INTRODUCTION Kingdom and not health care professionals who

INTRODUCTION

1.1      What is
non-medical prescribing?

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Non-medical prescribers (NMPs) are healthcare
professionals who, despite not being doctors or dentists, are legally permitted
to prescribe medicines, dressings and appliances subsequent to attaining an
advanced level qualification in prescribing. Non-medical prescribing within
healthcare settings enables healthcare professionals to enhance their roles,
using their skills and competencies effectively in order to improve patient
care in varied settings (Cope, et
al., 2016). The role of NMPs can range from nurses,
pharmacists, optometrists, chiropodists or podiatrists, radiographers and
physiotherapists (Department
of Health, 2017).

1.2 An international perspective

 Currently, only pharmacists and nurses have been granted prescribing
rights outside of the United Kingdom and not health care professionals who are
distinct from medicine, nursing and pharmacy (also known as Allied Health
Professionals). In the United States of America, independent pharmacists
currently 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 prescribe
alongside 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 the
use of a clinical management plan or independent prescribing using locally
agreed protocols, such as the Veterans’ Affairs Centres run by the Veterans
Health Administration (VHA) (Clause, et al., 2001, cited in Cope, et al., 2016).

Nurses in the USA
must qualify as Advanced Practice Registered Nurses at postgraduate level,
specialise and then gain additional prescriptive authority credentials
proceeding certification by the relevant board (Greenberg,
et al., 2003 cited in Cope, et al., 2016). The extent of prescriptive
authority that nurses acquire varies between states, as the profession is
dependent on individual state regulation. However, 21 states currently approve
the full practice status for nurse practitioners, allowing them to prescribe (Greenberg, et al., 2003). However, some
states still hold ‘restricted practice regulations for nurse practitioners’ (Cope, et al., 2016). In a similar way to
pharmacists, nurse practitioners with prescriptive authority who are VHA
employees, can be given rights to independently prescribe (Konnor, 2007).

Pharmacist prescribing is currently not
permitted anywhere else in Europe – the UK is an exception. However, countries
such as Ireland, Finland, Spain, the Netherlands and Sweden have introduced
nurse prescribing and the consequent legal restrictions on which nurses can
prescribe, what they are legally permitted to and for whom, and whether they can
independently (Kroezen, et al., 2011). Pharmacists in
Canada with prescribing rights can prescribe independently or in collaboration
with a medical practitioner (American Pharmacists Association, 2014). Similarly, New
Zealand has recently introduced legislation which allows qualified pharmacists
to prescribe (Parliamentary Counsel Office, 2013).

In Australia, the Health Workforce has
developed a national pathway for prescribing by other healthcare professionals
apart from doctors, dentists and nurses (Hale, et al., 2016). Nurse practitioners can currently
prescribe medications if they are endorsed by the Nursing and Midwifery Board
of Australia (NMBA), and medications are limited by the nurse practitioner’s
scope of practice, Medical Protection Society (MPS)/Pharmaceutical Benefits
Scheme (PBS) requirements and by hospital formularies or prescribing measures (South Australia Health, 2017). In 2015,
physiotherapists expressed an interest in non-medical prescribing and national
processes have commenced in order to evaluate the clinical need, quality and
safety issues surrounding physiotherapist non-medical prescribing (Australian Physiotherapy Association, 2015). Currently, the
Australian Health Workforce Council has published a guidance document regarding
developing a case in order for Health Ministers to ‘consider endorsing the prescribing
of scheduled medicines for health professions that currently do not have this
endorsement, such as physiotherapy’, which will allow the profession to
consider whether it wants to pursue prescribing rights (Physiotherapy Board of Australia, 2017).

1.3 The United Kingdom

Non-medical prescribing has been in existence
in the UK since 1989 (Drugs and Therapeutics Bulletin, 2006), and played a
significant part in the Department of Health’s agenda since. The Cumberlege
Report (Department of Health and Social Security, 1986), indicated that
patient access to treatment could be enhanced, and patient care improved and
resources used more effectively if community nurses were able to prescribe as
part of their practices from a limited list of items. The recommendations from
the Cumberlege Report, (Department of Health and Social Security, 1986), were reviewed
by an advisory group chaired by Dr June Crown. The Crown Report (Department of Health , 1989) proposed several
benefits would occur with nurse prescribers – improved patient care, improved
use of nurses’ and patients’ time and communication between multidisciplinary
team members from clarification of professional responsibilities. It required a
further 3 years until primary legislation permitting nurses to prescribe was
passed in 1992 (Department of Health and Social Security, 1992).  

