Medication errors were significantly reduced when hospitalised patients with diabetes received medicines management interventions from a diabetes specialist nurse prescriber (Carey et al, 2008; Courtenay et al, 2007). An assessment of prescriptions issued by NPs also found them generally compliant with good practice in prescription writing (Carey et al, 2009b; Courtenay and Carey, 2008).
Health professionals consider nurses to be more approachable than doctors, better at communicating and more likely to involve patients in discussions about their healthcare (Courtenay et al, 2009a; 2009b; Watterson et al, 2009). Patients also think NPs offer more patient-centred consultations. This is due to nurses’ approachability, ability to build rapport, listening and communication skills, unhurried style and tendency to invite patient involvement (Stenner et al, 2011; Jones et al, 2007). These skills make it easier for patients to share information, ask questions, and address problems, meaning they understand their condition and treatment better. It also makes it easier for patients to self-manage long-term conditions and adhere to treatment regimens (Courtenay et al, 2011; Stenner et al, 2011).
These findings are supported by several case studies examining NPs’ consultations in detail (Courtenay et al, 2009a; 2009b; Latter et al, 2007). Independent observation and assessment of NPs’ clinical practice confirmed that they showed high levels of communication and assessment skills.
Observations of clinical practice and data from patient questionnaires also showed NPs encouraged informed choice, consistently asked about symptoms, listened to patients and explained problems or treatment. They also gave information about medicines, put patients at ease and showed caring or concern. Patients who saw NPs reported significantly higher satisfaction with medication-related information compared with those seen by a doctor (Jones et al, 2010). Similar findings have also been reported in relation to pharmacist supplementary prescribers (Hobson et al, 2010; Bissell et al, 2008; Stewart et al, 2008).
In addition to good communication skills, NMPs have considerable knowledge and expertise in their practice area. Research suggests that when nurses adopt the prescribing role, these attributes combine with the knowledge gained through the prescribing course to benefit patient care (Stenner and Courtenay, 2008; Bradley and Nolan, 2007). Patients regard some NPs as having greater specialist and practical expertise than a typical GP, for example in conditions such as dermatology (Courtenay et al, 2011).
Both health professionals and patients say nurses provide relevant information in a way that is understandable, and that they consider wider aspects of the patient’s lifestyle when providing advice (Stenner et al, 2011; Jones et al, 2007). Patients with diabetes and dermatological conditions say this, coupled with nurses’ practical experiences of different treatment options, helps to ensure treatment and advice is tailored to their individual needs (Courtenay et al, 2011; Stenner et al, 2011).
Despite these positive findings, there is uncertainty over the extent to which nurses regularly discuss the potential side-effects and risks of treatment. Latter et al (2007) argued that full concordance is not possible unless patients are given this information. However, there is increasing evidence to suggest most patients are happy with the information NPs provide about their medicines, and the potential side effects (Courtenay et al, 2009a; 2009b). This suggests patients’ views of concordance may differ from those of professionals.
The benefits of non-medical prescribing have been consistently reported in the literature. The evidence suggests it is acceptable to patients and health professionals, with those who have experienced non-medical prescribing reporting high levels of satisfaction (Courtenay et al, 2011; Jones et al, 2010; Watterson et al, 2009)However, this evidence is largely based on self-reported data obtained via questionnaires, interviews and focus group studies. Although detailed explorations of their clinical practice and prescriptions have demonstrated that NPs can provide high-quality care, there has been little research that directly compares non-medical prescribing with doctor or medical prescriber consultations (Jones et al, 2010; Norman et al, 2010; Courtenay et al, 2009a). There is also little evidence reporting the clinical and economic outcomes of non-medical prescribing. Only one study has adopted an experimental design and generated objective data that confirms NPs can improve quality of care and patient safety (Carey et al, 2008).
At a time of financial constraint in the NHS, non-medical prescribing has important implications for maximising resources and improving patient care. Ensuring the quality and effectiveness of care is a growing priority and further research providing clinical and economic outcome data, as well as quality measures, is required. Only then will the impact of non-medical prescribing on healthcare provision be fully known.
Box 1. non-medical prescribing in the UK
- There are more than 50,000 non-medical prescribers, including 30,000 community practitioners who prescribe from a restricted formulary
- Around 19,000 nurses, 2,000 pharmacists and several hundred allied health professionals are qualified as independent and/or supplementary prescribers
- Independent prescribers can prescribe any licensed medicine and some controlled drugs within their areas of competence
- Supplementary prescribers can prescribe any medicine stated in a patient-specific clinical management plan agreed with a doctor
- The UK has the most extended non-medical prescribing rights in the world
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