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

After nurses had lobbied parliament for years to be legally allowed to prescribe, which eventually happened in 1992 (Department of Health [DH], 1989; 1998; 1999) slowly with the change in legislation and policies, nurses 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 NMP rights anywhere in the world and has caused great concern in the medical profession initially (Avery and Pringle, 2005; British Medical Association [BMA], 2005; Day, 2006). However, now NMP is seen to complement busy general practitioners in primary care (Courtaney et al, 2017). NMPs are registered prescribers who are not doctors (physicians) such as nurses, pharmacists, physiotherapists, radiographers, podiatrists, and recently, paramedics (Table 1).

Background

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, 2020). Other studies have identified motivators, such as job satisfaction and the opportunity to improve patient care, linked to increased prescribing activity (Taylor and Bailey, 2017). Barriers identified to NMP have been the lack of access to training and support from colleagues and 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, 2014), the prescriber's confidence (Courtenay et al, 2018), their experience (Maddox et al, 2015), the expectations of others and the organisation (Hindi et al, 2019).

The role of non-medical prescribers

The new NHS Long Term Plan (Winter, 2019) proposed an additional 20 000 NMP roles for primary care. Inadequacies within traditional doctor-led care systems mean that to maintain patient access to prescription medicines, new approaches are urgently required. Allied health professionals such as physiotherapists, podiatrists and radiographers have been identified as having an integral part in the required transformational change. The reduction of the number of General Practitioners (GP) and the new ways of working in primary care, are prompting the need for NMPs fill theses gaps (Winter, 2019).

The present situation in the United Kingdom

NMP 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 United Kingdom is the need to deliver high-quality healthcare to patients where and when they require it, within a limited financial resource (Winter, 2019). 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, 2020). The reduction in the number of GPs is also cause for concern regarding patients getting access to timely medical intervention (Winter, 2019).

In the United Kingdom, it is estimated that there are currently over 90 000 registered NMPs including nurses, midwives, pharmacists and allied healthcare professionals (eg optometrists, physiotherapists, podiatrists and radiographers) (Courtenay et al, 2017). Independent prescribing by advanced paramedics has now come into force from 2018, but this excluded prescribing controlled drugs (NHS England, 2018).

Primary health 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 health services more often. To meet these needs practices have begun working together and with their local community, mental health services, social care provider, pharmacies, hospitals, and voluntary services to form primary care networks (King's Fund, 2019). Around 7 000 practices across England – more than 99% - have come together to form more than 1 300 Primary Care Networks (PCNs). PCNs are based on GP registered lists typically serving natural communities of around 30 000 to 50 000 (King's Fund, 2018; NHS England and NHS improvement, 2018).

Research aim

The goal of this study is to conduct an overview of the contemporary literature available on the role and impact of non-medical prescribers on primary care patients.

The key research questions are:

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

Method

A systematic process was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (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, Consolidated Criteria for Reporting Qualitative Studies (COREQ) (Tong et al, 2007) for interview and focus groups and the Quality Assessment Tool for studies with Diverse Designs - QATSDD (Sirriyeh et al, 2011) for diverse design. All articles were scored and graded against the two checklists and then presented as percentages so they could be compared (Graham-Clarke et al, 2019). QSR International NVivo 12 is a software programme used for the thematic analysis.

Figure 1. PRISMA 2009 Flow Diagram

Literature Search

The literature search was undertaken in January 2021 using a range of databases from the University of Central Lancashire and resources selected because of their relevance to the subject (Table 2). To gather an insight into the factors that could impact on the NMP, the search included qualitative, quantitative and mixed-methods studies. Table 3 shows the search strategy of Nurs*, Non-medical, Primary care, and prescrib*.

Inclusion criteria

Articles published in English language from January 2015 to January 2021 were reviewed in line with aims. This short timeframe 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 due to a lack of resources for translation.

Ethics approval

Ethics approval was not required.

Summary of Results

In the 15 eligible studies (Table 4), 3016 participants were identified (Table 5). Most prescribers being nurses 75% (n=483), followed by pharmacists 11% (n=72), physiotherapist accounting for 4% (n=21) participants and finally four podiatrists (1%). In Holden et al (2019) study, 1646 physiotherapists responded to a questionnaire regarding non-medical prescribing for osteoarthritis; however, only 1% (nine) 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 interviewer, the relationship with the participant and whether any bias existed was covered. However, there were no details of non-participants and only three papers included interview guides (Maddox et al, 2016; Williams et al, 2017; Nelson et al, 2019). No studies repeated and did follow up interviews and only one paper mentioned duration of the interview and returning interview transcription to be checked by participant (Maddox et al, 2016). Within data analysis no data coders or description of the coding tree were given most paper 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 from the 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 positive contribution to patient care including speedier access to medication (Armstrong, 2015; Heklots et al, 2015; Carey et al, 2020; Heklots et al, 2015; Courtenay et al, 2017). 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) (Table 6,7).

Negative perceptions

Negative perceptions were identified, including challenges such as NMPs 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 due to 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; Carey, 2020). Lack of support from management and from colleagues was also identified as a barrier (Maddox et al, 2016). Lack of CPD, lack of guidance and increased workloads were identified as well (Armstrong, 2015; Courtenay et al, 2017; 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, 2014) (Table 6,7).

Patient's perception

Patient's perception on NMP was positive, reporting positive experience and high satisfaction with accessibility and length of consultation (Carey et al, 2020; 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, 2014) (Table 6,7).

Organisation support

The results of this review are that the implementation of NMP is strongly influenced by organisational support (eg local policies, workload, funding and availably of medical resources and additional skills) (Courtenay et al, 2017; 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 NMPs, but the whole team, so that the NMPs can be supported and reach their full potential. For NMPs to be successful the organisation must ensure adequate preparation for not only the NMPs but the whole team, so that the NMPs can be supported and reach their full potential (Table 6,7).

Discussion

Employing non-medical prescribers NMPs 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, 2020). For NMPs to become more widely accepted, healthcare managers, clinical care quality and safety agencies, as well as the public require evidence of the overall value of NMPs 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, 2017).

Multiple studies have a focus on new roles and appropriate skill mix for general practice, not least because of the on-going shortage of GPs but also because of the growing number of different issues and tasks that general practices must tackle (Maddox et al, 2016; Nelson et al, 2019; Carey et al, 2020).

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 (2014) highlighted the importance of organisational features such as role collaboration and teamwork. They suggested that in the organisations they observed where the 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 excluded from this paper. There were no studies looking particularly at the impact of NMPs 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 and 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 (i5 Health, 2015). To ensure that practitioners wishing to enhance their skills can undertake the appropriate training with 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. CPD must be placed to strengthened and support NMPs and ensuring that they are up to date and confident to prescribe within 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 health care provision. To enable the population to have adequate access to medicines, it will be key that NMPs are utilised, and their expertise and competences 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 NMPs 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, it is essential that practices 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 NMPs are job autonomy, satisfaction, and quicker access to medication.
• Negative perceptions of NMPs are litigation risk, increase workload and lack of support.
• To successfully implement NMPs the whole organisation 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?