Journal of Health Services Research & Policy >
Volume 13, Number 4 >
Pp. 215-221
Original research |
Centre for Pharmacy, Health and Society, University of Nottingham, Nottingham, UK;
1 Community Health Sciences, University of Nottingham, Nottingham, UK;
2 Section of Public Health, ScHARR, University of Sheffield, Sheffield, UK;
3 School of Nursing, University of Nottingham, Nottingham, UK;
4 School of Sociology & Social Policy, University of Nottingham, Nottingham, UK;
5 School of Nursing and Midwifery, University of South Australia, Adelaide, Australia;
6 School of Medicine, Flinders University, Bedford Park, Australia
Correspondence to: Richard.cooper{at}nottingham.ac.uk
Objectives: Supplementary prescribing (SP) by pharmacists and nurses in the UK represents a unique approach to improving patients' access to medicines and better utilizing health care professionals' skills. Study aims were to explore the views of stakeholders involved in SP policy, training and practice, focusing upon issues such as SP benefits, facilitators, challenges, safety and costs, thereby informing future practice and policy.
Method: Qualitative, semi-structured interviews were conducted with 43 purposively sampled UK stakeholders, including pharmacist and nurse supplementary prescribers, doctors, patient groups representatives, academics and policy developers. Analysis of transcribed interviews was undertaken using a process of constant comparison and framework analysis, with coding of emergent themes.
Results: Stakeholders generally viewed SP positively and perceived benefits in terms of improved access to medicines and fewer delays, along with a range of facilitators and barriers to the implementation of this form of non-medical prescribing. Stakeholders' views on the economic impact of SP varied, but safety concerns were not considered significant. Future challenges and implications for policy included SP being potentially superseded by independent nurse and pharmacist prescribing, and the need to improve awareness of SP. Several potential tensions emerged including nurses' versus pharmacists' existing skills and training needs, supplementary versus independent prescribing, SP theory versus practice and prescribers versus non-prescribing peers.
Conclusion: SP appeared to be broadly welcomed by stakeholders and was perceived to offer patient benefits. Several years after its introduction in the UK, stakeholders still perceived several implementation barriers and challenges and these, together with various tensions identified, might affect the success of supplementary and other forms of non-medical prescribing.
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There are approximately 4500 nurses7 and 1400 pharmacists8 qualified as supplementary prescribers in the UK, with actual reported use of SP being 49% among a sample of pharmacists9 and 44% among a nurse sample.5 For nurses, this represents a significant increase compared to previous research that indicated 34% of nurses using SP10 and, although it has been suggested that SP may be over-shadowed by IP,11 SP may allow new prescribers to gain confidence after qualifying.5 Furthermore, SP has also been introduced for several other allied health professionals such as chiropodists, podiatrists, physiotherapists and radiographers.2
A recent review of the SP literature by Cooper et al.11 suggested that nurses and pharmacists have welcomed their new prescribing role despite implementation barriers, such as using CMPs.10,11 Furthermore, patients appear to have valued pharmacist SP and also received more medicines information and longer consultations from SP pharmacists than their doctor. The review also identified research indicating support from other stakeholders, such as hospital managers. A mixed response from doctors was identified. Although DMPs were positive about non-medical prescribing, others cited boundary encroachment concerns, or more critical comments such as non-medical prescribing representing a ‘dangerous, uncontrolled experiment’ that could threaten patient safety.12
Despite increasing research involving SP, some studies represented prospective opinions prior to SP being introduced or involved early SP cohorts and experiences, and some stakeholders have been under-represented.11 The aim in this paper, therefore, is to present recent views from a range of stakeholders involved in the training, development, implementation and practice of SP in the UK for pharmacists and nurses to offer insights into how the development of his form of non-medical prescribing has proceeded, to indicate possible benefits and challenges, and to inform policy and practice, both in the UK and internationally, in countries considering introducing non-medical prescribing. It is also hoped that while the focus is upon SP, that it may also be used to inform other forms of prescribing, such as IP, given the similarities identified in terms of training and implementation problems.
