Non-medical prescribing in primary care in the UK: an overview of the current literature

The new NHS Long Term Plan (Winter, 2019) proposed an additional 20 000 non-medical prescribing (NMP) roles for primary care. Inadequacies within traditional doctor-led care systems means that to maintain patient access to prescription medicines, new approaches are urgently required. Allied health professionals, such as therapeutic radiographers, have been identified as having an integral part in the required transformational change (Chief Allied Health Professional Officers' Team, 2017). A reduction in the number of General Practitioners (GP) and the new ways of working in primary care are prompting the need for NMPs to fill these gaps (Winter, 2019).

After nurses lobbied parliament for years to be legally allowed to prescribe, nurses slowly earned more and more prescribing rights, until April 2006, when they were given the same prescribing rights as doctors (Pearce, 2016). This exceeds any other non-medical prescribing rights anywhere in the world and initially caused great concern in the medical profession (Avery and Pringle, 2005; British Medical Association [BMA] 2005; Day, 2006). However, NMP is now seen to complement busy general practitioners in primary care (Courtenay et al, 2017).

The primary focus of the research in NMP to date has been on its impact on patients, practitioners and organisations (Courtenay et al, 2018; Carey et al, 2019). Other studies have identified motivators, such as job satisfaction and the opportunity to improve patient care, linked to increased prescribing activity (Bailey and Taylor, 2017). Barriers identified to NMP included the lack of access to training and support from colleagues and the risk of litigation (Armstrong, 2015; Nelson et al, 2019; Holden et al, 2019). There is a wide range of influences on NMP, including the trust of other members of the team (Weiss et al, 2016), the prescriber's confidence (Courtenay et al, 2018), their experience (Maddox et al, 2016) and the expectations of others and the organisation (Hindi et al, 2019).

The present situation in the UK

Non-medical prescribing is increasingly being recognised as an essential healthcare practice, with at least 18 countries adopting NMP across Europe, the Americas and Australasia (Courtenay et al, 2017). The drive behind NMP in the UK is the need to deliver high-quality healthcare to patients where and when they require it, with limited financial resources (NHS England, 2015; NHS England, 2017). Innovative patient-centred care pathways have been developed using the most appropriate healthcare professionals, such as clinical pharmacists in general practice and prescribing physiotherapists streamlining musculoskeletal pathways (Carey, 2019). The reduction in the number of GPs is also causing concern regarding patients getting access to timely medical intervention (Winter, 2019).

In the UK, it is estimated that there are currently over 90 000 registered NMPs including nurses, midwives, pharmacists and allied healthcare professionals (such as optometrists, physiotherapists, podiatrists and radiographers) (Courtenay et al, 2017). Since 2018, independent prescribing by advanced paramedics has been permitted, but this excluded prescribing controlled drugs (NHS England, 2018).

Primary care networks

Since the NHS was created in 1948, the population has grown, and people are living longer (Winter, 2019). Many people are living with long-term conditions such as diabetes and heart disease or suffering from mental health issues and may need to access their local healthcare services more often. To meet these needs practices have begun working together with community, mental health, social care, pharmacy, hospital and voluntary services in their local area through primary care networks (Kings Fund, 2019). Around 7000 practices across England – more than 99% - have come together to form more than 1300 primary care networks (PCNs). Primary care networks are based on GP-registered lists typically serving natural communities of around 30 000 to 50 000 (The King's Fund, 2018; NHS England, 2018).

The key research questions are:-

• How do non-medical prescribers perceive themselves?
• How do patients perceive non-medical prescribers?
• How do other staff perceive non-medical prescribers?

Method

A systematic process was conducted according to the PRISMA guidelines (Figure 1). This utilises a transparent, structured process to review the literature and this approach is equally important when reviewing qualitative literature as it requires the identification of clear criteria to support credibility, transferability, dependability and confirmability (Bearman and Dawson, 2013). The quality of the studies was evaluated using two validated tools, COREQ (Tong et al, 2007) for the interview and focus groups and the QATSDD (Sirriyeh et al, 2011) for a diverse design. All articles were scored and graded against the two checklists and then presented as percentages so they could be compared and are presented in Table 1 (Graham-Clarke et al, 2019). QSR NVivo 12 was used for the thematic analysis.

