Paramedics have had a long relationship with medicines, which dates back over two decades, and they are personally and professionally responsible for ensuring that they adhere to standards set by the Medicines and Healthcare products Regulatory Agency (MHRA) (2013) and the National Institute for Health and Care Excellence (NICE) (2014), regarding the use of patient group directions (PGDs), patient specific directions (PSDs) and exemptions.
Many patients benefit, and will continue to benefit, as a result of paramedics being able to administer medicines using these mechanisms. It is not uncommon, however, for these mechanisms to prove ineffective. This can result in delays for patients receiving the care that is best suited to their individual needs. Independent prescribing by paramedics would allow patients to receive the care and medicines they need, resulting in a far greater number of patients benefiting from improved and more timely care and greater convenience.
The journey begins: a brief history of non-medical prescribing
The Review of Prescribing, Supply and Administration of Medicines (Department of Health (DH), 1999), chaired by Dr June Crown, proposed that prescribing rights should be extended to a range of health professionals in order to improve services to patients.
The original policy objectives for the development of non-medical prescribing related to the principles set out in The NHS Plan: a plan for investment, a plan for reform (DH, 2000), including: improvements in patient care, choice and access; patient safety; better use of health professionals' skills; and more flexible team working across the NHS. In working towards these objectives, the NHS embarked on a graduated move to increase the scope and responsibilities of non-medical prescribing.
As a result of this graduated move, over recent years revised regulations have enabled experienced nurses, optometrists, pharmacists, physiotherapists and podiatrists to undertake training to independently prescribe medicines within their professional scope of practice and competence.
When paramedics became a part of the journey
In 2005, Taking Healthcare to the Patient: Transforming NHS Ambulance Services (DH, 2005) recognised that work should be undertaken to consider the need for independent prescribing by eligible paramedics and that investing in the clinical development of front-line ambulance clinicians would yield significant benefits for both patient outcomes and the health economy.
In 2011, Taking Healthcare to the Patient 2: A review of 6 years' progress and recommendations for the future (Association of Ambulance Chief Executives, 2011) reported that significant reductions in conveyance rates to accident and emergency had been achieved through the introduction of specialist and advanced paramedic roles. However, the review also identified that the extension of independent prescribing to eligible paramedics could further enhance their effectiveness. The Urgent and Emergency Care Review End of Phase 1 Report (NHS England, 2013) recognised ambulance services as being fundamental to providing a highly responsive service that delivers care as close to home as possible for patients with urgent care needs. The vision to develop 999 ambulance services into community-based mobile urgent treatment services, outlined in the report, requires highly skilled paramedics with the ability to ‘see and treat’ more patients at the scene. This in turn requires paramedics to have appropriate prescribing responsibilities.
During 2014, the NHS England AHP Medicines Project Team, in partnership with the College of Paramedics, developed a case of need (NHS England, 2014) for the progression to independent prescribing by paramedics, based on improving quality of care for patients in relation to safety, clinical outcomes and experience, while also improving efficiency of service delivery and value for money. Approval of the case of need was received from NHS England's Medical and Nursing Directorates Senior Management Teams in May 2014 and from the Department of Health Non-Medical Prescribing Board in July 2014.
What stage of the journey are we at now?
NHS England is currently consulting on proposals to allow four allied health professions to be able to prescribe or supply and administer medicines within their professional scope of practice and competence, across the United Kingdom, as appropriate for their patients. These are:
Medicines Regulations (2012) by orthoptists.
The Consultation on proposals to introduce independent prescribing by paramedics across the United Kingdom (NHS England, 2015a) opened on 26 February 2015 and will run for 12 weeks, closing on 22 May 2015 and can be viewed on the NHS England consultation hub website at: http://tinyurl.com/ka6dpu6.
The consultation document suggests five different options for how independent prescribing by paramedics could be introduced, as well ascontaining a number of questions NHS England are seeking responses to. These are reproduced and summarised below for information.
The options
Option 1: no change
Paramedics would continue to supply and/or administer medicines under existing mechanisms, (PGDs, PSDs and exemptions) to some patients in certain situations.
