On completion of the independent and supplementary prescribing course in 2019, I was proud to be one of 689 Allied Health Professionals, Non-Medical Prescribers (NMPs) on the HCPC (Health and Care Professions Council) register (i5 Health, 2015). I was excited to get started and put my new skill into practice. What was not in the script was to begin my prescribing journey during a great shift in normal practice due to the emergence of COVID-19.
Experience through the pandemic
Throughout my training, and as a newly qualified NMP, I was fortunate to work closely with a multidisciplinary team of consultants and nurse specialists in the specialty of rheumatology, all of whom had great depth of knowledge and experience in prescribing. I felt this team guidance and support was still required as this was only at the beginning of my prescribing journey. Alongside this, physiotherapy prescribing roles in comparison to nursing are still in their infancy. I was reliant upon my team for support as there was only one other physiotherapist NMP within the trust, working in a more classical nursing role within a different specialty. As a physiotherapy prescriber working in advanced practice within a therapeutic role, differences in what was required in my practice compared to my team were anticipated, as the prescribing need in therapies is very different to a nursing or medical role. With our clinics running in the same location as other members of the team, I was confident the prescribing support could continue, as would the support we usually provide for each other for any other need. But what happened when the pandemic hit? Clinicians stopped meeting in groups, they became less accessible and patients were reviewed virtually. Is telemedicine the environment to safely start prescribing? It was certainly not one that I anticipated.
Writing my first FP10 brought fear and anxiety. It had been a number of months since completing the course. It took time to receive the HCPC annotation to include my prescribing qualification, and time to get the required approval to start prescribing by my hospitals Trust. How could I be sure to make the correct clinical decision when I had not physically reviewed the patient? In medicine the prevalence of prescribing errors is known to be high (Elliott et al, 2018), with new prescribers known to make more prescribing errors than experienced prescribers (Dornan et al, 2009). Generalisations cannot be made to NMPs as this data is not available. It is plausible that the environment in which you prescribe may make a difference to how and why errors occur, and supervision is a factor in helping to minimise errors (Coombes et al, 2008). Furthermore, communication with patients is key in reducing drug errors. Patients are known to not always accurately recite their medical and medication history; will virtual assessments make information more difficult to extract? Communication is different in face-to-face assessments. Non-verbal communication may be more difficult with telemedicine, with less cues (Bailenson, 2021).
My team are at the end of a phone, but now that we are spread out due to social distancing, I cannot quickly go into the room next door to check with them that I am making the right decision. I felt I needed reassurance in my decision making, which was not readily available or quickly accessible. To manage the situation, I used avoidance. If I did not prescribe, I could not make a mistake. The responsibilities of prescribing are clear, and the legalities that come with this are reinforced during training and this was at the forefront of my mind (Medicines Act, 1968; Misuse of Drugs Act, 1971; The Human Medicines Regulations, 2012). I regularly wrote in my clinic letters to the patient's GP with recommendations to prescribe, and at times these included controlled drugs of which I could not independently prescribe. The use of supplementary prescribing would be logistically challenging. Supplementary prescribing in conjunction with the Consultant Rheumatologist or GP could be a possibility, but this method is not suited to my role where I would not need to prescribe the drug long term, and it would inevitably be taken over by the GP.
There will always be conflicting views on this matter, but the limitations as a physiotherapist being unable to independently prescribe controlled drugs was always going to be a frustration. For controlled drugs, the only feasible option was to continue to make recommendations for the GP to prescribe. This may well be considered the safest option if the drug is thought to be required long term. For short term use, alongside other treatment options, staying on a drug long term poses a risk to the patient if the GP is not pro-active at deprescribing. As there is not any evidence to suggest that physiotherapists cannot safely prescribe controlled drugs, I am hopeful with time that the list of controlled drugs that physiotherapist's can independently prescribe will change.
After many discussions with patients expressing their frustrations regarding GP access, I made the decision to start issuing the FP10. Despite my anxiety, I needed to trust the skills and knowledge I had learnt. I was not using a treatment that I was able to offer. Anxiety is closely associated with confidence levels to prescribe (Weglicki, 2015), with confidence known to increase with prescribing practice (Abuzour, 2018).
With my first FP10 written I gained confidence and continued to prescribe as required. I remained apprehensive that I had made an error. Had I made the right decision to prescribe? Had I written all of the required information on the FP10? What if the patient does not take the drug as prescribed? What if they experience side effects? It was imperative I was able to gain feedback on the decisions I had made and reflect on those decisions. I may have been inordinately thorough, however, following providing an FP10 I arranged a telephone consultation to check the patient had received the prescription, was taking the drug as prescribed and was tolerating it. This provided valuable feedback that my FP10 was correct and acceptable as the medication had been dispensed. I was able to reflect on not having caused harm to the patient and with some, had made a difference to their symptoms. My experiences did not highlight any frequent themes requiring a change in my practice, but it did reiterate the known potential challenges of prescribing. Patients may change their mind and decide against taking the prescribed drug. There will be instances when patients do not take the medication or take it as advised. This is minimised through information giving. Methods including verbal communication alongside a copy of the clinic letter with written advice sent to the patient, and the information being written on the dispensed medication. There will always be variability in patient concordance. Our aim must be to ensure joint decision making and inform patients the best we can to minimise the risks.
Conclusion
One year on in my prescribing journey I reflect on the positives and the challenges the pandemic has brought. Telemedicine is not the ideal environment for any prescriber, old or new. Telemedicine may be seen to be a more difficult consultation method, with the possibility of an effect on the clinician's concentration and being able to pick up on non-verbal cues less readily (Bailenson, 2021). We gain so much more information from face to face consultations, but telemedicine is here to stay and therefore prescribing following virtual consultations is also going to continue. A consideration may be to include how to safely prescribe remotely for current cohorts that are attending prescribing courses.
Positively, prescribing throughout the pandemic with a reduced level of support has ensured that I am fully independent and not reliant on others just because they are available. I have had to consider every decision made and be confident in my decision making. It may have been too easy to seek reassurance from others and I may have learnt less. The route to starting prescribing may not have been an easy one but long term I feel it has made me a safer and truly independent prescriber. Every time I write an FP10 it is my responsibility, one that has huge implications if the decision is not the correct one. There is nowhere to hide as an independent prescriber but the role is also one that comes with a great privilege. That fine line between helping and hurting patients is always at the forefront and one that we should all aim to keep in our focus.