What's in a name? The complex conundrum of prescribing nomenclature in practice

Prescribing by health professionals other than doctors or dentists in the UK was first proposed in the Cumberledge report in 1986 (Department of Health and Social Security (DHSS), 1986). This was specifically for the nursing profession. The report highlighted that community nurses were wasting a significant amount of time seeking prescriptions from GPs for medications and items for which they had carried out a thorough clinical assessment. The report suggested that increased efficacy of practice, and better use of time, could be achieved if community nurses were able to undertake prescribing from a limited formulary. This recommendation was supported by the government, leading to the Report of the Advisory Group on Nurse Prescribing (Department of Health (DH), 1989), led by Dr June Crown. The report expanded on the Cumberledge report, recommending that district nurses and health visitors should be able to prescribe from a specific nurse formulary.

The necessary legislation permitting nurses to prescribe medicines from the limited formulary were enacted in the Medicinal Products: Prescription by Nurses etc. Act 1992, and came into force in 1994 through further amendments in law through The National Health Service (Pharmaceutical Service and Charges for Drugs and Appliances) Amendment regulations 1994. The new role of ‘nurse prescriber’ was initially piloted and evaluated across eight sites in the UK (Luker et al, 1997) before being opened to all eligible nurses in 1998. Implementation was rapid, and by the spring of 2001 there were 20 000 qualified nurse prescribers (Courtenay and Butler, 2002). In 1997, the government commissioned a second review led by Dr June Crown, the conclusions of which were published in the Review of Prescribing, Supply and Administration of Medicines (DH, 1999). The report described various changes within the health service including:

• Increased level of training and specialisation of health professionals
• Changes to patient expectations
• Differences in the way that care is delivered (e.g. more multidisciplinary working).

‘There has been a seemingly generic move towards referring to “independent prescribers”; however, this is not inclusive of the range and diversity of professional prescribing annotations’

It recommended that to meet the pressure on the health service, the ability to prescribe medicines should be expanded to a broader range of healthcare professions.

Legal annotations of prescribers

The DH (1999) report marked a critical shift in the phraseology, legal premise and practice scope of prescribing professionals that remains in place today. Prescribing activity and legal permissions were clearly defined into specific categories: independent and dependent.

• Independent prescribing was defined as activity where a prescriber is responsible for the initial assessment, diagnosis, formulation of the treatment plan, and ability to prescribe the required medications for the plan.
• Dependent prescribing (which later came to be known as supplementary prescribing) was defined as activity where the prescriber may prescribe medications for patients whose condition has been assessed and diagnosed by an independent prescriber, and may only prescribe within the boundaries of an agreed treatment plan. With independent prescribing, as presented above, there is a formal transfer of responsibility from the assessing independent prescriber to the supplementary prescriber for ongoing treatment. Critically, the independent prescriber in this type of prescribing partnership retains oversight and responsibility for the initial diagnosis. Subsequently, the DH (2006) clarified that the independent prescriber governing the supplementary prescribing process must be a doctor or dentist.

The recommended expansion of prescribing rights following the second Crown report has been steady; supplementary prescribing was introduced for nurses and pharmacists in 2003 (DH, 2002), for optometrists, physiotherapists, podiatrists and radiographers in 2005 (Health and Care Professions Council (HCPC), 2005; General Optical Council, 2008), dietitians in 2016 (NHS England (NHSE), 2016), and paramedics in 2018 (NHSE, 2018). Independent prescribing for nurses and pharmacists was introduced in 2006 (DH, 2006), for optometrists in 2007 (DH, 2007), for physiotherapists and podiatrists in 2013 (DHSC, 2012), for therapeutic radiographers in 2016 (NHSE, 2016) and for paramedics in 2018 (NHSE, 2018).

Nursing and Midwifery Council (NMC) registrants may also undertake education, which cumulates with qualification and annotation as a community practitioner nurse prescriber (CPNP). Prescribing as a CPNP is limited to the medicinal products noted in the specific nurse prescriber formulary for community practitioners housed within the British National Formulary (Joint Formulary Committee, 2023). This formulary includes medicines and products such as limited analgesics, catheter maintenance solutions, laxatives, emollients and wound dressings, and has been expanded upon from the original limited nurse prescriber formulary detailed previously. All prescribers, be they independent (IP), supplementary (SP), or CPNPs, are identified by an annotation next to their name in the relevant professional register.

