Last month's research roundup provided an overview of articles assessing the role and remit of physiotherapist prescribers (Robertson, 2022). This month, we will review papers concerning podiatrists and their prescribing practice. The first is a review of the progress made in podiatry prescribing in the UK, while the second reviews podiatric prescribing in Australia. The final paper examines UK podiatric surgery and the role of the prescribing podiatrist in this advanced field of practice.
A decade of independent prescribing in the UK: a review of progress
This paper, published in the Journal of Foot and Ankle Research, is a review of progress made in independent prescribing in the UK (Fitzpatrick and Borthwick, 2022). Its publication marks the 10-year anniversary of podiatrists securing the right to train as independent prescribers in the UK, and reviews the journey podiatrists and other allied health professionals have had to take to gain the prescribing rights they now hold. Progress to independent prescribing status was slower for the aforementioned professionals than for nurses and pharmacists, and they still do not have equal access to all prescribing privileges. However, the milestone advent of independent prescribing has enabled a significant advance in clinical autonomy and a broader scope of practice, improving access to medications for many patients.
The authors go on to discuss how recent attempts by the profession to expand their scope, to allow access to more controlled drugs, have brought the limitations of the current legislative provision to attention. Fitzpatrick and Borthwick (2022) suggest that the limitations applied to allied health professionals create restrictions where none are needed, and that they could have full, safe access and work within their scope and competence, as nurses and pharmacists already do. There is also a comprehensive discussion about the impact of medicines reclassification on podiatrists, as they only have access to a limited list of drugs that is not updated. Specifically, this discussion referenced the reclassification of Tramadol, which, prior to reclassification, had been widely used by podiatric prescribers, highlighting the issue of current legislation being restrictive and slow to change.
The data underpinning much of this paper were derived from the work undertaken by the authors as podiatry representatives for NHS England's Chief Professions Officers’ Medicines Mechanisms Programme, specifically that involving submissions to the Commission on Human Medicines and the Advisory Council on the Misuse of Drugs. The authors outline suggested options for change, including an amendment to legislation to bring podiatrists in line with other independent prescribers and remove current prescribing restrictions. Other suggestions include reforming the current misalignment between the Misuse of Drugs Regulations 2011 and Human Medicines Regulations 2012, to combine and streamline the prescribing and decision-making processes. They state that this would need to be underpinned by an integrated set of procedures between the Department of Health and Social Care and the Home Office. A further suggestion made is to address the matter of the utility of the prescribing authority embedded in regulations 6b and 6c of the Misuse of Drug Regulations 2011 for the non-medical/non-dental professions, to clarify the need for such authority. The authors conclude that no change to the current position for podiatrists is not a feasible option, as it constitutes a hindrance to the profession; however, it is noted that real change may be problematic and slow.
Australian podiatrists scheduled medicine prescribing practices and barriers and facilitators to endorsement: a cross-sectional survey
This paper, published in the Journal of Foot and Ankle Research, examines the practices, barriers and facilitators to obtaining a prescribing qualification and endorsement for Australian podiatrists, utilising a quantitative, cross-sectional study approach (Graham et al, 2022). The authors start by outlining the current prescribing context, noting that the use of non-medical prescribers in areas with a shortage of medical practitioners has proved to be cost-effective and acceptable to patients, with no detriment to patient care and outcomes. Therefore, podiatrists are well-positioned to create efficiencies through prescribing. However, only a small proportion of Australian podiatrists are endorsed to prescribe scheduled medicines.
The researchers approached participants who were practising podiatrists, via a combination of professional networks, social media and personal contacts. Participants were then given an online survey to complete and submit. This survey had been developed by the authors based on previous research and a pilot study. Demographic data and information on prescribing practice and on barriers and facilitators to qualification as a prescriber were collected. Of the 5759 registered podiatrists in Australia who were eligible to participate in this study, 225 responded to the survey invitation. Only 15% were already endorsed as prescribers, with a further 11% currently in training. The majority of respondents were female, aged between 25–45 years, were working in private practice and were located in cities. In the group of respondents who were not endorsed to prescribe, 66% reported a desire to undertake training to allow endorsement.
The most common indications reported where prescribing was considered necessary or medication recommendations occurred include nail surgery (71%), foot infections (88%), post-operative pain (67%) and mycosis (95%). The most recommended medications were ibuprofen, paracetamol and topical terbinafine. The most prescribed medicines among endorsed podiatrists included lignocaine (84%), cephalexin (68%), flucloxacillin (68%) and amoxicillin with clavulanic acid (61%).
With regard to facilitators to undertaking the prescribing endorsement, respondents cited the most useful factors as working with already endorsed prescribers; support and encouragement from leaders and managers; gaining essential skills for their scope of practice; and future career enhancement opportunities. When it came to barriers, participants cited factors such as lack of incentives to train; time away from practice to train; being located in remote areas with little opportunity; lack of funding; or being too close to the end of their career to make it worthwhile.
The researchers conclude that prescribing endorsement allows prescribing in areas such as pain and inflammation, as well as infection, which enhances patient care. However, the lack of funding to undertake this endorsement was the major barrier for aspiring prescribers.
Prescribing, supplying and administering medicines: a contemporary review of podiatric surgery in the United Kingdom
This paper, published as a preprint in Research Square, aimed to gain a greater understanding of the methods used by podiatric surgeons to access medications in the UK (Maher and Borthwick, 2021). The authors sought to identify whether prescribing was being adopted by podiatrists since the advent of independent prescribing, and whether alternate means of accessing medicines, such as patient group directions (PGDs) or exemptions, remain relevant in clinical practice. Information on medication access was recorded by podiatrists via a tailored database developed by the College of Podiatry, known as PASCOM 10. This database is divided into two domains that are dependent on the treatment offered, comprising invasive and non-invasive treatments. The PASCOM 10 system was accessed to generate reports and gather relevant data relating to podiatric surgery for 2019. A wide range of data were collected relating to episodes of care and medications as part of management.
It was found that there were 11 189 admissions for podiatric surgery in England recorded on the PASCOM 10 database in 2019. Some 103 surgery centres contributed data, resulting in the recording of 18,497 procedures. Surgery was typically performed in NHS settings (91%), with 94% of procedures carried out under local anaesthetic. In total, 18 576 medicines were supplied, administered or prescribed from a list of 70 individual items. Of this, 29% of medicines were prescribed by a podiatrist. Controlled drugs only accounted for 28.7% of prescriptions.
The authors identified an emerging trend in the methods of access to prescription-only medications by podiatrists, demonstrating a move towards independent prescribing as a means of better performing their role. However, the limited access to controlled drugs to manage conditions such as acute postoperative pain was problematic. The considerable use of exemptions, PGDs and recommendations for patients to purchase over-the-counter medicines where prescribing did not occur was noted.
Conclusion
Like other allied health professional prescribers, the number of podiatry prescribers has grown, with the Health and Care Professions Council (2021) recording 575 independent prescribers and 576 supplementary prescribers in 2021. It is clear that medication use is an important area of clinical podiatric practice, with prescribing being seen as a great advantage. However, podiatrists still continued to use PGDs and exemptions for access to medication relevant to the care they provide.