Exploring the roles and responsibilities of non-medical prescribing leads in the South West of England

The demand on the NHS is increasing, with a growing population who are living longer with multiple complex conditions (NHS, 2019a). Alongside this, there is an ongoing workforce crisis in the NHS, with approximately 100 000 staff vacancies (NHS Improvement, 2018). To ensure ongoing access to treatment and medicines, new models of service delivery have been developed, many of which require healthcare professionals to extend their role, undertaking advanced levels of practice supported by the independent and/or supplementary prescribing qualification (NHS, 2019b; Carter, 2016). Training for non-medical prescribing (NMP) generally takes place over a period of around 6 months (Department of Health (DoH), 2006). Taught content of the NMP course includes pharmacology and legal/ethical issues, and delivery tends to be through a combination of face-to-face and online learning (Doherty et al, 2019) with a mandatory aspect of supervised practice, followed by robust assessment by academic and practice assessors (Nursing and Midwifery Council (NMC), 2018a; General Pharmaceutical Council (GPhC), 2019a; The Health and Care Professions Council (HCPC), 2019a).

There are currently over 90 000 NMPs in the UK; 39 200 Community Nurse Practitioner Prescribers (NMC, 2019), 44 516 Independent/Supplementary Nurse Prescribers (NMC, 2019), 9308 Pharmacist Prescribers (GPhC, 2019b) and 1848 Allied Health Professional Prescribers (HCPC, 2019b). Following a series of legislative changes, the number of professions now able to prescribe has increased to eight, including physiotherapists, podiatrists, optometrists, dietitians, paramedics and radiographers, alongside nurses and pharmacists (NHS, 2016; College of Paramedics, 2018). As a result, UK healthcare professionals have the most extended prescribing rights in the world (Courtenay et al, 2017).

Recent regulatory changes have increased accessibility to independent/supplementary prescribing training for nurses, as the requirement for post registration experience has been reduced from 3 years to just 1 (NMC, 2006; NMC, 2018a). At the same time, the NMC and other healthcare regulators (GPhC and HCPC) have also made changes, allowing suitably qualified NMPs to undertake the role of practice assessor (NMC, 2018a; GPhC, 2019a; HCPC, 2019a). These changes have been supported by the introduction of a competency framework for individuals undertaking the role (Royal Pharmaceutical Society (RPS) 2019). Previously, the role of practice assessor could only be undertaken by a medical doctor or dentist, known as ‘designated medical practitioner’ (DMP). However, there was significant concern that limited availability of DMPs in some areas was acting as a barrier to those wishing to access training (Ryan-Woolley et al, 2007; McCormick and Downer, 2012; GPhC, 2016). The growing workforce of experienced NMPs and a desire to make best use of their skills led to the regulatory changes outlined above (NMC, 2018b).

Despite the growth in NMP, there are concerns regarding implementation of the NMP role, with 14% of nurse and 29% of pharmacist/AHP prescribers reportedly not using their qualification in practice (Latter et al, 2010; Stewart et al, 2017). Whilst some of this may be because of NMPs moving into roles that do not require them to use their prescribing qualification (Courtenay et al, 2012), evidence suggests that use of the prescribing qualification is also affected by a number of individual and organisational facilitators to implementation (Noblet et al, 2017). These include access to continuing professional development (CPD), peer support, a clear scope of practice, a comprehensive clinical governance policy and organisational support with practical issues, such as access to computer-generated prescriptions. A recent systematic review by Graham-Clarke et al (2018) identified that confidence and competence of the NMP, support from colleagues or managers and good governance structures all act as facilitators supporting successful implementation of the role.