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Box 1 Examples of interview schedule questions
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One of the research team undertook framework analysis13 of transcribed interviews initially, using a coding frame based upon broad categories such as education, implementation, safety and cost. This method was used in part because of the relatively large number of participants involved and to make the initial stages of coding more manageable, yet open to refinement and revision.13 A second researcher undertook additional open and axial coding, together with the process of constant comparison, with transcripts being re-read until all emergent themes had been coded. Independent ethics review was obtained from the University of Sheffield.
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All stakeholders commented upon SP training and the positive aspects were that many felt it prepared students for SP practice, there were flexible arrangements for studying, and nurses and pharmacists being trained together offered advantages. Negative aspects related to the limited timescale and content of the course, the lack of SP courses tailored to individual clinical specialties and variation between courses. Many stakeholders questioned how differences between supplementary and other models of prescribing or the skills and needs of nurses and pharmacists could be accommodated in training. Many stakeholders – irrespective of their professional background – commented that both nurses and pharmacists had different strengths, but also weaknesses, in relation to prescribing; nurses were perceived to have adequate skills in counselling and inter-personal skills, but lacked pharmacological knowledge, whereas pharmacists were perceived to be competent in pharmacology, but lacked counselling and diagnostic skills. This led to conflicting beliefs as to different professions being taught together, with some stakeholders arguing that inter-professional teaching on a joint SP course might be problematic, but others arguing that joint courses would offer insights into another profession and opportunities for mutual assistance:
‘Nurses have the consultancy skills already and just need to learn the pharmacology and the importance of prescribing whereas pharmacists, from what I have seen, [have] a lot more concerns about how to meet the patients, how to weigh up the patients [...] So combined courses can confuse me somewhat.’ (Primary care SP pharmacist)
There was a perception that a certain level of clinical skill and experience was needed by students before undertaking a prescribing course. Academic and lecturer stakeholders warned, however, that early ‘pioneering’ student cohorts may represent the most motivated and clinically competent but future cohorts might be less able.
The mentoring role of the DMP was viewed positively, but some nurses and pharmacists reported DMPs' dilatory attitude towards supervision. This was also reported by some course lecturers – including examples of cursory or retrospective signing of competency documents:
‘I work quite closely with... one of the GPs here anyway but [the GP] didn't really understand the role and kind of because I had got a lot of experience anyway [the GP] pretty much left it to me and just signed the paperwork at the end.’ (Primary care SP nurse)
Many stakeholders raised concerns about continuing professional development (CPD) once qualified. Concerns were raised that ongoing training was limited and restricted to individual professions, and that this might lead to prescribers being unaware of current clinical knowledge, to the detriment of patients.
Stakeholders were asked about the implementation of SP in practice and several themes emerged. There was a perception that patients were generally positive about SP, valued improved access and that it resulted in fewer delays in making appointments:
‘I get the feeling that the patients have certainly had access to their medicines more quickly [...] It has been a much more direct kind of route for them getting what they need, and that has been particularly useful for people with chronic problems.’ (SP course lecturer)
Several stakeholders, however, felt that patients remained largely unaware of SP, representing not only a barrier to the implementation of SP, but also, as a patient group representative noted, reflecting a broader concern about SP having being introduced without adequate patient consultation and information. Several stakeholders perceived there to be overall benefits from SP in terms of reducing doctors' workloads and also in encouraging greater interaction and understanding between different health care professions.
