Following several years of project work by the College of Paramedics, in 2018 the law was changed to allow paramedics to train and practice as non-medical prescribers for the first time (gov.uk, 2018). This represents a large step forward for the profession, and will likely only serve to help paramedics cross traditional boundaries, making an already attractive and sought-after professional group even more valuable. With paramedics already working in a diverse range of settings, far beyond the traditional ambulance work they are best known for, the addition of non-medical prescribing (NMP) as a skill can only help to increase the career options for paramedics, in a time where healthcare services are an under unprecedented demand to help patients access medication in a more timely manner.
Author’s Role
In order to provide some additional contextualisation, I will describe my own clinical practice and how prescribing fits this. I studied full time for an FdSc in Paramedic Science, followed by part time completion of a BSc (hons) in Emergency Care and then an MSc in Advanced Practice. This led me from ambulance practice to my current job where I work primarily in primary care, providing with a nurse practitioner colleague, around half of the same day appointments available at the practice, along with home visits and telephone triage as required. This role is one I developed into having spent time training in primary care as part of the progression into a specialist paramedic role within the ambulance service. When I moved into primary care full time, I found I was very much limited by not being able to prescribe medication, I was encouraged and empowered by the doctors to decide what was needed, using local formularies to guide me, but would always need to get someone else to produce the prescription, which was time consuming and frustrating at times. Upon completion of the course and annotation as a prescriber I could then take responsibility for most of my prescribing, making my consultations slicker and faster (Dixon, 2019), being able to provide, in most cases, a complete episode of care without senior input (although this always remains available should I need it). While being unable to prescribe controlled drugs (CDs) myself does present a limitation I have found that at least in my practice I can largely avoid prescribing CDs, and where they are needed it is infrequent enough that getting a prescription from an appropriate prescriber isn’t a significant issue. The ability for a paramedic in my position to prescribe allows me to work largely autonomously, this takes pressure away from the doctors and allows them to focus on the work that better utilises a GPs expertise, while my colleague and I deal with the generally less complex acute issues. This is very much in keeping with national objectives to support multi-professionalism within primary care (Primary Care Workforce Commission, 2015).
Current Scope of Practice
With the change in legislation in 2018, paramedics were for the first time able to undertake a multidisciplinary non-medical prescribing course. This came as a result of a project run by the college of paramedics (2018), establishing the implementation and educational standards, which included a stipulation that the course must be taken at Level 7 (M Level), mirroring the requirement for all allied health professionals who aren’t from a nursing background. The criteria for access to a course are specified such that only those who are suitably educated, with employment in a role that requires prescribing as a core component, and access to a designated medical supervisor would be eligible. These criteria were set by the College of Paramedics based upon their recommendation that NMP be restricted to paramedics working at an advanced practice level. This was defined as working at a high level of autonomy and undertaking complex decision making, with an underpinning masters level education. Providing a paramedic met the entry criteria to the course from 2018 onwards they were able to study on an approved course, resulting in the update of the HCPC register as a NMP. It is worth noting that the requirement to be in an advanced role prior to enrolment on a course presents something of catch-22 situation, prescribing is often although not always, considered a core element of advanced practice (NHS Education for Scotland, 2018). This results in a situation where the paramedic may need to be a prescriber to get an advanced practitioner level role but can’t get one due to the lack of a prescribing qualification. This issue may be remedied by development and student advanced practitioner posts or by incorporating non medical prescribing into a wider Advanced practitioner degree course. Time will tell whether this is a significant issue or not.
Once updated, the paramedic is then free to work to their own scope of practice within the area they work. This may or may not include limitations to local or organisational formularies. In the author’s case, the relevant local formulary for primary care prescribing provides a useful framework to work within, although deviation outside this is acceptable if justified in doing so.
Once qualified as a NMP, the paramedic is able to work as both an independent and a supplementary prescriber. An independent prescriber is a practitioner who is responsible and accountable for the assessment of patients, and for making decisions about the required nature of clinical management, including taking sole responsibility for the prescribing of any medication that may be appropriate (Royal Pharmaceutical Society, 2020). A supplementary prescriber is a practitioner who works in partnership with a medical or dental practitioner in order to implement a clinical management plan for a specific patient, being able to prescribe any medication for the patient in question, provided it is on a list pre-approved by the responsible medical or dental practitioner (NICE, 2019a).
‘Perhaps the most significant single restriction in current paramedic prescribing practice is the lack of the ability to independently prescribe any controlled drug.’
For non-CD medication, the only restriction on practice is that a paramedic prescriber cannot prescribe unlicensed medication (College of Paramedics, 2018b). An important distinction is drawn here between unlicensed medication, which doesn’t have a UK marketing authority and cannot be prescribed by a paramedic NMP, and off-license medication and is the prescribing of a medication outside the terms of its license, which is permitted with appropriate caution. An example of this is found in the case of ranitidine, which is licensed for the treatment of reflux oesophagitis (NICE, 2019b) but, while the drug is commonly used, its license doesn’t extend to children under the age of 3 years. Hence, prescribing this for a child aged under three would constitute the legal prescription of a licensed medication for an unlicensed indication. The General Medical Council (2019) describes what is required of a prescriber when prescribing a medication outside the terms of its license, stating: It is important to ensure that there is no reasonable alternative available that is licensed; when prescribing an off license medication the patient or their parent / carer are given enough information about the proposed treatment and why it is being used outside its license to be able to make an informed decision on the treatment.
