The United States (US) first suggested proposals to allow nurse practitioners to prescribe medicines in the 1960s (Kroezen et al, 2011; Graham-Clarke et al, 2019). Nurse practitioners were introduced to support the needs of underserved rural communities and immigrants in the US by providing physical care and other necessities such as medicines and making referrals to physicians and cities' hospitals (Kroezen et al, 2011). Since then, these practising and prescribing roles have been gradually developed and extended to include a wider population of nurses and healthcare professionals in various countries (Courtenay et al, 2011; Kroezen et al, 2011). A series of legislative changes in the UK has enabled it to lead on pioneering changes supporting the expansion of prescribing to pharmacists and allied health professionals (AHPs) (Graham-Clarke et al, 2019).
‘Non-medical prescriber’ is a term used in the UK to refer to nurses, pharmacists and AHPs who have undertaken an approved programme of training. Eligible professionals are legally able to prescribe within their level of professional expertise after completing an approved training programme (General Pharmaceutical Council, 2016; Nursing and Midwifery Council, 2018; Department of Health, 2000; Health Care Professions Council, 2021; General Optical Council, 2021). AHPs with prescribing rights in the UK include registered healthcare professionals, including dietitians, radiographers, optometrists, physiotherapists, paramedics and podiatrists (i5 Health, 2015; Health and Care Professions Council, 2021).
NMP programmes typically comprise a blend of face-to-face and online classes that equates to 26 days of taught learning plus 90 hours of supervised practice. Currently, more than 70 Universities across the UK deliver NMP courses to pharmacists, nurses and AHPs (General Pharmaceutical Council, 2016; Nursing and Midwifery Council, 2018; Health and Care Professions Council, 2021; General Optical Council, 2021). Nurses, Pharmacists and AHPS, including therapeutic radiographers, optometrists, physiotherapists, are awarded the dual qualification of independent prescribing (IP) and supplementary prescribing (SP), whereas dietitians and diagnostic radiographers qualify as SP alone (General Pharmaceutical Council, 2016; Nursing and Midwifery Council, 2018; General Optical Council, 2021; Health and Care Professions Council, 2021).
Those using IP are responsible for assessing patients' health conditions and making decisions about patients' treatment and clinical management, including prescribing, within their own scope of practice (Sharman, 2015; Weeks et al, 2016). Using SP, the initial assessment and diagnosis of a patient's condition is carried out by an independent prescriber (ie a doctor or dentist), and the clinical condition is managed using a patient-specific clinical management plan agreed by the independent prescriber, supplementary prescriber and patient (National Health Service England, 2016; Department of Health, 2006).
NMP in the UK was introduced and implemented by the NHS to improve access to medicine for patients and respond to increased patient demand, workforce shortage pressures and funding shortfalls (Graham-Clarke et al, 2019; Carey et al, 2020; Graham-Clarke et al, 2021). Both doctors and non-medical prescribers have reported that NMP improves patient access to medicine and healthcare services with greater convenience (Norman et al, 2010; Courtenay et al, 2012; Graham-Clarke et al, 2019). It is also perceived to reduce doctors' workload and free up time and resources (Stewart et al, 2009; Courtenay et al, 2011; Cope et al, 2016). NMP practice is becoming an integrated feature of the UK healthcare delivery in primary and secondary care. However, there is still a lack of evidence on the value of NMP in terms of service provision, efficiency and cost-effectiveness of services provided by non-medical prescribers (Cope et al, 2016; Noblet et al, 2018; Carey et al, 2020). This issue is becoming even more important as not all trained NMPs are reported to be using their prescribing qualifications (Courtenay et al, 2012; Cope et al, 2016; Alghamdi et al, 2020; Graham-Clarke et al, 2021).
This protocol outlines a proposal to undertake a scoping review on the global evidence of costs, health economics outcomes and consequences of services delivered by any non-medical prescriber using either SP and/or IP. Compared to a review of cost and cost-effectiveness evidence of NMP by Noblet et al (2018), this scoping review aims to generate new insight into the extent of the available evidence around NMP based on its safety, economic impacts, effectiveness and other consequences by considering a broader set of inclusion criteria to perform a more comprehensive search of the literature, including grey literature. In addition, the study will address the current gap in knowledge, and where possible, it will provide recommendations for policy and practice.