NMP leads are responsible for ensuring effective implementation of the prescribing role within their organisation (DoH, 2006; Latter et al, 2010; NPC, 2011). There is some evidence to suggest that NMP leads have responsibilities associated with communication, coordination, clinical governance and support (Courtenay et al, 2011). However, there is still a lack of agreement at a national level regarding the role and responsibilities of NMP leads in practice, with many reporting little or no preparation, a lack of clarity and little or no designated time for the role (Hacking and Taylor, 2010; Lim et al, 2013). The only available guidance is now dated, and does not reflect the numerous changes that have occurred since its original publication (NPC, 2011).

Prior to 2013, there were 10 Strategic Health Authorities (SHAs) in England, the majority of which employed a regional NMP lead. In addition to promoting and coordinating NMP activity at a regional level, this role provided support to organisational NMP leads, with respect to the implementation and the strengthening of governance structures, as well as maintaining national links (Ventura, 2010). Following the abolition of the SHAs, the majority of these regional roles ceased to exist. In many areas, regional support either does not exist or else has been coordinated through informal or unfunded networks, such as the NMP leads network in the southwest of England (Turner, 2019). Although the Association for Prescribers (AFP) has made a move to fill this gap by running well-attended annual ‘NMP lead’ events over the last 2 years, there continues to be a lack of structured support for NMP leads at a national level (AFP, 2019).

While the recent changes to the number of professional groups with authority to prescribe in the UK is to be congratulated, the increasing number and diversity of NMPs within each organisation have added to the complexity of the NMP lead role. If the benefits of NMP are to be fully realised, it is essential that the role, responsibilities and support needs of NMP leads are more clearly understood by organisations and service commissioners. Given that many of the above described changes have occurred since the previous limited work in this area (Hacking and Taylor, 2010; Courtenay et al, 2011; Lim et al, 2013), further evaluation of the NMP lead is urgently required.

Methods

This paper reports on an exploration of the role and responsibilities of NMP leads in the southwest of England.

The project was driven by collective action of the southwest NMP leads Forum, a recognised approach to initiating and undertaking improvement work in the absence of outside facilitators (Cornwall, 1996). The aim of the project was to develop understanding and consensus regarding the remit of NMP leads, facilitating change and improving service provision across the region. Full ethical approval was not required, as this project was deemed a service evaluation by the provider organisation of the lead author (SJ) (Twycross and Shorten, 2014; Health Research Authority (HRA), 2017).

Questionnaire

Informed by previous work in the area (lead author experience (SJ) in her role as Chair of the SW network and members of the SW network), a questionnaire exploring the roles and responsibilities of NMP leads was developed using Survey Monkey© (Courtenay et al, 2011; NPC, 2011; Lim et al, 2013). It is recognised that questionnaires, particularly those that are exploratory in nature, have a useful role in service evaluation, a key objective of which is to generate improved understanding of the subject area rather than generalisability of the data (Dillman, 1999; Twycross and Shorten, 2014).

The survey comprised of 10 questions. Questions 1–9 asked for demographic information about their role including job title, whether their role had a clinical aspect, professional background, inclusion of NMP lead in job description, designated time and amount of time for NMP lead activities, length of time in post, practice setting, number and types of prescribers covered. Question 10 asked NMP leads to use five-point Likert scales (one indicating not important and five very important) to rate the importance of 18 aspects of their role related to four main areas:

• Communication
• Coordinating
• Clinical governance
• Support and training.

Tick and or/free text boxes were provided for responses.

Prior to administration, the questionnaire was reviewed by three NMP leads in the southwest area, working in different practice settings (acute, mental health and general practice) and minor amendments were made. These included the addition of two questions about professional background and whether the job description acknowledged the role of NMP lead.

Data collection

An email containing an invitation letter, outlining the purpose of the questionnaire, advising that completion was voluntary and responses anonymous, with a link to an online survey, was sent to all NMP leads (n=40) in the southwest NMP leads Forum. A reminder was sent out 2 weeks later, and the survey closed when no further responses had been received for a week. Data collection took place during March–April 2019.

