In recent years, paramedics have branched out from their roots as ambulance clinicians and are now working in a variety of settings, including primary care. A figure from NHS Digital (2020) suggests that 837 paramedics were employed in primary care in March 2020, increased from 569 the previous year. This growing figure illustrates the increasing importance of prescribing and medicines management in primary care. In general, the paramedic works as an independent practitioner and, while in the ambulance setting, the traditional medicines management frameworks proved adequate, they were left lacking in general practice. The paramedic medicines exemptions (HM Government, 2012) apply only to a select few medications relevant to emergency and urgent care. While a potential solution in some settings, patient group directions (PGDs) take time and effort to set up and suffer from being unable to extend to the broader requirements of primary care. Indeed, where possible, the National Institute for Health and Care Excellence (NICE) (2017) recommends increasing prescriber numbers to avoid using PGDs.
As such, paramedic prescribing represents a significant step forward in streamlining the paramedic's use of medication in primary care, as well as a wider advancement for the profession. In terms of the author's own practice, being a prescriber meant the difference between independently managing a complete episode of care and doing everything up to the point of prescribing, then having to get someone else to produce a prescription on my behalf. In the author's experience, being a prescriber or working towards that qualification is essential if looking to maximise potential and utility in primary care. This article will explore some of the practical issues relevant to paramedic prescribing in primary care.
Scope of practice
The scope of practice of a paramedic in primary care will vary between employer, and depend to some extent on what the paramedic is used for. Speaking from experience, the author's practice is mostly urgent care, although there are almost no presentations they don't see—hence the need for a strong grasp of prescribing relevant to urgent and acute presentations in primary care. Although, there is also a need to maintain knowledge of managing chronic conditions such as hypertension, depression, respiratory conditions and chronic pain to name a few. Having a practice focused primarily on urgent and acute care means being able to become competent and familiar with prescribing guidance around these areas. However, it is important to know how and where to find advice and guidance for prescribing for other specialties and conditions.
Prescribing resources
There are four prescribing resources the author would recommend based on practical experience.
British National Formulary
The first is is the British National Formulary (BNF) (Joint Formulary Committee, 2020), which details all the medication available for use in the UK and is an excellent and accessible resource both in print and digital formats. The BNF is most useful for easily accessing information about indications, doses, interactions, side effects and contraindications, as well as useful information about modification of doses based on any impairment of renal or hepatic function and compatibility in pregnancy or breastfeeding. This resource allows the paramedic to easily check that doses are correct, that the choice of medication doesn't interact with something the patient already takes, and that renal and hepatic function don't require changes in dosing. Being both user-friendly and very accessible, the BNF is an important resource for the prescribing paramedic.
Electronic Medicines Compendium
The second recommended resource is the electronic medicines compendium (Datapharm, 2020). This provides the information found in the BNF, but goes further to include much more detailed information including the pharmacokinetics and pharmacodynamics of the drug in question. It is also useful in that rather than just searching by the active ingredient as in the BNF (e.g. ‘morphine’), it allows the user to search by exact form and dose (e.g. ‘morphine sulphate 10mg/ml injection BP’). This can be useful when looking for excipients and non-active ingredients. For instance, it may be necessary to take into account a patient's allergy, intolerance or religious objection to a non-active ingredient of a medication (e.g. pork gelatine).
Local prescribing formulary
The third resource that should guide day-to-day prescribing practice is the local prescribing formulary. In the example of the author's practice, this would be the Bristol, North Somerset and South Gloucestershire clinical commissioning group's (BNSSGCCG) (2020)Remedy guidance. This provides local primary care guidance on referral pathways, available services and clinical management advice. The website also includes the local formularies for primary care across the region and includes local antimicrobial prescribing guidance based on local patterns of resistance and use. These resources allow the prescriber to use the most suitable drug to treat a problem based on both clinical and non-clinical factors, such as price, availability, side-effect profile and antimicrobial stewardship principles. All areas will have a similar resource and the paramedic prescriber will need to be aware of these in order to work according to local differences and nuances in practice.
Multidisciplinary colleagues
Finally, a resource that can be drawn upon when needed are the doctors, pharmacists and nurses working alongside the paramedic. All have varied backgrounds, years of experience and special interests and areas of expertise. While there are plenty of scientific resources available to support prescribing practice, sometimes the advice of a GP provides the solution to a problem that requires knowledge of clinical practice balanced with the subtleties and more holistic style of care which is common to general practice.
Controlled drugs
A large limitation currently is the inability for paramedics to prescribe any controlled drug. In other settings, such as ambulance care and non-doctor-led urgent care, this would be countered by the use of PGDs. The nuance and broad scope of primary care, as well as the fact that a PGD only affords the clinician to supply the medication rather than a prescription for it, means their utility in primary care is significantly reduced. The law is likely to changed based on recommendations made by the Advisory Council on the Misude of Drugs (ACMD) (2019) but there is no timescale currently set for this.
Unlicensed medications
Worthy of consideration is that, currently, a paramedic prescriber may not prescribe an unlicensed medication (College of Paramedics, 2018); this is a medicinal product that does not have a UK marketing authorisation. It is uncommon to see unlicensed medications in practice as they tend to be experimental or niche treatments. However, especially when dealing with prescribing for paediatrics, many medications will have a marketing authorisation that does not include children and thus the clinician may find themselves prescribing a licensed medication for an indication that is outside the terms of the license. This is not the same as prescribing unlicensed medication; rather, it is more commonly known as off-label prescribing. This is acceptable practice; however, more emphasis is placed on the prescriber to ensure it is safe, appropriate and that a licensed alternative is not available (General Medical Council, 2020). This is common in children as research into safety often will not be carried out in younger children for ethical reasons, even though the medication may be commonly used in practice.
COVID-19 pandemic
No article about clinical practice during 2020–2021 would be complete without mention of the COVID-19 pandemic. This has changed the way primary care works, with a significant (in some places, complete) switch to remote consultations (NHS England, 2020). Along with this, the opportunities to prescribe using a paper prescription are greatly reduced. As such, the ability to prescribe electronically is critical. While there have been issues with software not supporting paramedic prescribing, these are slowly being resolved with several platforms (e.g. Emis Health, Systm1, adastra) now facilitating paramedic electronic prescribing in practice (Emis Health, 2020).
Remote prescribing
Remote prescribing is a common part of primary care and is acknowledged as an increased-risk practice (Royal Pharmaceutical Society, 2016). However, once again, due in part to the pandemic, the need for remote prescribing has increased and the paramedic in primary care is highly likely to encounter this scenario. While the intricacies of remote prescribing go beyond the scope of this article, it is important to understand the limitations inherent to remote consultation and prescribing and ensure that appropriate action is taken to best mitigate risk and prescribe safely.
Future
The future for paramedic prescribers will probably include expansion of scope through amendment of the Misuse of Drugs Act to allow prescribing of controlled drugs. This will likely include a small selection to begin with but as time passes, particularly to enhance provision of end of life and critical care, a more comprehensive authority to prescribe controlled drugs would be beneficial. The legal amendment to allow prescribing of the full range of controlled drugs would bring the paramedic prescriber onto par with nursing and some allied health professional colleagues. Beyond this, the most likely outcome of paramedics being able to qualify as independent prescribers is that the paramedic will find there are more and more career options, and more options for working in advanced roles, allowing more diverse careers and greater scopes of practice.