Methods
This scoping review protocol was registered with the Open Science Framework Registry on 31 July 2021 (registered DOI: 10.17605/OSF.IO/PSR3N), accessible from https://osf.io/psr3n.
This scoping review protocol is designed based on the methodological framework developed by Arksey and O'Malley (2005) and further refined by Levac et al (2010) and the Joanna Briggs Institute (2015) to ensure rigour in reporting the review and its methodology. The Arksey and O'Malley (2005) framework proposes five stages in conducting a scoping review:
- Identifying the research questions
- Search strategy and screening
- Study selection
- Data extraction and analysis
- Collating and reporting the results.
These five stages are explained in more detail in the following sub-sections. When reporting on the scoping review study, the authors will follow the Preferred Reporting Items for Systematic reviews and Meta-Analysis extension for Scoping Reviews (PRISMA-ScR) reporting guideline recommended by Tricco et al (2018).
Identifying the research questions
It is recognised that NMP is perceived and defined differently around the world and comprises more than writing a prescription (Courtenay et al, 2011). For this review, NMP will include medicine management activities that are legally and technically considered prescribing and provided by non-medical professionals. Consistent with Courtenay et al (2012), these medicine management activities include ‘making recommendations for patients to buy medicine(s) over the counter; amending prescribed medication; medication review; written recommendation to GPs; recommending in patients' hospital notes; prescribing via hospital medication charts; patient group directions; remote prescribing via telephone, email and fax; issuing hospital-specific prescription; signing issued prescription via GP repeat prescribing system; issuing private prescription directly to the patient’.
The research questions for the review are as follows:
- What is the evidence for the costs and consequences of NMP practices by non-medical healthcare professionals in the peer-reviewed and non-peer-reviewed ie grey) literature?
- What different types of NMP practices (eg SP, IP) are implemented and evaluated across different non-medical health professions (eg nurses, dietitians, radiographers, etc) and across different settings?
- What are the measures used to assess the economic impacts, safety, effectiveness and other consequences of prescribing rights by non-medical healthcare professionals in various settings?
- What are the research gaps concerning cost and consequence outcomes of NMP which could guide future research, policy development and service provisions with respect to giving and extending NMP rights to nurses, pharmacists and AHPs?
Since the scoping review is iterative, there is the possibility of revising the research questions and introducing further questions when conducting the protocol.
Search strategy and screening
A comprehensive search strategy will be developed by the research team to enable a stepwise search process. Based on our initial exploratory research, the authors will include grey literature and journal and conference articles with full-text written in English from 1999 (ie the first occurrence of NMP in the UK) to 2021 from systematic searches of the following electronic databases: PubMed, Embase, MEDLINE, Scopus, CINAHL, Web of Science, Cochrane Database of Systematic Reviews, and Google Scholar. The scoping review will include any type of review articles, original research, clinical trial studies and grey literature of any type of intervention to evaluate NMP services provided by non-medical healthcare professionals. Commentaries, letters and editorials will be excluded.
A broad search strategy will be designed to ensure that the inclusion of studies is as comprehensive as possible. Search terms are derived from titles, abstracts, and keywords identified in key publications and from search terms used in previous reviews related to the scope of this review. The possible search terms to be used are: (non-medical prescribing OR NMP OR non-doctor prescribing) AND (pharmacists OR nurses OR non-medical healthcare professionals OR allied health professionals OR AHPs OR dietitians OR radiographers OR midwives OR physiotherapists OR podiatrists OR optometrists OR paramedics) AND (consequences OR health outcomes OR clinical outcomes OR effectiveness) AND (economic impacts OR costs).
