The last research roundup provided you with an overview of some papers covering the areas of prescribing errors and of electronic prescribing (Robertson, 2021). The studies looked at prescribing error rates between doctors in pharmacists in one trust and then at errors using an electronic prescribing system for discharge prescriptions and the impact of electronic prescribing on prescribing opioids and the issue of overprescribing.
This month we look at the impact of non-medical prescribing in some clearly defined settings. The first article looks at the subject of perceived medical dominance and how the introduction of non-medical prescribing may have impacted on this dominant stance. The second looks at the impact of paramedic prescribing in emergency, urgent and critical care. Finally, we will review the impact of optometrist prescribing in primary care settings.
The rise of non-medical prescribing and medical dominance
This article published in the Journal of Research in Social and Administrative Pharmacy seeks to contribute to the ongoing dialogue in the professional arena of the dominance of the medical professional since the inception of non-medical prescribing (Weiss, 2021). The author focuses on the fact that prescribing allows the clinician to exercise their clinical autonomy stating that the right to prescribe gives them control over the object of their work, that being the prescription, through their ability to independently make decisions on care involving medications. The issue of whether or not non-medical prescribers pose a threat to the medical dominance of doctors is discussed. The profession discussed in this paper are pharmacists; the rationale for choosing them is that the author feels they are a profession that poses a competing claim to dominance due to the long association with medicines and supply. The issues of jurisdiction and professional ideology are also covered. The article gives a background to the inception and development of pharmacist prescribing and the legislative changes required before exploring the profession of pharmacy in general. The dominance of the medical profession and the perceived threat to this is then discussed and the author identifies strategies supporting this dominance such as the legitimising and overseeing of supplementary prescribing, deference to doctors by other professions, and diagnostic skills and responsibilities.
The paper suggests that the professional ideology of medicine has shifted from valuing prescribing to valuing the indeterminacy involved in complex clinical decision making, illustrating medicine's ability to adapt, retain dominance and maintain cultural authority over clinical knowledge. In contrast, pharmacist prescribers' professional ideology surrounds specialist medicines expertise and being seen to be safe prescribers. Pharmacists draw upon this ideology to argue their unique competence as a prescriber: given their pharmacological knowledge and their acknowledged attention to detail, which makes them a ‘safety net’ on prescribing. However, medicine's cultural authority in clinical decision-making enables, when there are competing jurisdictional claims overprescribing, for doctors to retain intellectual jurisdiction: control over the cognitive knowledge base involved in prescribing and clinical decision making. This makes a very interesting read.
Non-medical prescribing by paramedics in emergency, urgent and critical care
This article published in the Journal of Paramedic Practice considers the impact of paramedic prescribing in the clinical areas of emergency, urgent and critical care (Bedson, 2021). The drive for this occurred partly from the lack of publications in this clinical setting of paramedic prescribing compared to those in the primary care areas.
This article considers some of the unique considerations and challenges that are associated with non-medical prescribing in the context of paramedic emergency care. In contrast to primary care, advanced paramedics practicing in emergency settings are more likely to encounter patients who require an immediate supply or administration of medication and access to a range of controlled drugs. Due to legislation surrounding controlled drug prescribing paramedics are unable to prescribe these independently and must rely on exemptions, PGDs or supplementary routes of supply. The other challenge they can face are access to patients' medical records and access to clinical support in decision making. The issue of prescribing, dispensing and simultaneous administration is also discussed. This mainly applies to ambulance and prehospital settings and is an area of concern as separating prescribing and dispensing is widely considered to be best practice in reducing prescribing errors and promoting good medicines management. The authors conclude that while the adoption of non-medical prescribing by advanced paramedics is likely to be associated with a range of improvements to patient care and professional practice, several potential issues currently exist for advanced paramedics working in emergency, urgent and critical care. They recommend that further research is required to understand whether the anticipated benefits are being realised for patients and NHS services. This is particularly the case in the context of prehospital emergency, urgent and critical care settings.
Towards transforming community eye care: an observational study and time-series analysis of optometrists' prescribing for eye disorders
This article published in the Journal of Public Health looks at the impact of optometrist prescribing for eye disorders in community settings in Scotland (Jonuscheit et al, 2021). It aimed to provide evidence on the therapeutic prescribing activity by community optometrists and determine its impact on workload in general practice and ophthalmology clinics. In order to qualify as optometrist independent prescriber (OIP), optometrists are required to have a minimum of two years of clinical work experience, to undertake three postgraduate modules in therapeutic prescribing, to complete 24 clinical hospital sessions under the supervision of an ophthalmologist and to pass a common computer-based assessment.
Anonymised data were provided by the Information Services Division (ISD) of NHS National Services Scotland for a 53-month period (November 2013–April 2018) and were used to analyse non-medical prescribing practice by optometrists.
The study employed an interrupted time-series regression to assess the impact of optometrist prescribing on ophthalmology outpatient attendances and general practice prescribing for eye disorders. In total 54 246 items were found to have been prescribed by 205 optometrists over the study period. The analysis focussed specifically on OIP and general practice prescribing activity relevant to eye care and was limited to eye-related medicines specified in section 11 of the British National Formulary (BNF). A consistent trend of increasing prescribing activity with some seasonal dips was observed.
Since the commencement of data recording, optometrist prescribing activity increased steadily from a baseline of zero to 1.2% of all ophthalmic items prescribed. However, the monthly number of items prescribed was not associated with a reduction in ophthalmology outpatient appointments over time.
The authors conclude that although optometrists are increasingly contributing to community ophthalmic prescribing in Scotland, which in turn is freeing up capacity and lessening general practice involvement it is not having an impact on secondary care workload. They suggest an underutilisation of optometrists related to the management of dry eye, which represents an opportunity to release further capacity and recommend further investigation and roll out of prescribing.
Conclusion
As qualified, training or aspiring non-medical prescribers, you will be aware of the impact that it has had on practice form your own experiences or those of the people you care for. These articles demonstrate the impact of non-medical prescribing in some well-defined areas. As prescribing continues to be embedded in the professions allied to medicine, especially in developing professional roles we should hope to see more research evaluation the impact on patient care.