Literature search

The literature search was undertaken in January 2021 using a range of databases from the University of Central Lancashire and resources were selected because of their relevance to the subject (Table 3). To gather insight into the factors that could impact the NMP, the search included qualitative, quantitative and mixed-methods studies. Table 4 shows the search strategy of Nurs*, Non-medical, Primary care, and prescrib*.

Inclusion criteria

Articles published in the English language from January 2015 to January 2021 were reviewed in line with the aims. This short time frame was selected to give an overview of contemporary literature in this fast-moving field.

Exclusion criteria

Articles were ineligible for inclusion if they were published only in abstract form, opinion paper, narrative reviews, related only to secondary care or not in the UK and not published in the English language. The latter is because of a lack of resources for translation.

Ethics approval

Ethics approval was not required.

Summary of results

Of the participants, 3016 were identified in the 15 eligible studies. Most prescribers, 75%, were nurses (n=483), followed by pharmacists at 11% (n=72), physiotherapists accounting for 4% (n=21) of participants and finally four podiatrists at 1%. In Holden et al (2019), 1646 physiotherapists responded to a questionnaire regarding non-medical prescribing for osteoarthritis; however, only 1% (9) were prescribers.

All papers showed how participants were selected and the method of sampling and gave sample size. Across all papers, the details of the reflexivity of the interviewer, the relationship with the participant and whether any bias existed were covered. However, there were no details of non-participants and only three papers included interview guides (Maddox et al, 2016; Williams et al, 2018; Nelson et al 2019). No-one repeated an interview and only one paper mentioned the duration of the interview and returning the interview transcription to be checked by the participant (Maddox et al, 2016). Within data analysis no data coders or description of the coding tree were given as most papers did show deviations of themes and the software used.

This study highlighted the negative and positive perceptions of NMP by prescribers as well as from their colleagues and patient's perception. It gives a wider perception of the whole impact of NMP in primary care.

Positive perspective

The prescribers' perceptions of their role are mainly positive, especially about their ability to prescribe as it is generally seen as making a positive contribution to patient care including speedier access to medication (Armstrong, 2015; Heklots et al 2015; Carey et al, 2019;

Heklots et al, 2015; Courtenay et al, 2019). Autonomy, increased job satisfaction and being able to make better use of skills/knowledge are also acknowledged as being positive by NMPs (Armstrong, 2015; Taylor and Bailey, 2017; Hindi et al, 2019).

Negative perceptions

Negative perceptions were identified, including challenges such as non-medical prescribers having to adopt to new roles, manage extra responsibility and integrate with their practice settings in a way which supports cohesive teamwork between doctors, independent prescribers and other colleagues (Armstrong, 2015; Maddox et al, 2016; Nelson et al, 2019). The risk of potential legal consequences because of the additional responsibility of prescribing was raised as a concern (Holden et al, 2019) and deterred many practitioners from training to be an NMP (Holden et al 2019; Holden et al; Carey, 2019). Lack of support from management and from colleagues was also identified as a barrier (Maddox et al, 2016). The lack of CPD, lack of guidance and increased workloads were identified as well (Armstrong. 2015; Courtenay et al, 2017a; Maddox et al, 2016; Taylor and Bailey, 2017). Independent prescribing presents novel challenges to both independent prescribers and those working in a setting where they practice (Weglicki et al, 2015; Weiss et al, 2016).

Patient's perception

Patient's perception on non-medical prescribing was positive, reporting positive experience and high satisfaction with accessibility and length of consultation (Carey et al, 2019; Hindi et al, 2019). Doctors also perceive benefits from working along-side independent prescribers such as having more time for complex cases (Herklots et al, 2015; Weiss et al, 2016).

Organisation support

The results of this review are that the implementation of NMP is strongly influenced by organisational support (such as local policies, workload, funding and availability of medical resources and additional skills) (Courtenay et al, 2018; Hindi et al, 2019; Taylor and Bailey, 2017) and for it to be successful the whole organisation has to ensure adequate preparation for not only the NMP, but the whole team, so that the NMP can be supported and reach their full potential.