Data analysis

Using Microsoft Excel©, descriptive statistics were used to describe the demographic details of participants, the number and type of NMPs employed and key aspects of the NMP lead role. The Likert scale responses were easily reducible to very important/important and not or slightly important. Results are summarised in Tables 1–3.

Results

Demographics

Completed responses were received from 22 (55.0%) members of the forum (Table 1). The majority were nurses (n=20, 90.9%); this is reflective of the overall membership of the group (85.0% are nurses). Many of the participants had a clinical aspect to their role (n=18, 81.1%), with 11 (50.0%) employed as either Nurse Consultants or Clinical Nurse Specialists. Participants worked in a variety of different organisations including acute, community and mental health trusts, with nine (n=40.1%) working in acute care, and seven (31.8%) for an independent healthcare provider, such as an hospice or social enterprise. Five (22.7%) covered two practice settings, such as community and acute. No responses were received from NMP leads based in primary care. The majority (n=14, 63.7%) had more than 2 years' experience as an NMP lead, with only fifteen (68.2%) reporting that the NMP lead role was included in their job description. Ten (45.5%) reported that there was no designated time allocated to them for NMP lead activities, and 12 (54.5%) had between 30 minutes–8 hours a week.

Despite the lack of acknowledgement in the job description, 16 (72.7%) participants reported spending time on NMP lead activities each week. Of these seven (43.8%) spent 8 or more hours per week on the role (range 0.5–22.5 hours).

Number and type of non-medical prescribers

There were 2388 NMPs employed across all 22 organisations, of which 1711 (71.6%) were nurse independent/supplementary prescribers, 479 (28.0%) community practitioner nurse prescribers, and 100 (5.8%) pharmacist independent/supplementary prescribers. The number of NMPs employed within each organisation ranged between 7–204 (Table 2). All organisations (n=22) reported that they employed nurse independent supplementary prescribers, 20 (90.1%) pharmacists IP/SPs and 13 (59.1%) community nurse practitioner prescribers. The numbers of optometrist, podiatrist, physiotherapist, therapeutic radiographer and dietitian prescribers are relatively small compared to the other professions, with most organisations employing one or two NMPs from each of these professional groups. There were exceptions, for example one organisation employed 12 optometrists.

Aspects of the NMP lead role

Respondents were asked to rate the importance of 18 aspects of their role related to four main areas (Table 3):

• Communication
• Co-ordinating
• Clinical governance
• Support and training.

Communication

There was a high level of consensus regarding the importance of the communication elements of the role, with 21 respondents (95.5%) reporting that it was either essential or important for them to facilitate communication between managers and NMPs and to disseminate national/local changes to NMPs. Acting as a point of contact for NMPs was also deemed to be essential/important by 91% (n=20) of participants.

Co-ordination

There was a similar high level of agreement regarding the coordination aspects of the NMP lead role. Overall, 21 respondents (95.5%) reported integrating and expanding NMP within service planning, and 20 (91.0%) reported that ensuring applicants meet NMP selection criteria, coordinating and promoting NMP within the organisation, and working at a strategic level to increase NMP in underdeveloped areas as essential or important. Less emphasis was placed on liaising with education providers, with only 17 (77.3%) reporting this to be essential or important.

Clinical governance

Ensuring clinical governance processes were in place, identifying and dealing with any governance issues that arose, and monitoring NMP practice were deemed to be essential or important elements of the role by 95.5% (n=21) of respondents. Less importance was placed on monitoring and supporting those not using the NMP qualification in practice, with only 14 (63.6%) participants reporting this as essential or important to their role.

Support and training

There was less agreement with respect to the support and training aspects of the NMP lead role. Providing information on CPD opportunities (n=20, 91.0%), and practical support and training for NMPs (n=18, 81.8%) were areas with the highest level of agreement. Less importance was placed on supporting newly qualified NMPs when first implementing the role (n=16, 72.7%), during initial training (n=15,68.2%) and/or supporting DMPs (n=11, 50.0%).