The first author will conduct the search (in late November 2021) after discussing and developing the search strategy with the research team. All articles identified from the searches will be transferred to the EndNote reference manager software, and all duplicates and titles in other languages will be removed. The PICOS (population, intervention, context, outcome, and study design) framework is used to establish eligibility criteria (Petticrew and Roberts, 2006). More information regarding the inclusion criteria according to the PICOS approach is provided in Table 1
Table 1. Inclusion criteria based on PICOS
| Item | Description |
|---|---|
| Population |
|
| Intervention |
|
| Context |
|
| Outcome |
|
| Study design |
|
AHP: allied health professionals; NMP: non-medical prescribing
Study selection
The review process includes an initial screening of the title and/or abstract of the studies by the first author to assess their eligibility for full-text retrieval. Prior to this step, the authors will conduct a pre-test on a sample (ie 20%) of articles retrieved to improve the quality and consistency of including eligible articles among the reviewers. The inclusion criteria may be refined after piloting this 20% sub-sample of articles to ensure that all relevant studies are included in the review process. Any studies that may not be excluded confidently through title and abstract screening during the initial screening step will be included for full-text screening. Two reviewers will conduct a full-text screening of the selected studies independently. A third reviewer will be employed if the disagreements cannot be resolved through discussions.
Data extraction and analysis
The authors will extract data from the full-text journal and conference articles and grey literature based on the inclusion criteria mentioned above using a bespoke data extraction form. A Microsoft excel-based form will be initially developed by the first author and validated by other authors for charting the data from selected studies and reporting the variables regarding the study, participants, intervention and outcome characteristics – such as authors, publication year, study setting, aim, population information, type of prescribing, data collection methodology, data analysis method and outcomes – based on the research questions, and identifying gaps in the literature. The data charting form will be piloted on a sample of 20% articles by the team to reduce the risk of error in data extraction, systematically determine the variables and extract data through a common framework and ensure that relevant variables/information are extracted from included studies. As this stage is iterative, further variables may be identified and included in the study. The authors of selected studies might be contacted for missing or unclear essential information.
Collating and reporting the results
The authors will use the PRISMA-ScR reporting guideline to synthesise and report the results of the review process and the final numbers of articles included in our scoping review Tricco et al (2018). Data synthesis will be undertaken by the first author in consultation with the research team. The findings of selected studies will be summarised and presented in tabular forms, graphics and a descriptive report to highlight the key research findings (eg economic impacts, benefits and consequences of NMP, setting, intervention, etc) of selected studies and the existing research gap around the NMP.
The findings will provide invaluable evidence to understand the impacts of non-medical prescribing services, including – but are not limited to – the effectiveness of NMP training and of capacity-building for healthcare workforce specialities to better use their skills, the role and impact of non-medical prescribers on service delivery, patient's access to medicines, and associated costs.
Conclusion
Although NMP practice is becoming an integrated feature of healthcare delivery in the UK and around the world, there is still a lack of evidence on the cost-effectiveness of the prescriptive authority given to non-medical healthcare professionals. This protocol is designed for a scoping review of an under-researched area to provide state-of-the-art evidence on economic impacts, consequences (eg service improvement, patient satisfaction, waiting times, safety, etc) of services managed by non-medical prescribers. This study will generate fresh insight into the research, magnitude and nature of existing evidence on the economic impacts and effectiveness and other consequences of NMP authorities by non-medical professionals on patients and the health system. The findings of the scoping review will inform policy and practice around NMP.
Key Points
- NMP is becoming an integrated part of the healthcare system in the UK and around the world
- NMP is an under-researched area, and there is a lack of evidence on the cost-effectiveness of prescribing authorities given to non-medical healthcare professionals
- This protocol is designed for a scoping review of state-of-the-art evidence on economic impacts and consequences (eg service improvement, patient satisfaction, waiting times, safety, etc) of services delivered by non-medical prescribers
- The scoping review will search a broad literature, including peer-reviewed and grey literature written in the English language, without setting or country restrictions.
CPD reflective questions
- What are some potential benefits of adopting the prescribing role in your area of practice?
- What percentage of your patients require you to manage their prescriptions?
- What percentage of your patients do you refer to other prescribers?
- What aspects of your prescribing role would you improve in your area of practice?