INTRODUCTION1.1 What isnon-medical prescribing? Non-medical prescribers (NMPs) are healthcareprofessionals who, despite not being doctors or dentists, are legally permittedto prescribe medicines, dressings and appliances subsequent to attaining anadvanced level qualification in prescribing. Non-medical prescribing withinhealthcare settings enables healthcare professionals to enhance their roles,using their skills and competencies effectively in order to improve patientcare in varied settings (Cope, et al., 2016). The role of NMPs can range from nurses,pharmacists, optometrists, chiropodists or podiatrists, radiographers andphysiotherapists (Department of Health, 2017). 1.2 An international perspective Currently, only pharmacists and nurses have been granted prescribingrights outside of the United Kingdom and not health care professionals who aredistinct from medicine, nursing and pharmacy (also known as Allied HealthProfessionals).
In the United States of America, independent pharmacistscurrently have the ability to prescribe from a limited list of medications,however, this is only apparent in the state of Florida (Cope, et al., 2016). Pharmacists can only prescribealongside doctors within Collaborative Drug Therapy Management Clinics (Drugs and Therapeutics Bulletin, 2006) in at least 16 states.Other US states use dependent prescribing (supplementary prescribing) with theuse of a clinical management plan or independent prescribing using locallyagreed protocols, such as the Veterans’ Affairs Centres run by the VeteransHealth Administration (VHA) (Clause, et al., 2001, cited in Cope, et al., 2016).Nurses in the USA must qualify as Advanced PracticeRegistered Nurses at postgraduate level, specialise and then gain additionalprescriptive authority credentials proceeding certification by the relevantboard (Greenberg, et al.
, 2003 cited inCope, et al., 2016). The extent of prescriptive authority that nurses acquirevaries between states, as the profession is dependent on individual stateregulation. However, 21 states currently approve the full practice status fornurse practitioners, allowing them to prescribe (Greenberg, et al., 2003). However, somestates still hold ‘restricted practice regulations for nurse practitioners’ (Cope, et al., 2016).
In a similar way topharmacists, nurse practitioners with prescriptive authority who are VHAemployees, can be given rights to independently prescribe (Konnor, 2007). Pharmacist prescribing is currently notpermitted anywhere else in Europe – the UK is an exception. However, countriessuch as Ireland, Finland, Spain, the Netherlands and Sweden have introducednurse prescribing and the consequent legal restrictions on which nurses canprescribe, what they are legally permitted to and for whom, and whether they canindependently (Kroezen, et al., 2011). Pharmacists inCanada with prescribing rights can prescribe independently or in collaborationwith a medical practitioner (American Pharmacists Association, 2014).
Similarly, NewZealand has recently introduced legislation which allows qualified pharmaciststo prescribe (Parliamentary Counsel Office, 2013). In Australia, the Health Workforce hasdeveloped a national pathway for prescribing by other healthcare professionalsapart from doctors, dentists and nurses (Hale, et al., 2016). Nurse practitioners can currentlyprescribe medications if they are endorsed by the Nursing and Midwifery Boardof Australia (NMBA), and medications are limited by the nurse practitioner’sscope of practice, Medical Protection Society (MPS)/Pharmaceutical BenefitsScheme (PBS) requirements and by hospital formularies or prescribing measures (South Australia Health, 2017). In 2015,physiotherapists expressed an interest in non-medical prescribing and nationalprocesses have commenced in order to evaluate the clinical need, quality andsafety issues surrounding physiotherapist non-medical prescribing (Australian Physiotherapy Association, 2015). Currently, theAustralian Health Workforce Council has published a guidance document regardingdeveloping a case in order for Health Ministers to ‘consider endorsing the prescribingof scheduled medicines for health professions that currently do not have thisendorsement, such as physiotherapy’, which will allow the profession toconsider whether it wants to pursue prescribing rights (Physiotherapy Board of Australia, 2017). 1.3 The United KingdomNon-medical prescribing has been in existencein the UK since 1989 (Drugs and Therapeutics Bulletin, 2006), and played asignificant part in the Department of Health’s agenda since.
The CumberlegeReport (Department of Health and Social Security, 1986), indicated thatpatient access to treatment could be enhanced, and patient care improved andresources used more effectively if community nurses were able to prescribe aspart of their practices from a limited list of items. The recommendations fromthe Cumberlege Report, (Department of Health and Social Security, 1986), were reviewedby an advisory group chaired by Dr June Crown and the Crown Report (Department of Health , 1989) proposed severalbenefits would occur with nurse prescribers – improved patient care, improveduse of nurses’ and patients’ time and communication between multidisciplinaryteam members from clarification of professional responsibilities. It required afurther 3 years until primary legislation permitting nurses to prescribe waspassed in 1992 (Department of Health and Social Security, 1992).
Further to the success and acceptability ofcommunity nurse prescribing, the prescribing of medicines was reviewed (Department of Health, 1999) and it was recommendedthat prescribing authority should be extended to other groups of professionalswith training and expertise in specialist areas. Thus, districtnurses and health visitors became legally able to prescribe independently fromthe renamed Nurse Prescriber’s Formulary, and the range of medications nurseswere able to prescribe was increased. However, this was permitted only within asupervised framework, which was termed ‘dependent prescribing’ (Department of Health, 1999) which was laterrenamed as ‘supplementary prescribing’.
