1.1 What
is non-medical prescribing?  

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. The development of non-medical
prescribing within healthcare settings enables healthcare professionals to
enhance their roles and use their skills and competencies effectively, in order
to improve patient care in varied settings including the management of long
term conditions and medicines, emergency and palliative care, mental health
services and much more (Cope, et al., 2016). Non-medical prescribers can range from
roles such as nurses, pharmacists, optometrists, chiropodists or podiatrists,
radiographers and physiotherapists (Department of Health, 2017).


1.2: Non-medical
prescribing – 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).

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In terms of nurse prescribing in the USA, in order for
nurses to gain ‘prescriptive authority’, they must additionally qualify as
Advanced Practice Registered Nurses at postgraduate level, and then specialise
as Nurse Practitioners, only to then further apply for additional prescriptive
authority credentials following board certification (Greenberg, et al., 2003 cited in Cope, et al., 2016). The extent
of prescriptive author that nurses acquire varies between states, as the
profession is dependent on individual state regulation. However, 21 states and
the District of Columbia allow nurses to prescribe independently due to having
approved full practice status for nurse practitioners (Greenberg, et al., 2003). This is a
controversial topic, as many states disagree with this and some 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 the types of nurses
that may prescribe, what they are legally permitted to prescribe and for whom,
and whether they are able to do so independently (Kroezen, et
al., 2011).

Pharmacists in Canada with prescribing rights can prescribe independently or in
collaboration with a medical practitioner (such as a doctor) (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 hospital prescribing measures
(South Australia Health, 2017). In 2015, physiotherapists
expressed an interest in non-medical prescribing and national processed 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).

Non-medical prescribing in 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 and 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) which was 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

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). Physiotherapists
can be effective for people with a wide range of health conditions including
problems affecting the bones, joints and soft tissue, brain or nervous system, heart
and circulation or lungs and breathing (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).


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, physiotherapists became be able to prescribe a
limited range of medicines in partnership with a doctor, using an agreed
patient specific clinical management plan, as well as administer some medicines.

Medications had to be defined in writing within a Clinical Management Plan
(CMP) and appropriate to the needs of the patient (Chartered Society of Physiotherapy, 2016). Two years
later, in 2007, optometrists became able to act as independent prescribers (Department of Health, 2007). 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). Early last year, NHS England announced new legislation
permitting independent prescribing by therapeutic radiographers and
supplementary prescribing by dieticians (National Health Service England, 2016).

1.5: The research problem

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. In regard to physiotherapists, non-medical
prescribing is viewed as an essential component of expanding their 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), only 1.4% (n=784) are supplementary prescribers and 1.25 (n=659) are independent prescribers (REF) . 
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 practice for non-medical prescribers
(Afseth & Paterson, 2017) and is at the global
forefront of providing allied health professionals such as physiotherapists
with 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 published literature regarding any 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 which may allow more
physiotherapists to utilise their right to prescribe and become prescribers,
whether supplementary or independent. 


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