Further to the success and acceptability of
community nurse prescribing, the prescribing of medicines was reviewed (Department of Health, 1999) and it was recommended
that prescribing authority should be extended to other groups of professionals
with training and expertise in specialist areas. Thus, district
nurses and health visitors became legally able to prescribe independently from
the renamed Nurse Prescriber’s Formulary, and the range of medications nurses
were able to prescribe was increased. However, this was permitted only within a
supervised framework, which was termed ‘dependent prescribing’ (Department of Health, 1999), later renamed as ‘supplementary
prescribing’. The original policy objectives for the development of
non-medical prescribing were set out in 2000, and were related 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 team
working. In 2001, support was provided by the Government for the extension of
prescribing to nurses other than district nurses and from a wider selection of
medicines (Department of Health, 2001).

In November 2005, it was announced that
qualified extended formulary nurse prescribers would become able to prescribe
any licensed medicine for any medical condition (and some controlled drugs for
specified conditions) as independent prescribers in the following year, ending
the existence of the Extended Formulary (Department of Health, 2005). Evaluation of
non-medical prescribing (Department of Health Policy Research Programme 2010)
indicated that nurse and pharmacist independent prescribing was becoming a
well-integrated and established means of managing patients’ conditions.

1.4 Physiotherapist prescribing

Physiotherapists are registered healthcare
professionals who help with the rehabilitation of individuals who are affected
by injury, illness or disability through movement and exercise manual therapy,
education and advice (Charterd
Society of Physiotherapy, 2013). Physiotherapy can be effective for people
with a wide range of health conditions including problems affecting the musculoskeletal,
central nervous, cardiovascular and respiratory systems (NHS Choices,
2017). In addition to this role, physiotherapists
are able to give medicinal advice to their patients, which is an expectation of
reasonable physiotherapy practice for the management of many conditions (Chartered
Society of Physiotherapy, 2017).

Physiotherapists, alongside other Allied
Health Professionals such as podiatrists, were granted prescribing rights to
become Supplementary Prescribers (SPs) in 2005 (Statutory
Instrument , 2005). As supplementary prescribers, they were able
to prescribe a limited range of medicines in partnership with a doctor, using
an agreed patient specific and appropriate clinical management plan, as well as
administer some medicines (Chartered
Society of Physiotherapy, 2016). Proposals to introduce independent
prescribing by physiotherapists were put forward to the Department of Health in
2012 to increase their quality of care, patient safety, experience and
effectiveness. Independent prescribing physiotherapists were predicted to
enhance patient care by improving access to medicines (Department
of Health, 2012). They would reduce the patient care pathway
as a follow up appointment with a GP to obtain a prescription would not be
required. This was built on the white paper (Department
of Health, 2010), which aimed to ensure patients had
increased access to timely treatment by liberating frontline healthcare staff
to maximise the benefit they can offer to patient. In 2013 for England and 2014
for the rest of the UK, physiotherapist and podiatrist prescribing was widened
to include the independent prescribing status (Department
of Health, 2013).

1.5 The research problem

Non-medical
prescribing has taken many years of planning, review, and discussion, and it
has been a long-fought and hard-won battle to reach today’s current status
where not only nurses and pharmacists have the ability to prescribe in the UK,
but allied health professionals do also. The ability to prescribe is viewed as
an essential component of expanding physiotherapists” scope of practice
(Morris and Grimmer 2014), however current statistics indicate that out of
54,980 registered physiotherapists with the profession’s regulatory body, the
Health and Care Professions Council (HCPC) (Health and Care Professions Council, 2017), only 1.4% (n=784) are supplementary prescribers
and 1.25 (n=659) are independent
prescribers (Health and Care Professions Council, 2017). This study aims to
explore the reasons for these modest and somewhat disappointing numbers, given
that the UK is one of the least restrictive countries in terms of scope of
prescribing for non-medical professionals (Afseth &
Paterson, 2017) and is at the
global forefront of prescribing rights. Physiotherapy prescribing has been
recognised as producing a more consistent, transferable and recognised
workforce (Atkins 2003) yet Robertson et al 2016 indicated that a lack of
published evidence on the effectiveness of physiotherapists prescribing exists
and more studies have been undertaken on other extended scope of practice roles
such as orthopaedic triage (Kersten et al, 2007). The purpose of this study is
to provide insight into the conundrum of the lack of research into the changes
that physiotherapist prescribing rights has brought to the profession through
the exploration of the attitudes and feelings physiotherapists have towards
prescribing. Understanding the reasons, whether they be barriers or reluctance
(if any) that physiotherapists have towards becoming prescribers, as well as
their general attitudes towards pharmacotherapy and medicines management will
allow for the development of future interventions. As a result, this may allow
more physiotherapists to utilise their right to prescribe.