Since 2005, radiographers have had the authority to act as non-medical supplementary prescribers Department of Health (DoH, 2005a). It is only in recent years, however, that the introduction of radiographer independent prescribing has been passed.
Although the primary role of the therapeutic radiographer is treatment planning and delivery, it has been recognised that the role extends far beyond this. NHS England acknowledge that ‘therapeutic radiographers play a vital role in the delivery of radiotherapy services and are extensively involved at all stages of patients' cancer treatment’ (NHS England, 2016a).
Non-medical prescribing (NMP) is becoming invaluable to evolving radiotherapy roles and practices, enabling radiographers to provide the best possible care to patients.
NMP is important to both the radiography profession and to the modernisation of the NHS by improving services, patient pathways and patient's access to medicines (DoH 2005b, DOH, 2006). The NHS Cancer Plan, supported by the College of Radiographers (CoR), encouraged radiographers and other allied health professions (AHPs) to extend their roles and develop new skills, knowledge and competencies, which crossed traditional boundaries (DoH, 2000; CoR, 2000; CoR, 2002). The National Radiotherapy Advisory group (NRAG) report acknowledged that a significant proportion of a doctor's routine work (20%) could be delivered by appropriately trained non-medical health care professionals in specialist roles (NRAG, 2007).
Radiographer NMP was thought to have the potential to relieve clinical oncology workload pressures (NHS England, 2016a). The Royal College of Radiologists (RCR) estimates a shortfall in the UK oncology workforce of approximately 250 full-time consultant clinical oncologists by 2022 (RCR, 2017). The NHS strategy for England 2015-2020 recognises the need to address these critical workforce deficits, including clinical oncology, by undertaking a strategic review of workforce needs and skill mix (NHS England, 2015). Advances in radiographer roles and services, including radiographer NMP, have been developed to facilitate these requirements. A survey carried out by the Society of Radiographers in 2012 evaluated radiotherapy services from 43 centres across the UK and identified the variety of roles and scopes of practice within the therapeutic radiographer profession (SCoR, 2012). At the time of the survey, it was reported that 67% of centres had radiographerled treatment planning service, 65% had tumour site specialist radiographers, and most centres (81%) had radiographer-led on treatment review services. Therapeutic radiographers in advanced, expert and consultant practitioner roles are becoming ever more pertinent to the maintenance of clinical oncology services, with prescribing medicines considered an essential competence for advanced and consultant radiography practice (Hogg et al, 2015).
Radiographer NMP ensures patients are mostly able to receive all of their care at a single point of contact from one professional (NHS England, 2016a). It is considered essential to prevent unnecessary and avoidable delays in care provision (NHS England, 2014; Hogg et al, 2015; SCoR, 2016a). It also improves accessibility of care to patients (NRAG, 2007; NRAG, 2016b; NRAG, 2007).
Where have we been and where are we now?
The NMP initiative dates back to 1986 and was primarily intended for community nurses (DHSS, 1986; DHSS, 1992; DoH, 1999). The potential for extending prescribing rights to include other health care professionals was recognised in the second crown report, which recommended health care professionals, including radiographers, be given the authority to prescribe to meet the demands of the modern NHS (DoH, 1999; DoH, 2001). Since 1998, radiographers have been trained to administer drugs from a limited list, for management of treatment side effects under patient group directions (Francis and Hogg, 2006). In 2005 legislation was passed for therapeutic radiographers to qualify as supplementary prescribers under the Medicines for Human Use (Prescribing) order 2005 (DoH, 2005).
Supplementary prescribing was thought to be most suited to chronic conditions such as cancer and was a major mile stone for the radiography profession (Francis and Hogg, 2006). It has enabled some therapeutic radiographers to change the way their services are delivered, providing benefits for patients (NHS England, 2016a). It is still widely used in radiotherapy and is essential to aspects of radiographer prescribing. However, fundamental issues in its mechanism have been identified that have made it difficult to implement in some situations (Kinsman, 2015). Limitations have notably included: poor uptake in the signing of clinical management plans (CMP), or unanticipated side effects or a change in the patient's condition requiring unplanned care rendering the CMP obsolete (Kinsman, 2015; Evans, 2018; Kinsman, 2015; NHS England, 2016a). These limitations have resulted in delays in access to medicines and prolonged symptoms (Courtenay et al, 2012; Evans, 2018). It was recognised that extending prescribing rights of radiographers from supplementary to independent had the potential to improve patient experiences by reducing delays as well as improving patient choice, safety and outcomes (NHS England, 2016a). In the 2016 public consultation proposing to introduce independent prescribing for radiographers, it was reported that 94% of both organisations and individuals supported amendments to legislation (NHS England, 2016a). Amongst those were the Society and College of Radiographers (SCOR), the Health and Care Professions Council (HCPC), the RCR, Macmillan Cancer Support, members of the public and individual radiographers.