Nomenclature and its impact on prescribing clinicians, policy and practice expectations

‘All things are defined by names. Change the name, and you change the thing.’ Terry Pratchett, Pyramids (1989: 100).

Currently, there are various means by which prescribers who are not doctors or dentists (collectively medics) are described. The adoption of naming convention across this collective group lacks consistency and at times is confusing.

The study of names (onomastics) is, in part, concerned with the function that names have in providing a meaning to something (Nordquist, 2019). Names provide a person or a role with an identity; these can be inclusive or exclusive (Mackenzie, 2018). By using a role descriptor that includes the identification of their core registration (dietitian, paramedic, nurse, etc), it is immediately apparent that the health professional is a prescriber who is ‘non-medical’; i.e. by default they are not a doctor or dentist. When looking at individual classes or roles within this collective, the use of a professional prefix, followed by the legal prescribing activity permitted, adds value and meaning to the name as it further informs others as to the core profession of the prescriber (i.e. pharmacist supplementary prescriber). Subsequently, the use of the noun ‘prescriber’ adds meaning to the name as it describes the activity that the professional can undertake.

In the health literature and government documentation there is an inconsistent approach to naming convention. Reports and policy refer to the terms ‘independent prescriber’ or ‘supplementary prescriber’, alongside the profession where appropriate (e.g. independent pharmacist prescriber); however, there has been a move within the wider healthcare community and associated literature to use ‘non-medical prescribers’. While the meaning is now explicit, it is not clear where this term came from initially. A scoping search identified only one article published up until 2000, which used the term ‘non-medical prescribing’: a discussion piece in the Archives of Disease in Childhood about the implications of the Crown Report (Stephenson, 2000). This paper fleetingly mentions ‘non-medical prescribers’ as a collective noun. A further reference to non-medical prescribing was made by The King's Fund (2001) report on nurse prescribing. It was not until 2003–04 that references made to ‘non-medical prescribing’ have increased over time, becoming more commonplace in the professional literature; for example, by the College of Podiatry (2018) and Health Education England (HEE, 2023).

Although the intention of the term ‘non-medical’ may have been to collectively identify groups of practitioners, it has been anecdotally recognised that, to give a title that starts with ‘non’ may hold negative connotations and is not well received. It may be seen to imply a lesser level of skill or competence, rather than a different and highly skilled role, and form of career development. The collective noun ‘non-medical prescribers’ may be effective when used to describe the group of prescribers who are not doctors or dentists in policy and overarching governance.

The Royal Pharmaceutical Society's (RPS) (2021)Competency Framework For all Prescribers represents the core competencies and expectations of all prescribers. It forms the foundation of all prescribing education delivered to health professionals who are not doctors or dentists. The RPS (2021) seeks to offer clarity to the wider audience, detailing practitioners who have prescribing rights, but who are not doctors or dentists as non-medical independent and/or supplementary prescribers. Here, the relevant annotation and title is subsequently aligned to the individual prescriber.

This approach is inclusive as it denotes the professional variation, but also the legal premise of prescribing activities variation. It is paramount to remember that all prescribing health professionals have undertaken extensive education and competence, irrespective of annotation or ‘type’ of prescriber. All hold professional responsibility, have demonstrated clinical skill in their area of practice, and autonomy in the type of prescribing for which they are legally permitted to prescribe.

Discussion

There has been a seemingly generic move towards referring to ‘independent prescribers’; however, this is not inclusive of the range and diversity of professional prescribing annotations. At best, this overarching approach may detail some professionals' legal prescribing annotation and rights, but at worst could exclude groups of highly skilled prescribers, and misrepresent, and mislead clinicians, patients, and services regarding the scope of legal practice and policy.

While education provision covers NMC, HCPC and General Pharmaceutical Council registrants in CPNP (NMC only), IP and SP, each HCPC profession holds its own professional, legal boundaries in prescribing (and not all HCPC professions have legal prescribing rights). Some HCPC registrants may only become SP at present; additional legal boundaries are in place around independent prescribing of controlled drugs depending on professional registration, all prescribing HCPC registrants are prevented by law from independently prescribing unlicensed medicines (HCPC, 2021). This legal boundary has implications for those in practice, whereby a medication is licensed for another use but is known to have a beneficial side effect profile (which it is not licensed for), or prescribing for children. As such, some HCPC registrants who are IP and SP may need to use SP for certain elements of their practice daily.