Discussion

Employing non-medical prescribers within healthcare services has the potential to make savings across a range of health specialities, providing more holistic patient care within an individual profession's scope of practice (Carey et al, 2019). For NMP to become more widely accepted, healthcare managers, clinical care quality and safety agencies, as well as the general public, require evidence of the overall value of NMP through the implementation of services that are patient-centred, improving the quality and safety of patient care, while simultaneously reducing costs and improving the efficiency of treatment and patient outcomes (Courtenay et al, 2018).

Multiple studies have a focus on new roles and appropriate skill mix for general practice, not least because of the ongoing shortage of GPs but also because of the growing number of different issues and tasks that general practices have to tackle (Maddox et al, 2016; Nelson et al, 2019; Carey et al, 2019).

National policies have identified that ‘GPs will recruit multi-disciplinary teams, including pharmacists, physiotherapists, paramedics, physician associates and social prescribing support workers, freeing up family doctors to focus on the sickest patients (NHS Long Term Plan, 2019).

The studies conducted by Weglicki et al (2015) and Weiss et al (2016) highlighted the importance of organisational features, such as role collaboration and teamwork. They suggested that in the organisations they observed where different social identities were respected and supported, a positive organisational identity in terms of multi-disciplinary working may also be more likely to provide better patient care than those practices where traditional hierarchies and rigid professional boundaries predominated.

Limitations

To the best of our knowledge, there were no studies carried out in Northern Ireland and many studies included participants from secondary care and therefore were excluded from this paper. There were no studies looking particularly at the impact of NMP in primary care on minor illness. Therefore, more research needs to be carried out in this area. The literature that has been reviewed is only from the last 5 years to ensure that it is contemporary but it does not show past trends or practices in Northern Ireland.

Implications to Practice

Since 1992 with the development of NMP, patients and other practitioners have come to accept that prescribing can be safely performed by another member of staff as well as medical practitioners. To ensure that practitioners wishing to enhance their skills can undertake the appropriate training with a suitable practice mentor in place in the clinical practice. Organisational policies and procedures need to be in place to support NMPs with a clear level of responsibilities and scope of practice. Continued professional development must be in place to strengthen and support NMPs, ensuring that they are up-to-date and confident to prescribe within the scope of practice.

Conclusion

With the increased demand for general practice services and the decrease of medical practitioners, it will be necessary for GP surgeries to develop a multi-disciplinary approach to primary healthcare provisions. To enable the population to have adequate access to medicines, it will be key that NMPs are utilised, and that their expertise and competencies are adequately resourced. The studies identified in our search and included in the literature review have shown that outcomes and patient satisfaction are the same, if not higher than doctors. Organisations will need to develop robust continuous professional development for NMP along with clear professional and organisational guidelines on prescribing. To ensure that non-medical professionals are willing to undertake the prescribing training, they will need adequate financial incentives and career structure as well as good clinical support and supervision. GP services will have to ensure that they have systems in place to recruit, train, retain and promote non-medical prescribers to enhance primary care.

Key to making the new roles work will be to understand their place in the core general practice team or broader team and to build the relationship between professionals so that patients do not face multiple handoffs or get confused about how to access care. In choosing what additional roles to add to the team, practices must have a deep understanding of the needs of the population they serve and employ/train the right professionals with the right skills, supported by appropriate governance structure, to provide that care (Primary Care workforce commission, 2015). More research needs to be done in this area to ensure good integration of NMP into primary care.

Key Points

• Non-medical prescribing in primary care is on the increase with more professions being able to prescribe.
• Positive perceptions of NMP are job autonomy, satisfaction and quicker access to medication.
• Negative perceptions of NMP are litigation risk, increase workload and lack of support.
• To successfully implement NMP the whole organsation must be ready to work with NMPs and support them.

CPD reflective questions

• What are the perceived benefits of having NMPs in primary care?
• What are the perceived challenges for NMPs in primary care?
• If you were a manager what would you do to support NMPs in primary care?
• How would you minimise the risks of NMPs in primary care?