Supporters commonly referred to the impact this would have on improving patient care and their support of the redesign of radiotherapy services. Subsequently, in 2016 the legislation changed to allow independent prescribing in therapeutic radiographers (SCoR, 2016b). The HCPC's most recent published data from 2018, quantified the numbers of radiographers who hold a qualification in NMP. At the time of publication, 78 therapeutic and seven diagnostic radiographers were supplementary prescribers and 56 therapeutic radiographers were independent prescribers (HCPC, 2018a). These numbers are likely ever increasing.
Radiographer NMP in practice
The SCoR define the scope of an independent prescribing therapeutic radiographer as including prescribing any licensed medicine, within national and local guidelines, for any condition within the practitioner's area of expertise and competence under the overarching framework of cancer treatment (SCoR, 2016b). All professional groups who prescribe follow the same standards set out in the single competency framework (RPS, 2016). The HCPC also outlines specific standards for AHPs to ensure registrants work within the scope of practice and legal framework (HCPC, 2018b). Due to the diverse nature of the radiotherapy profession; radiographers should develop their own individual scope of practice as they determine competency and the demands of service, depending on their role (SCoR, 2016b).
It is predominantly radiographers in advanced practice and expert consultant roles that are suited to NMP (Hogg et al, 2015). A prerequisite of an AHP becoming a NMP is that they should have 3 years' relevant postgraduate experience, allowing for the practitioner to develop and become specialised in their field. It has been proposed that maturity in a role can improve self-efficacy and self-confidence in NMP practices (Courtenay and Berry, 2007; Cope et al, 2019).
Therapeutic radiographer undergraduate training, although intense, is limited to radiotherapy, oncology and cancer care. Similar to other AHPs, radiographer training embodies a specific scope of practice but does not necessarily prepare radiographers for prescribing. It is postgraduate NMP courses that provide the theory, knowledge and skills required to prescribe. According to the HCPC, radiographers should be capable of making ‘a prescribing decision based on relevant physical examination, assessment and history taking' (HCPC, 2018b). These are skills that are taught and assessed in the NMP educational syllabus. It is not mandatory however, in the author's local practice, completing further education in advanced practice such as clinical examinations and diagnostics (not necessarily inherent to radiographer training) has enhanced clinical analytical skills and been conducive to the development of advancing practice within radiotherapy and expanding prescribing practices and personal formularies.
Radiographer formularies may cover a plethora of medicines for the management of cancer-related symptoms, radiation induced toxicity and medicines used for treatment and cure of specific cancers within the radiographer's individual scope of practice (SCoR, 2016b). The most common cancers treated with radiotherapy are prostate, breast and lung. However, radiotherapy, and therefore specialist roles, extend to other sites including head and neck, neurological, upper and lower GI, urological, gynaecological, bone, skin and soft tissue cancers in both a radical and palliative setting. Common side effects include pain, nausea and vomiting, altered bowel and bladder function, mucositis, oesophagitis and skin reactions. Appropriate management of these side effects therefore requires a wide range of drugs such as analgesia, antiemetics, proton pump inhibitors, topical creams, and steroidal and non-steroidal treatments. Those in advanced and consultant site specialist roles who have been suitably trained may also be responsible for prescribing treatment and adjuvant therapies such as endocrine and other systemic anti-cancer therapies.
The formularies of radiographers are not exhaustive. Currently, independent prescribing therapeutic radiographers are not permitted to prescribe controlled drugs. Legislation is due to be changed in 2019, subject to relevant amendment of The Misuse of Drugs Regulations 2001. This will permit prescribing from a list of controlled drugs which support patients with conditions most commonly seen by radiographers (SCoR, 2016b). The proposed formulary includes: tramadol, lorazepam, diazepam, morphine, oxycodone and codeine (SoR, 2018). The current radiographer prescribing statute dictates that these drugs can be only prescribed under the supplementary prescribing scheme, via a CMP, developed and agreed prior to prescribing (SCoR, 2016b). For a CMP to be legally valid, the independent prescriber must be a medical doctor or a dentist who is part of the team responsible for the patient's care (SCoR, 2016b; NICE, 2019).
As radiographer roles develop, more autonomy will be gained and, as such, integrating efficient supplementary prescribing into practice can be difficult in some cases. An example of this can be seen in the consultant radiographer-patient pathway. Consultant radiographers are seen as autonomous practitioners and may need to assume responsibility for their own caseloads in their specialist field. Unlike other advanced practitioner roles, a patient may be referred directly from the multidisciplinary team (MDT) to the consultant radiographer. If the consultant radiographer identifies the need for a drug such as morphine, commonly used for pain management in cancer care, they must prescribe under the supplementary prescribing scheme. A CMP is unlikely to have been agreed as this group of patients is not routinely reviewed by an oncologist, leading to potential delays in treatment whilst the radiographer seeks support from the MDT to enable appropriate prescribing.
There are many external factors that can facilitate or inhibit NMP. These can be organisational constraints, policy, or the ability to prescribe or support patients (Francis and Hogg, 2006; Latter et al, 2010). The impact of support on the success of implementing and maintaining NMP is well-documented and deemed as influential to prescribing practices (Francis and Hogg, 2006; Courtenay et al, 2012; Graham-Clarke et al, 2018; Evans, 2018). Evans (2018) highlights that it is a challenge for the newly qualified NMP radiographer to develop trust, understanding and appreciation of the NMP role within the MDT. They found that peer support and monitoring can minimise prescribing risks and aid the development of competence and confidence. Kinsman (2015) further discusses the impact of support within the radiotherapy arena.
