Non-medical prescribing has been permitted in the UK since 1992. The largest group of prescribers are doctors who, along with dentists, are able to prescribe on registration. Over the years, they have been joined by independent and supplementary prescribers from a variety of health professions, who are permitted to prescribe within their scope of practice.
Extending prescribing responsibilities to other professional groups is likely to continue wherever there are clear patient benefits (Royal Pharmaceutical Society, 2016). Since 1994, there have been considerable additions to prescribing health professionals in the UK. These include: nurses, pharmacists, radiographers, physiotherapists, podiatrists, chiropodists and optometrists. After a period of specific training, these professionals are often referred to as non-medical prescribers (NMPs). NMPs are health professionals who are legally allowed to prescribe medicines, dressings and appliances after achieving an advanced qualification. Currently in the UK, NMPs must all be registrants of their professional regulatory bodies.
A Review of Prescribing, Supply and Administration of Medicines was set out by the government in 1997 and, in 1999, the second report of the review acknowledged the potential patient benefits of extending prescribing responsibilities. The Department of Health and Social Care (DHSC) (1999) published Making a Difference, reaffirming the government's intention to extend the roles of nurses, midwives and health practitioners to make better use of their knowledge and skills, including introducing prescribing. The NHS Plan (DHSC, 2000) was published, making the following proposals; the service was to:
This was to be achieved by empowering frontline staff and patients, harnessing and expanding the skills of all health professionals, breaking down those traditional demarcations between clinical roles and increasing the flexibility of team working. Prescribers are governed by strict laws and regulations—there are key elements of legislation that govern the prescription and supply of medicines and poisons. Growth in non-medical prescribing over the past two decades has been marked by amendments in such legislation and current developments predict that paramedics may become the latest health profession to prescribe.
The first time around
The Commission on Human Medicines (CHM) considered and discussed feedback from an ad hoc group on proposals for independent prescribing for paramedics in 2015. The CHM has a range of functions that are set out in the Human Medicines Regulations (HMR) (2012). In England, the CHM advises ministers on the safety, efficacy and quality of medicinal products. It is an advisory non-departmental public body, sponsored by the DHSC.
Back in 2015, NHS England held a public consultation on proposals to introduce paramedic prescribing. The findings were presented to the CHM for its consideration and recommendations were then made to ministers at the DHSC. After this initial bid, the CHM did not support the proposals for independent prescribing by advanced paramedics. This decision was made on the basis that paramedics encounter a very wide range of conditions, and it was not apparent if they would have adequate training to assess, diagnose and prescribe appropriately according to these conditions. The CHM also felt there was a lack of clarity regarding what defined an advanced paramedic practitioner. All things considered, the CHM felt that independent prescribing by paramedics could pose a risk to patient safety (NHS England, 2016).
Paving the way for paramedic practice
The ad hoc group did not give in and on 7 September 2017, the CHM decided to endorse its recommendations to support independent prescribing for paramedics—which is a significant recommendation that may pave the way for prescribing in our practice.
Presently, paramedics are only able to supply medicines working to patient group directions (PGDs): written instructions for the supply or administration of named medicines to specific groups of patients who may not be individually identified prior to presenting for treatment. Drawing up PGDs and operating within them depends on context and need. It is vital that anyone delivering care within a PGD is aware of the legal requirements that allow for the supply and administration of specified medicines. They are carried out by named, authorised, and registered health professionals, to a pre-defined patient group needing treatment, without the need for a prescription or instructions from a prescriber.
Using a PGD is not a form of prescribing. An amendment to Regulation 7 of the 2001 Misuse of Drugs Regulations was made in 2012, extending the range of PGD-administered drugs to include any drug in Schedule 2, 3, 4 and 5 of the Misuse of Drugs Act 1971. Overarching legislation supporting the use of PGDs is now contained within the HMR. Therefore, there is still some way to go before paramedics can become independent prescribers. There will need to be much discussion with service users, service user groups and service providers. Should independent prescribing become a reality, medical legislation throughout the UK will need to be amended. New policies will apply to any setting in which paramedics work, including the NHS, private, independent and voluntary sectors.
Independent prescribers
An independent prescriber is a practitioner responsible and accountable for the assessment of patients with diagnosed and undiagnosed conditions. They make clinical management decisions, including prescribing medicines. Therefore, any programme of study to become an independent prescriber within the UK has to be rigorous and must involve a combination of taught curricula and practical experience.
For the practical element of the course, a medical practitioner is required to supervise students. The designated medical practitioner (DMP) must have a minimum of 3 years of clinical experience in the relevant field of practice. The DMP provides supervision, support and opportunities to develop the students' competence in prescribing, and they should also have experience or training in teaching or supervising in practice.
Shaping the future
Prescribing is a complex skill. It is an error prone, high risk activity with a number of influencing factors. It should be assumed that the paramedic in training to become a prescriber should be deemed competent as a prescriber after successful completion of training and earning the appropriate qualification (Cope et al, 2016).
If independent paramedic prescribing materialises, the profession must adapt to monitor, evaluate and research its impact. This must be carried out from several perspectives, e.g. patient and paramedic opinions and outcomes. The aim of independent paramedic prescribing has to be based on improving quality of care for patients, while also improving efficiency of service delivery and value for money. Its benefits for paramedics would include: greater use of clinical skills, increased job satisfaction, increased autonomy and flexibility, and the ability to deliver complete episodes of care. Patients would benefit as they would be able to access medicines faster, subsequently receiving more timely and convenient care. For the NHS, independent prescribing brings a much more effective use of resources.
On the other hand, the increased pressure and workload must be borne in mind. However, what is essential is improvement in patient care and patient safety must be assured.