The CMP was frequently mentioned by stakeholders in relation to SP practice, with benefits cited as helping patients distinguish supplementary from other forms of prescribing, increasing safety and, as several SP nurses and pharmacists noted, offering opportunities to interact with doctors. Many stakeholders noted that CMPs offered not only nurses and pharmacists, but doctors, too, a good opportunity to review and reflect on current treatment guidelines. CMPs, however, also attracted a significant amount of criticism from many stakeholders. One concern was that using a CMP re-enforced a biomedical model, to the detriment of a holistic approach to patient care and treatment:
‘It is not a way to look at patient care. It is very un-patient centred. It is seeing patients as disease states.’ (Clinical lead)
A tension was also apparent between the safeguards that CMPs offered in terms of a formalized care plan informed by current guidelines and the practical expediencies of prescribing in a limited time for patients with multiple diseases. The CMP was also believed to be less suitable for patients with co-morbidities and more complex presentations, and was frequently described as being restrictive in nature resulting in inflexible prescribing that inconvenienced patients.
Facilitators and barriers to implementing SP
Stakeholders were asked to comment further about their experiences or perceptions of the success of implementing SP in practice and several suggestions were forwarded. Supplementary prescribers' enthusiasm was considered a key facilitator, helping to overcome barriers, but also in acting as a role model to encourage their professional peers to become supplementary prescribers. Support was also identified as a facilitator, both in terms of local networks of fellow prescribers, and in relation to the specific support needed from employers and commissioning bodies. A ‘top-down’ approach was advocated as being important for support and overall commitment to SP:
‘Where supplementary prescribing works very well in the organizations that I have seen is where the lead director is very passionate about modernization in general and can see a place for it, you know – it is kind of culturally embedded within that organization.’ (Non-medical prescribing lead)
Less formal support offered by peers was also argued to be an important facilitator and was often described by supplementary prescribers, offering reassurance and a forum for addressing concerns in their practice. Access to appropriate information technology (IT) and facilities were identified as further facilitators and were argued to make the SP process easier, as was a pre-existing working relationship between a doctor and a supplementary prescriber. Some argued that a prior relationship meant that a doctor would have gained confidence in the capabilities of the prescriber, but in contrast to nurses – who have increasingly worked alongside doctors in both primary and secondary care – pharmacists, and especially those working in the community, were perceived as being more isolated and lacking close medical contact.
In terms of barriers to implementing SP, stakeholders identified the lack of awareness and understanding of SP by patients, peers, doctors and also those involved in commissioning new services such as SP in local PCTs or hospitals. Supplementary prescribers gave examples of pharmacists refusing to dispense their prescriptions, and colleagues making inappropriate SP prescription requests. Several stakeholders described delays between SP training and subsequent practice. A further barrier was argued to be pressure on supplementary prescribers to return to previous roles, once qualified, rather than to prescribe:
‘There are still some people out there, in hospital in particular, that have qualified and can't get practising because they are being dragged back to their dispensary.’ (Clinical lead)
An inadequate IT infrastructure was also identified among several stakeholders and this involved practical issues such as not being able to print prescriptions and more general problems such as a lack of access to patients' medical records.