Perhaps the most significant single restriction in current paramedic prescribing practice is the lack of the ability to independently prescribe any CD, as of December 2019. While the Human Medicines Regulations detail the paramedics new authority to prescribe non-CDs, the legalities of prescribing CDs fall under the Misuse of Drugs Act, which hasn’t yet changed. There is some scope depending on setting to work around this issue: with PGDs for the supply or administration of certain CDs, there is a reliance upon the paramedic medicines exemptions (gov.uk, 2012) to administer morphine and diazepam. Those working as supplementary prescribers, using only a set list of medication on an individual patients clinical management plan, may prescribe any CD if approved by a doctor for inclusion in the clinical management plan. While initially it was only theorised, it does now appear that that this legislation will change as a result of a recommendation from the Advisory Council on the Misuse of Drugs (2019).
However, there is no time scale for any change, so for the foreseeable future, paramedic prescribers are unable to independently prescribe any CD.
Restrictions to practice
As mentioned previously, a potentially significant limitation to practice is the inability to prescribe CDs. While this doesn’t affect the practice in primary care to any great extent, it would likely be a large limitation to paramedics practicing in a critical care environment. In ambulance service critical care, it is common to use drugs such as ketamine, midazolam, and fentanyl, amongst others, for the provision of analgesia, sedation and anaesthesia (von Vopelius-Feldt and Benger, 2014). These can be used under PGDs. However, being restricted to PGDs is a limitation when a patient is encountered who needs treatment with these medications but doses or indications fall outside of those specified by the PGD. This may leave a paramedic, who is entirely capable and qualified to make those decisions, unable to do so due to the current legal situation.
The extent of the potential legal limitation may also become more obvious to those working with palliative care or acutely unwell patients, as the increased need to utilise CDs beyond what is possible with a PGD or clinical management plan is likely to present situations where a prescribing decision is required, but legally cannot be made by the paramedic.
As well as an inability to prescribe CDs at this time, another restriction to practice exists in terms of electronic prescribing. Paramedics can produce handwritten prescriptions but due to what is anecdotally becoming a widespread issue with primary care clinical software paramedics are finding it hard or even impossible to prescribe electronically. This is because of the relatively recent idea of paramedics in primary care, as well as prescribing independently, as such no software at the time of writing is set up to allow paramedics to be appropriately authorised as non-medical prescribers.
Future Challenges
The ability for paramedics to become prescribers represents a significant step forward for the profession and patient care. However, there are several immediate challenges to overcome in order to better realise the benefits that can be seen from this skill.
The first one is amendment of the law on CDs. This should just be a matter of time as the recommendation has been made for amendment of the law. Although, it is worth noting that the recommendation is currently only for the ability to prescribe the following five controlled substances: morphine, diazepam, midazolam, lorazepam and codeine (Advisory Council on the Misuse of Drugs, 2019). While these drugs represent a solid starting point for palliative, primary, urgent and emergency care prescribing, they will likely fall short of the further requirements of paramedics working in critical care, who will remain unable to prescribe other CDs such as ketamine and a wider range of opiates for the foreseeable future.
The second would be a quicker response to the current issues with electronic prescribing experienced by myself and many of my primary care paramedic colleagues. While the evidence is merely anecdotal, the author and many colleagues have had to overcome working with clinical management software that doesn’t recognise that a paramedic can be a prescriber. This has left many unable to prescribe electronically as medical and nursing colleagues can. For the author, it means manually adding the legally required prescriber details to every prescription, while for others it means they must handwrite all their prescriptions and are completely unable to send prescriptions electronically. Various fixes for this problem are reported to be on the horizon but with several different software platforms from different manufacturers, there as yet seems to be no uniform solution. This issue extends itsef to the ambulance service setting – with the current limitations of the IT systems used for documentation and communication, there is no ability for any form of remote electronic prescribing at this time. There is access to a patient’s summary care record, but in my experience the extent of access doesn’t go far enough to provide important information, such as renal and liver functions, only offering an overview of medications and allergies/sensitivities. With limited access to important background information, no ability to directly link into primary care records and the often-austere nature of diagnostic equipment and ability, prescribing would need to be conducted in a very cautious manner if working in an ambulance environment. In many cases, it is likely to need liaison with out of hours or primary care to safely facilitate it.
The third potential problem to overcome, which will apply to paramedics in particular, but also to colleagues in primary care and out of hours working remotely, is how to deal with prescribing in remote environments. NHS digital (2019) is set to shortly move to a model where the vast majority of prescriptions are dealt with entirely digitally, without the need for a paper prescription or even a physical signature. Hand written prescriptions are said to remain an option where fully electronic prescribing isn’t available. The impact of this is unclear, as handwritten prescriptions will always need to be a backup option in cases of IT failure. This requirement, in general, may be a catalyst for improved IT systems, increasing the ability to prescribe electronically from the patient’s home.
Conclusion
The ability of paramedics to become non-medical prescribers represents a large step forward for the profession. The full impact on patient care will need assessment and research to quantify, but it seems likely that paramedic prescribers will be a valuable addition to the wider healthcare system; supporting increased access to medication; doctors to remain available for work that most benefits from a doctors expertise, and giving increased career and professional development opportunities to paramedics.
Key Points
- Paramedic prescribing is a large step forward for the profession
- Current issues with lack of legal right to prescribe controlled drugs represent a barrier to practice
- Current issues with electronic prescribing in primary care is a hurdle to overcome
- There is little research around the impact of paramedic prescribing and this will be essential to quantify the impact and utility of the paramedic prescriber.
CPD reflective questions
- Do you see yourself as becoming a paramedic prescriber? If so, how would you meet the entrance criteria for an NMP course?
- Do you believe that lack of access to CDs is a significant issue and how does / might this affect your own practice?
- Where do you see the profession going and how does non-medical prescribing fit into this?