The failure to acknowledge the use of, and legal rights granted by, SP may signal working practice that does not align to legal prescribing rights, and devalue this important, facilitative part of prescribing practice. Table 1 details HCPC registrants' legal prescribing annotations.

Hypothetically, for a HCPC registrant to only refer to their role as IP (when potentially dual annotations of IP and SP are in place) may lead to confusion in professional expectations, and a pressure to prescribe out with the legal entitlements. For example, the current legal inability for paramedics to independently prescribe controlled drugs or unlicensed medication may not be communicated to those they interact with. If a prescription for controlled drugs was required, the paramedic in this instance would need to employ their SP rights, or refer to an IP with the legal permissions to prescribe controlled drugs.

Physiotherapists and podiatrists are also included in the variance in legal permissions, but are afforded restricted ability to IP certain controlled drugs for specified routes of administration (Table 2). What is important is that all prescribers, irrespective of registration and prescribing annotation, are cognisant of the legal boundaries of their prescribing rights and only prescribe when competent, confident and within the scope of their practice.

The future of prescribing

In response to significant changes in the workforce, healthcare systems will require clarity and total inclusion for increasing extended or advanced clinical roles (HEE, 2017; NHSE, 2020). The rate at which ‘non-medical’ prescribing roles are evolving is rapid (NMC, 2022). England has seen a more than 220% (5124) increase in pharmacist independent prescriber between 2016 and 2020, with pharmacist prescribers outside of hospitals prescribing 32.5 million items in 2020/2021 (Wickware, 2021). Further to this, the NMC saw an increase in recorded prescribing qualifications to their register from 39 777 to 54 951 from 2018 to 2022 (NMC, 2022). This growth has taken place in response to systems changes with it being stated that national policy aimed for an additional 20 000 ‘non-medical’ prescribing roles in primary care in 2020 (Armstrong, 2023). In addition, there are an increasing number of advanced clinical practitioners who are often ‘non-medical’ prescribers (The Open University, 2023). These roles are being widely implemented into provision for mental health, acute and primary care (Bracegirdle and Carroll, 2022), and are expanding into social care settings such as care homes.

More recently, there has also been consideration of other, newer healthcare roles gaining prescribing rights, such as medical associate professions, including physician associates (PAs) and anaesthesia associates (AAs) (GMC, 2023). The Royal College of Physicians (Guest et al, 2022) states that there are approximately 2850 PAs and, in 2021 there were a reported 300 AAs (British Medical Association, 2022). These roles are currently not regulated, so are unable to be considered for prescribing rights, although there is movement towards GMC regulation (DHSC, 2019).

Conclusion

The naming and identification of roles should be facilitative to allow others to understand the legal context of prescribing activity, boundaries and role expectations. In some instances, such as policy or governance, the collective noun ‘non-medical prescribing/prescriber’ may be useful and inclusive; however, for individuals, a clear role descriptor that indicates professional registration and prescribing entitlements gives clarity to health and social care professionals and those they care for. It is not to be determined by a perceived hierarchy of skill or status. All types of prescribing represent a high level of skill, decision making and knowledge.

Key Points

• The term non-medical prescribing can be an effective descriptor-defining prescribers who are not doctors or dentists; however, this may not identify the scope or framework of prescribing in use
• Effective use of naming conventions will allow patients and members of the public a greater understanding of the role, function and capabilities of the prescriber that they are working with
• Organisations should consider the adoption of a shared naming convention to facilitate easy identification of prescribers by legal responsibility and core role
• Teams and organisations must be aware of the differing professional limitations places on prescribers
• Changes to prescribing rights are governed by legal and professional process. New prescribing professions, and expansion to current professions legal entitlements is ongoing

CPD reflective questions

• Do you consider the use of the phrase ‘non-medical’ to add or detract value from a person's prescribing annotation? Why?
• Does the use of core profession descriptions allow easier identification of the likely scope and role of the prescriber for patients and members of the public?
• Are you aware of the different profession's prescribing in your clinical area, and any differences in their prescribing abilities linked to that profession?
• Are you aware of how to access your organisational non-medical prescribing policy and clinical lead?