This study found that medical support was improved when the medic was directly involved in NMP training. Having witnessed the intensity of training, the medic had more confidence in the ability of the radiographer to safely prescribe. Furthermore it has been suggested that collaborative working can help to better prepare the patient. Other members of the MDT introducing NMP to the patient early in the patient pathway heightens awareness and acceptance of the radiographer's ability to prescribe (Evans, 2018). This is essential for involved and shared decision-making in prescribing. Patient partnerships should be central to NMP practices to ensure patients are satisfied, involved and comfortable with the care they are receiving.
There are undeniably many benefits to NMP within radiotherapy. However, limitations to prescribing practice can negatively impact the patient pathway and the development of evolving radiographer roles, especially in more autonomous roles. As prescribing practices develop within the radiography profession, these limitations will gradually dissipate.
The impact of NMP in radiotherapy
NMP not only has the potential to improve patient experiences, but also the prescriber's personal development and furthermore the experiences of the extended workforce. In radiotherapy, the impact of NMP is under-reported. However, from the available evidence base it is clear that NMP has positive influences on the patient pathway (Francis and Hogg, 2006; Kinsman, 2015; Nisbet, 2019). Nesbit (2019) evaluated how the introduction of NMP impacted radiographer led on-treatment review services in a single radiotherapy department. They concluded that NMP supports the delivery of a seamless review service, reducing the need for repeated assessment and review, enhancing patient care, improving accessibility and supporting the MDT by using the skills of the workforce more effectively. They note that, in auditing practices, the presence of prescribing radiographers in clinics positively impacted the oncologist's time. Where the task of assessing and prescribing medications was carried out by a radiographer, the oncologist saved approximately 3 hours a week (Nisbet, 2019). Evans (2018) supports this by confirming that prescribing by radiographers allows patients to have access to medicines in a timely manner and frees up consultants time for more complex cases. Kinsman (2015) reports the results of a patient satisfaction survey evaluating radiographer-led review services and acknowledges the impact of NMP. All of the respondents felt that the radiographer gave them clear information about the name and purpose of any medications they prescribed, quoting radiographers did so with ‘competence’ and ‘good knowledge’. The study goes on to consider the competence of experienced radiographers in managing radiotherapy toxicity. Currently, radiographers have to seek assistance from a doctor for a prescription to be written, which not only is a waste of resources but can also be professionally demoralising for the radiographer. NMP facilitates the growth of advanced and consultant practitioners within oncology and facilitating advanced practice has been found to encourage staff retention (Evans, 2018; Hogg et al, 2015).
The impact of NMP amongst nurses and other health care professions has been more widely reported, and outcomes are similar to that found in radiotherapy. A systematic review and thematic analysis of 42 studies was carried out in 2018 to assess facilitators of, and barriers to NMP (Graham-Clarke et al, 2018). This study summarises the impact of NMP on the professional. Themes identified included enablement of autonomy, increased job satisfaction, role enhancement and support of professional development. Although results were mainly positive, some practitioners did express increased anxiety due to NMP. Latter et al (2005) report that practitioners feel that prescribing authority improves their relationships with patients.
Weeks et al reviewed 46 studies and found that patients were satisfied with the NMP care they received (Weeks, et al, 2016).
Conclusion
The introduction of radiographer NMP has been pivotal to the professional development of therapeutic radiographers. The implementation of both supplementary and independent prescribing has proved to benefit the patient, the radiographer and the workforce as a whole. The ever advancing and developing roles of the radiographer can be enhanced with NMP and are essential to the continuing development and maintenance of oncology services. The challenges of prescribing limitations are gradually being overcome with recognition that the practice of the therapeutic radiographer is not limited to delivery of radiotherapy but can extend across the whole patient pathway. There is a need to further assess the impact of NMP within radiotherapy as there is currently a limited evidence base.
Central to healthcare is the patient. Objectives set out in the NHS' Five Year Forward View, the NHS Cancer Plan, and NHS Long Term Plan focus on improving patient pathways, patient experiences and accessibility to care (NHS England, 2014; (DoH, 2000; 2001; 2007; NHS England, 2019). NMP in radiotherapy embodies these notions providing radiographers with the tools to fulfil these requirements.
CPD reflective questions
- What implications has non-medical prescribing had on your specific role or service?
- Can you use this article to identify gaps in the evidence base that you may wish to investigate within your field of practice?
- Do your prescribing practices reflect your scope of practice as a radiographer?
Key Points
- The role of the therapeutic radiographer is ever developing. Non-medical prescribing has been noted as essential to the advancing roles.
- Workforce preasures within clinical oncology mean that non-medical prescribing has the potential to ease workload pressures by improving skill mix within the multidisciplinary team. Non-medical prescribing by radiographers has shown to be safe effective and beneficial to patient care.