Professional relationships and boundary encroachment
There was a perception among some stakeholders that SP might be beneficial for professional relationships and could provide an opportunity for increased interaction and trust, especially between doctors and non-medical prescribers. In contrast, other stakeholders argued that some doctors might feel threatened by SP – one doctor recognized a ‘certain amount of suspicion and sometimes antipathy’ among medical peers – and several primary care SP practitioners recalled instances where a GP had made negative comments about, or appeared to resist, non-medical prescribing. There was a perception, however, that SP might be a less threatening model of non-medical prescribing because it maintained medical authority in the initial diagnosis and subsequent decision-making. Occasional examples were provided of conflicts between nurses and pharmacists in practice, where pharmacists had encroached upon nurses' existing clinics. Several stakeholders also identified intra-professional tensions and there was a concern that nurse and pharmacist prescribers may be resented by colleagues:
‘I think it has raised some issues with some professional jealousies where some nurses in particular have found that some of their peers don't like it really (the fact that they are prescribing) and [their peers] would sooner go to the GP rather than ask the nurse prescriber about things.’ (Clinical lead)
Overall, there was a perception that SP might offer an inherently safer framework than IP because of the need for a patient-specific CMP, because of the joint decision-making by non-medical prescriber and doctor, and because SP involves patients with less complex medical conditions. There was also a perception, particularly among course providers and policy-makers, that safety could be ensured by adequate training, and subsequent auditing and review of practice. However, stakeholders believed lack of access to IT, and especially a common, electronic patient record, might affect the safety of SP because of potential multiple records and delays in updating records as more and varied prescribers provided care for one patient. Fragmentation of care was considered a concern. Access to patients' records was believed to be more problematic for those working in remote sites (such as community pharmacists and midwives), threatening their involvement in SP. The competency of non-medical prescribers was identified as a possible safety concern and stakeholders involved in policy warned of the need for prescribers to recognize their clinical limitations and for their competency to be formally audited and assessed. Differences between nurses and pharmacists were again raised, and several stakeholders remarked that pharmacists' understanding of pharmacology might lead to safer prescribing, but other stakeholders argued that nurses' diagnostic training could provide an additional safety check.
Stakeholders were asked for their comments on economic aspects of SP, and several cost-related issues emerged, concerning salaries, prescribing and indirect costs. In relation to salaries, several stakeholders made reference to positive and negative economic aspects of SP. It was argued in a positive sense that SP might help reduce costs by having lower paid professionals such as nurses or pharmacists undertake routine prescribing duties. This was recognized by all stakeholders, including prescribers themselves:
‘It is cost-cutting and that was fully intentional and that was the only reason they would allow nurses to expand their role is to get cheaper labour basically.’ (Hospital SP nurse)
There was a concern that costs would rise as non-medical prescribers demanded higher salaries, although SP nurses reported colleagues being dissuaded from prescribing due to meagre salary increases relative to the extra responsibility. Several stakeholders referred to the costs associated with prescribing and, in particular, beliefs about the prescribing patterns of nurses and pharmacists, and the impact of non-medical prescribing on overall prescribing. Opinions differed, however, as to whether SP would increase, decrease or have no effect upon overall NHS medicine costs. Many stakeholders argued that costs would remain the same, either because SP represented such a small percentage of overall NHS prescribing, or because SP was perceived as substitute prescribing. However, several stakeholders believed prescribing costs would decrease because of nurses' and pharmacists' more recent training, guideline-based CMPs, a perception that pharmacists were very aware of medicine costs and patients' increased compliance through better information provision with SP. A minority of stakeholders, however, believed that SP would result in increased prescribing costs due to perceptions of supplementary prescribers being influenced by pharmaceutical companies, nurses being unaware of medicine costs and the sheer numbers of additional prescribers increasing overall prescribing. Several stakeholders commented on a number of indirect costs associated with SP, such as those associated with training nurses and pharmacists, and concerns about perceived longer consultation times involving nurses and pharmacists, all of which could result in increased overall SP costs.
Differences between SP and IP were mentioned by many stakeholders, with IP being perceived to have a number of advantages overall. It was argued to be a more flexible model of prescribing in not requiring a CMP; it would improve access to medicines, by addressing delays in appointments for acute treatment by doctors; and it represented a more prestigious and more autonomous prescribing model for non-medical prescribers. However, these perceived benefits were countered by a number of concerns which SP was argued to address, such as that IP might be a greater threat to medical dominance, that IP might not suit less confident non-medical prescribers, that IP might increase prescribing costs, that IP could lead to prescribing beyond nurses' and pharmacists' competencies, and that their diagnostic skills might be inadequate for some presenting conditions.