The original policy objectivesfor the development of non-medical prescribing were set out in 2000, and wererelated to the principles in the National Health Plan (Department of Health, 2000). These were improvements in patient care, choice and access,patient safety, better use of health professionals’ skills and flexible teamworking. In 2001, support was provided by the Government for the extension ofprescribing to nurses other than district nurses and from a wider selection ofmedicines (Department of Health, 2001).In November 2005, it was announced thatqualified extended formulary nurse prescribers would become able to prescribeany licensed medicine for any medical condition (and some controlled drugs forspecified conditions) as independent prescribers in the following year, endingthe existence of the Extended Formulary (Department of Health, 2005). Evaluation ofnon-medical prescribing (Department of Health Policy Research Programme 2010)indicated that nurse and pharmacist independent prescribing was becoming awell-integrated and established means of managing patients’ conditions. 1.4 Physiotherapist prescribing Physiotherapists are registered healthcareprofessionals who help with the rehabilitation of individuals who are affectedby injury, illness or disability through movement and exercise manual therapy,education and advice (Charterd Society of Physiotherapy, 2013).
Physiotherapists can be effective forpeople with a wide range of health conditions including problems affecting thebones, joints and soft tissue, brain or nervous system, heart and circulationor lungs and breathing (NHS Choices, 2017). In addition to this role, physiotherapistsare able to give medicinal advice to their patients, which is an expectation ofreasonable physiotherapy practice for the management of many conditions (Chartered Society of Physiotherapy, 2017). Physiotherapists, alongside other AlliedHealth Professionals such as podiatrists, were granted prescribing rights tobecome Supplementary Prescribers (SPs) in 2005 (Statutory Instrument , 2005). As supplementary prescribers,physiotherapists became be able to prescribe a limited range of medicines inpartnership with a doctor, using an agreed patient specific clinical managementplan, as well as administer some medicines.
Medications had to be defined inwriting within a Clinical Management Plan (CMP) and appropriate to the needs ofthe patient (Chartered Society of Physiotherapy, 2016). Two years later, in 2007, optometristsbecame able to act as independent prescribers (Department of Health, 2007). Proposals to introduce independentprescribing by physiotherapists were put forward to the Department of Health in2012 to increase their quality of care, patient safety, experience andeffectiveness. Independent prescribing physiotherapists were predicted toenhance patient care by improving access to medicines (Department of Health, 2012). They would reduce the patient care pathwayas a follow up appointment with a GP to obtain a prescription would not berequired. This was built on the white paper (Department of Health, 2010), which aimed to ensure patients hadincreased access to timely treatment by liberating frontline healthcare staffto maximise the benefit they can offer to patient. In 2013 for England and 2014for the rest of the UK, physiotherapist and podiatrist prescribing was widenedto include the independent prescribing status (Department of Health, 2013).
Early last year, NHS England announced newlegislation permitting independent prescribing by therapeutic radiographers andsupplementary prescribing by dieticians (National Health Service England, 2016).1.5 The research problem Non-medicalprescribing has taken many years of planning, review, and discussion, and ithas been a long-fought and hard-won battle to reach today’s current statuswhere not only nurses and pharmacists have the ability to prescribe in the UK,but allied health professionals do also. In regard to physiotherapists,non-medical prescribing is viewed as an essential component of expanding theirscope of practice (Morris and Grimmer 2014), however current statisticsindicate that out of 54,980 registered physiotherapists with the profession’sregulatory body, the Health and Care Professions Council (HCPC) (Health and Care Professions Council, 2017), only 1.4% (n=784) are supplementary prescribersand 1.25 (n=659) are independentprescribers (REF) . This study aims to explore the reasons forthese modest and somewhat disappointing numbers, given that the UK is one ofthe least restrictive countries in terms of scope of prescribing practice fornon-medical prescribers (Afseth & Paterson, 2017) and is at theglobal forefront of providing allied health professionals such asphysiotherapists with prescribing rights.
Physiotherapy prescribing has beenrecognised as producing a more consistent, transferable and recognisedworkforce (Atkins 2003) yet Robertson et al 2016 indicated that a lack ofpublished evidence on the effectiveness of physiotherapists prescribing existsand more studies have been undertaken on other extended scope of practice rolessuch as orthopaedic triage (Kersten et al, 2007). The purpose of this study isto provide insight into the conundrum of the lack of published literatureregarding any changes that physiotherapist prescribing rights has brought tothe profession through the exploration of the attitudes and feelingsphysiotherapists have towards prescribing. Understanding the reasons, whetherthey be barriers or reluctance (if any) that physiotherapists have towardsbecoming prescribers, as well as their general attitudes towardspharmacotherapy and medicines management will allow for the development offuture interventions which may allow more physiotherapists to utilise theirright to prescribe and become prescribers, whether supplementary orindependent.