Discussion

This is the first exploration of the role and responsibilities of NMP leads, following legislative changes extending independent prescribing rights to physiotherapists, podiatrists, paramedics and therapeutic radiographers, and supplementary prescribing rights to dietitians (HCPC, 2013; NHS, 2016; RPS, 2016). The established southwest NMP forum ensured that NMP leads were active participants in identifying the issue, project design, reflecting on findings and agreeing a plan for change (South West NMP leads, 2019a; South West NMP leads, 2019b).

The findings indicate that compared to previous studies, the number and types of prescribers within individual organisations has increased. The complexity of the NMP lead has consequently changed, with responsibility for larger numbers of prescribers and an increased number of professional groups (Latter et al, 2010; Cope et al, 2016).

Clinical governance processes, including monitoring NMP practice, disseminating national/local changes and ensuring two-way communication, were reported to be essential aspects of the NMP lead role, as in previous studies (Latter et al, 2010; Courtenay et al, 2011; Lim et al, 2013). However, it unfortunately appears there has been little or no change to the infrastructure supporting the NMP lead role. Previous work as indicated that the role of NMP lead may be impeded by lack of organisational infrastructure, including deficiencies in designated time to undertake the role and lack of clarity about NMP Lead duties (Courtenay et al, 2011). Findings from this study regarding a lack of designated time and lack of acknowledgement in job descriptions are therefore of significant concern, given the key role that NMP leads have in supporting implementation and development of NMP within organisations (DoH, 2006). The continued lack of infrastructure and support for NMP leads means it will become increasingly difficult for those in this role to meet the changing requirements, the resultant effect being sub-optimal implementation of the prescribing role.

The increased range of eligible professions and, more importantly, the difference in governance structures of the four healthcare regulators such as the General Optical Council (2020), GPhC (2019a), HCPC (2019a) and the NMC (2018a) has led NMP leads to express concerns about the increased complexity associated with managing the associated differences in governance (AfP 2019; South West NMP Leads, 2019a). Each regulator and professional group has individual requirements and legal frameworks that underpin practice. For example, independent nurse and pharmacist prescribers are able to prescribe most drugs within their scope of practice, whilst prescribers from other professions have restrictions (such as physiotherapists and podiatrists only being able to prescribe certain controlled drugs, while dietitians are only able to prescribe as supplementary prescribers using a clinical management plan) (HCPC, 2019a).

The changing demands of the role were evident in the key areas of activities reported by NMP leads in this study. For example, 91% of leads reported that their role included ensuring that applicants meet NMP course entry requirements, compared to only 52% by Courtenay et al (2011), perhaps reflecting the different entry requirements for NMP training across the regulatory bodies (NMC, 2018a; GPHC, 2019a; HCPC, 2019a). While it is reassuring to know that organisations take the selection of candidates seriously, the ‘Preparing to Prescribe’ toolkit (Carey and Stenner, 2020), a relatively new and freely available resource, could be used by NMP leads to help alleviate the burden association with this part of the role, as well ensuring consistency in the information provided.

Providing support to DMPs was reported to be part of the NMP lead role by only 50% of participants, compared to 80% of NMP leads in previous work undertaken by Courtenay et al (2011). While universities tend to provide support and guidance for DMPs through meetings and practice visits, it is possible that the reduced level of support in this area reflects the fact that DMPs have been undertaking this role for a number of years, and NMP leads are confident in their ability to do so. However, it is important to note that recent regulatory changes allowing NMPs to take on the supervision and assessment of students undertaking the prescribing course (NMC, 2018a; GPHC, 2019a; HCPC, 2019a) may mean that NMP leads, are in the future, more involved in this area, as new governance structures will be required to support this activity (AfP, 2019, South West NMP Leads, 2019a).