Stakeholders were also asked to comment upon the future of SP, and although some believed it would become an integral part of nurses' and pharmacists' roles and ultimately undergraduate training, others argued that it might be superseded by IP. In addition, a minority of stakeholders believed recent changes relating to non-medical prescribing had been too rapid and that a more conservative approach to policy in this area was needed. Key challenges were perceived to be increasing awareness of SP, introducing local strategies for implementing SP more effectively, addressing deficiencies in CPD and training in consultation and therapeutic skills, undertaking more research into non-medical prescribing and addressing access to patients' medical records.
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The results of this study may also be viewed in terms of several key differences and tensions, and these are argued to represent threats either to SP itself or to non-medical prescribing more generally, including IP (Box 2). Tensions unique to SP include the differences between SP and IP as prescribing models, which leads to important questions relevant to policy, such as whether both models are needed; whether the flexibility and clinical autonomy offered by IP outweigh the legal and procedural safeguards of SP, and whether SP comes to be viewed as an introductory prescribing model for inexperienced prescribing only. Several studies have reported a belief, particularly among pharmacists, that IP is their ultimate aim.9,16 with SP undertaken either because it was the only form of prescribing initially available or because it served as a preparatory form of non-medical prescribing to gain confidence.5 This raises the possibility of a two-tiered non-medical prescribing system in the UK, with IP becoming the main model of non-medical prescribing and SP considered as an introductory model. However, the reported increased use of SP among nurses10 and also stakeholders' perceptions of enhanced safety with SP, hint at a continued role for SP – even if just to gain prescribing confidence after training, or perhaps as a way of allaying some doctors' fears about safety and non-medical prescribing.12,17
Box 2 Differences and tensions emerging from SP stakeholder interviews
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Perhaps more significantly, however, are a number of existing health care tensions that SP not only highlights or exacerbates but may also be affected by, such as inter-professional conflicts and changes in the division of labour in health care, and differences between community and primary care settings. These are argued to be potentially more entrenched tensions that show little sign of being resolved, and hence represent enduring threats to the success of SP and IP. These may be manifest as medical resistance to nurses' and pharmacists' developing roles that might threaten medical dominance, or barriers to the majority of UK pharmacists (in the community, retail sector)14 potentially undertaking SP due to their relative isolation, and lack of medical relationships and access to records.
A further policy concern involves raising awareness and understanding of SP and IP as alternatives to medical prescribing, particularly among many doctors, those involved in commissioning services and patients, as other research has suggested.11,14 This could include more advertising of SP and IP as prescribing models and their potential benefits to the medical profession in terms of reducing workloads and costs, and in meeting performance targets for general practitioners in primary care. This may also encourage more doctors to undertake DMP roles, though remuneration may be required for this service.
This study is the first to explore issues of safety and cost in relation to SP specifically and it appears that many stakeholders perceive SP to be a relatively safe prescribing model. This may be contrasted with some reported medical opinions,12,17 although it is apparent that IP with its diagnostic component and lack of medical supervision may be particularly problematic for doctors.11 As several stakeholders noted, such features are not associated with SP and this may have contributed to a perception of relative safety. However, further empirical research is required to complement stakeholders' perceptions and experiences. Similarly, although a range of economic issues emerged – with some conflicting views about whether SP will lead to increased NHS costs – further research is needed to explore the costs of SP.
Study limitations involved the possibility that stakeholders' views were not necessarily representative of SP stakeholders nationally. For example, the doctors interviewed had all experienced SP to some extent, in contrast to other members of their profession. It was not possible to recruit patients for this study and despite the use of patient group representatives as proxies, further research is needed to consider patients' views and experiences more fully. Finally, the study relied upon stakeholders' perceptions of SP and this may differ from actual practice; some stakeholders not involved in practice, for example, appeared to espouse received wisdom or offered responses that reflected what they had read in the literature.
In conclusion, SP represents a novel approach to providing patients with medicines and appears to be broadly welcomed by stakeholders. Several years after its introduction in the UK, however, implementation problems and challenges, together with a number of tensions remain, and these potentially threaten the success of supplementary and other forms of non-medical prescribing.
| Acknowledgements |
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