The recently published outcomes from the meeting of the Commission on Human Medicines (CHM) regarding independent prescribing by radiographers and paramedics was not the news that we as a profession had hoped for, and has caused significant disappointment and frustration among those advanced paramedics anticipating the opportunity to become a prescriber. This editorial is intended to provide clarity in relation to the outcome of the CHM meeting, give some thoughts on what may happen next, and suggest some ways in which we as paramedics can continue to work towards independent prescribing in the future.
While there has been an increased focus on what paramedics have to offer in relation to new ways of working for the NHS, we can never assume that achieving independent prescribing will ever be a formality, or even a reality. It is important to remember that for any healthcare profession to be enabled to independently prescribe medicines, legislative change must occur. This process, led by NHS England, includes making a case for need within NHS England itself and receiving ministerial approval to undertake a 12 week UK-wide public consultation, the findings of which are presented to the CHM for the commission to be able to form recommendations to ministers regarding the proposal. The CHM is an advisory non-departmental public body, sponsored by the Department of Health, whose primary function is to advise ministers on the safety, efficacy and quality of medicinal products, as well as advising on other aspects of public safety related to medicines. Ministers responsible for final decisions regarding changes to medicines legislation rely on the expert advice of the CHM, therefore the recommendations from CHM are considered carefully by ministers. As a profession we must look at the comments provided by the CHM as high-quality critique, and act to try and resolve these challenges so that, should we have the opportunity, we can return in the future better prepared.
The important fact regarding the outcome of the CHM meeting is that while it means we are not moving forward now, we may in the future be able to again present the proposal to introduce independent prescribing by paramedics, and we will continue to work with NHS England to progress the proposal, and to ensure that the challenges identified are addressed. Moreover, we should continue to celebrate the successes of the wider allied health professions (AHP) community and the agreement by the CHM to recommend a submission to ministers for the use of exemptions by orthoptists, supplementary prescribing by dietitians, and independent prescribing by therapeutic radiographers. We have significant support from the other AHPs that have been through this process prior to us, namely physiotherapists and podiatrists, and we can continue to benefit from the learning and experience of our AHP colleagues as we also continue to work to support the wider AHP medicines agenda. We will continue to work closely with the Society and College of Radiographers and with NHS England to ensure that should we be in a position to make future submissions they are as robust as possible for both professions.
‘While there has been an increased focus on what paramedics have to offer in relation to new ways of working for the NHS, we can never assume that achieving independent prescribing will ever be a formality, or even a reality’
So, how do we respond as a profession? We should reflect on the main points in the summary given by the CHM: the breadth of the scope of practice of an advanced paramedic and assurance of competency to diagnose the conditions that will be prescribed for and, importantly, the definition of advanced practice.
Definition of advanced practice
The CHM feel that the definition of advanced practice is not sufficiently robust, and that the perceived scope of practice is too wide for advanced paramedics to safely prescribe. The College of Paramedics describes advanced practice, and this definition was included in the submission to the CHM, but there is no standard and consistent definition of advanced practice across different healthcare professions. As paramedics, we have a further challenge in the wide range of roles and role titles that exist in different practice settings. While professional nomenclature may appear a minor issue for some, the basis for consistency in practice level can only be achieved if the role titles are simplified and used appropriately—allowing absolute clarity of what advanced practice is. Paramedics who progress through the career framework continue to be paramedics, and the diverse range of job titles that have proliferated have, in some examples, appeared to make generic the different professions that are engaged in a multi-professional healthcare model. We should be proud to be paramedics, regardless of where we are working, and I feel that it is not an understatement to say that this lack of consistency and resistance to consensus has been a contributor to our inability to demonstrate a definition of advanced practice sufficient to reassure the CHM.
The original case for need that was produced by NHS England in collaboration with the College of Paramedics refers to independent prescribing by advanced paramedics as a way to reduce the impact that the limitations of the current mechanisms have on patient care. Across the differing levels of practice, exemptions are fit for purpose in emergency and critical care, and the use of patient group directions (PGD) have a utility for patients with urgent care needs, but are limited in the very patients for whom changes to healthcare delivery is aimed at for the future.
Patients living independently or in supported living in the community, with one or more long-term health conditions, within an increasingly ageing population, are at the heart of the new models of care. It is increasingly apparent that paramedics provide care for these patients at times of crisis—either as 999 calls to ambulance services, attendance by out-of-hours providers, or in community- or acute-based urgent care settings. The usefulness of PGDs decreases as the patient becomes older and more co-morbid, and the basis for independent prescribing addresses these issues through proposing improved decision making and care planning options available to prescribers. The proposal for independent prescribing is limited to paramedics practising at advanced level—hence the need for increased clarity in role titles.
Scope of practice and competency in assessment and diagnosis
This aspect can really be considered in parallel along with the definition of advanced practice, and centres around core curriculum and evidence of competency. Health Education England, supported by the College of Paramedics, has done a huge amount of work to define the post-graduate curriculum. Moreover, the College has endorsed other pathways for paramedics that complement its own career and curriculum frameworks, and many of these provide ample opportunity to answer the challenges raised by CHM, such as the Advance Clinical Practice (ACP) programme and its accompanying credentialling process.
The ACP is being developed by the Royal College of Emergency Medicine, in collaboration with Health Education England, the Royal College of Nursing and the College of Paramedics, and enables clinicians from medicine, nursing and paramedic science to achieve common competencies for advanced practitioners within a portfolio of evidence. Working more closely with partner organisations and most importantly Health Education England, the body that forms the common link to all healthcare professional education, and that has supported the paramedic profession via the Paramedic Evidence Based Education Project (PEEP), will be vital to ensure any disparate strands of practice are pulled together. The national education lead recently advertised by the College of Paramedics will be central to this work.
‘The focus for paramedic independent prescribing has been to provide more access to care for as many patients as possible, reducing pressure on services, and providing care closer to home’
We must also ensure that we define the scope of practice, and how the associated competencies and curricula can inform the types of patients treated by advanced paramedics, as the perceived breadth in practice is considered to be too wide, and describing the limits of practice will be essential. Linked to this, where we can demonstrate that paramedics practising at an advanced practice level are working to a common curriculum, along with quality assured evidence of competency, we can show that we have the requisite professional profile and that we engage across the multi-professional landscape. From here the issue of the perceived breadth of paramedic scope of practice is addressed and can inform meaningful discussions regarding local formularies and governance frameworks—including robust continuing professional development, supervision and prescribing peer-review.
Conclusions
As paramedics, we must remember what has been achieved in a very short period of time and we will be judged on how we respond to the challenges we face. The focus for paramedic independent prescribing has been to provide more access to care for as many patients as possible, reducing pressure on services and providing care closer to home. None of this can be achieved at the expense of patient safety, and where we are required to develop further in the face of scrutiny we should respond professionally and with the core value of the patient being paramount, placing patient safety above and beyond our own professional ambitions.
With consistency in role titles, better defining of advanced practice, and improvements in how we demonstrate competency, we can continue to collaborate and engage with key partners, and in particular NHS England, who are leading this work. With this in mind, and in closing, we must acknowledge the support we receive from within the AHP team at NHS England, thanking in particular Suzanne Rastrick, chief allied health professions officer, Shelagh Morris, deputy chief allied health professions officer, and Helen Marriott, allied health professions medicines project lead.