Benefits
In some situations, the way paramedics currently provide patients with medicines works well and will continue to work well. For example, when paramedics provide medicines to patients with life-threatening conditions such as cardiac arrest or major trauma.
Limitations
The existing way paramedics provide patients with medicines may not allow paramedics to provide the most effective medicines for patients with non-life threatening problems (which make up approximately 70% of the patients paramedics see). These patients may then need to visit another healthcare professional (such as a GP), or even be conveyed to hospital to receive the treatment required. This can result in unnecessary delays, put patients at risk (especially vulnerable groups such as the elderly) and are costly to administer.
This option will significantly limit the changes that can be made to the way healthcare services are organised and delivered to meet the needs of patients. There would also be less choice and ongoing unnecessary costs for service commissioners. As a result, an opportunity to improve patient outcomes and their experience of care would be missed.
Option 2: independent prescribing for any condition from a full formulary
Appropriately trained advanced paramedics would be permitted to prescribe independently any medicine for any condition, within their professional scope of practice and competence.
Benefits
Patients would be able to receive the care and medicines they need, without having to make additional appointments with other prescribers. A greater number of patients could benefit from improved care, more timely care and greater convenience. This option would also support new ways of working to help deliver services that better meet patient needs.
Limitations
This option has no obvious limitations.
Option 3: independent prescribing for specified conditions from a specified formulary
Appropriately trained advanced paramedics would be permitted to prescribe independently from a list of specified medicines for a specified list of conditions.
Benefits
This option could benefit patients provided that their condition and the medicines they need, appear on the list.
Limitations
A patient whose condition does not appear on the list or who required a medicine that did not appear on the list would not be able to have medicines prescribed for them by a paramedic independent prescriber and would therefore not benefit. These patients may then need to visit another healthcare professional to access the medicines they need. In addition, the limited list of medicines and list of conditions would need updating regularly to support ongoing current best practice, and this would require lengthy administrative and legislative processes and would therefore be slow to update.
Option 4: independent prescribing for any condition from a specified formulary
Appropriately trained advanced paramedics would be permitted to prescribe independently for any condition within their professional scope of practice and competence but only from a list of specified medicines.
Benefits
A wider range of patients could benefit from this option when compared to option 3.
Limitations
Patients who need medicines that do not appear on the list would not be able to benefit fully. As with option 3, the lists would quickly become out of date and slow to update.
Option 5: independent prescribing for specified conditions from a full formulary
Appropriately trained advanced paramedics would be permitted to prescribe independently any medicine within their professional scope of practice and competence, but only for specified conditions.
Benefits
A wider range of patients would benefit from this option when compared to option 3.
Limitations
Patients with a condition that does not appear on the list would not be able to benefit fully. As with option 3, the lists would be difficult to administer and keep up to date.
A number of supporting documents have been provided alongside the main consultation document to inform consideration of the options above and the questions listed below; these include the Draft Proposed Practice Guidance for Paramedic Independent Prescribers (College of Paramedics, 2015), Draft Outline Curriculum Framework for Education Programmes to Prepare Paramedics as Independent Prescribers (Allied Health Professions Federation, 2015) and the Consultation Stage Impact Assessment (NHS England, 2015b).
After reading these documents, respondents are being asked to answer the following questions:
The next stage of the journey
Following the close of the consultation, the Commission on Human Medicines (CHM) will be asked to consider the proposals in light of answers and comments received. Subject to the advice from CHM and agreement by ministers, the MHRA will then make the necessary amendments to medicines legislation.
If, after considering the responses to the consultation, CHM recommend taking forward work to enable prescribing of controlled drugs from the restricted list, further work will be undertaken with the Home Office to ask the Advisory Council on the Misuse of Drugs to consider the proposals relating to controlled drugs and to advise ministers. If ministerial approval is received, the Home Office will make appropriate amendments to the Misuse of Drugs Regulations (2001).
Everyone is welcome to respond to the consultation and NHS England hope to hear from the public, patients/patient representative groups, carers, voluntary organisations, healthcare providers, commissioners, doctors, pharmacists, allied health professionals, nurses, regulators, non-medical prescribers, the Royal Colleges and other representative bodies.