It is recognised that organisational governance of the practice assessor role has become more complicated as a result of the variation in regulatory requirements (AfP, 2019; RPS, 2019; South West NMP leads, 2019b); for example, the NMC requires nurses undertaking the NMP course to have both a practice assessor and practice supervisor/s (NMC, 2018a), whereas the HCPC and GPhC allow for just one individual to undertake the supervision and assessment of practice with regard to AHPs and pharmacists, respectively (GPhC, 2019a; HCPC, 2019a). While the recently published Competency Framework for Designated Prescribing Practitioners provides a structure for the DPP role, a lack of consensus regarding prerequisites and/or educational preparation and CPD for the NMP lead role means there is a significant risk this will result in an ad-hoc approach to revising governance processes and an inconsistent and fragmented approach to implementing the regulatory changes (RPS, 2019).

Increasing numbers of NMPs mean there is an urgent need for a step change that improves the support and infrastructure surrounding the NMP lead role. Members of the southwest NMP lead forum have therefore agreed that the next step is to use the project results to inform the development of a regional NMP lead framework, identifying key role requirements and responsibilities (South West NMP leads, 2019b). It is hoped that this will be beneficial not only for those currently undertaking the role, but could also be used to support educational preparation of future NMPs for the role. However, further work will be required to explore whether the planned changes have the desired effect on supporting southwest NMP leads and what, if any, further actions need to be undertaken in this area.

Limitations

The authors acknowledge that the work is limited to participants from one UK regional NMP lead support network and the findings reflect the views of those who participated, and as a result there is a lack of representation of NMP leads employed in primary care. The nature of the voluntary network means that there are proportionally fewer NMP leads based in primary care than other practice setting (n=3 in total). It should be considered that the NMP lead role in primary care may, therefore, vary from reported findings and, as such, results may not represent the wider experience of NMP leads across all practice settings. The authors acknowledge that while the response rate of 55% is low, the aim of this service evaluation was to improve understanding of the NMP lead role, rather than generalisability of the data. However, the authors are confident that their findings, which were discussed and validated during an NMP lead group meeting, do reflect the NMP lead role in this part of the UK. The authors are also confident that respondents were representative of the overall membership of the group, both in terms of professional background and area of practice (eg acute/primary care).

The methodological design allowed for a large quantity of information to be collected from multiple respondents in a short space of time. However, there is a need for more detailed understanding regarding the views and experiences of NMP leads, including those from primary care, using different methodologies to further develop our understanding in this area.

Conclusions

Communication, co-ordination, clinical governance, support and training remain important elements of the NMP lead role. At the same time, changes in professional regulation have meant that NMP leads now have responsibility for increasing numbers and types of prescribers. Recent regulatory changes allowing for non-medics to take on the role of practice assessor/supervisor are likely to impact further on the NMP lead role over coming months, as new governance processes will need to be introduced. With just under half of NMP leads in this evaluation undertaking the role with no designated time allocated to them, guidance is required to help organisations understand the role and responsibilities of the NMP lead role in order that it can be supported appropriately, together with a formal infrastructure. Without this, full implementation of non-medical prescribing is likely to be suboptimal. This study will be of interest to NMP leads in other regions of the UK and other countries looking to provide governance structures to support developments in NMP.

Key Points

• The number of and types of prescriber have risen over the last decade, resulting in increased responsibility and complexity for NMP leads
• Although many NMP leads do not currently provide support to DMPs, this is likely to change following recent regulatory changes, enabling NMPs to take on the role of practice assessor/supervisor/educator
• Clinical governance and communication between managers/NMPs continue to be the most important aspects of the NMP lead role
• Guidance on the role of the NMP lead is required to determine key roles and responsibilities and ensure organisations provide adequate support for the role

CPD reflective questions

• Are you aware of the NMP lead within your organisation and what their role entails? When would you go to them for support?
• What are the barriers and facilitators to implementation of NMP from your perspective? What have you done to overcome any barriers?
• What organisational support would/do you need to take on the DPP role?