Stakeholders’ views of UK nurse and pharmacist supplementary prescribing

J Health Serv Res Policy 2008;13:215-221
doi:10.1258/jhsrp.2008.008004
© 2008 Royal Society of Medicine Press

 

This Article
Right arrow
Abstract

Freely available
Right arrow

Full Text (PDF)

Right arrow
Alert me when this article is cited
Right arrow
Alert me if a correction is posted
Services
Right arrow
Email this article to a friend
Right arrow

Similar articles in this journal

Right arrow

Similar articles in Web of Science

Right arrow
Similar articles in PubMed
Right arrow
Alert me to new issues of the journal
Right arrow
Download to citation manager
Right arrow
Citing Articles
Right arrow
Citing Articles via HighWire
Right arrow

Citing Articles via Web of Science (1)

Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow
Articles by Cooper, R.
Right arrow
Articles by Ward, P.
Right arrow Search for Related Content
PubMed
Right arrow
PubMed Citation
Social Bookmarking

What’s this?


Original research


Richard Cooper ,
Claire Anderson,
Tony Avery 1,
Paul Bissell 2,
Louise Guillaume 2,
Allen Hutchinson 2,
Joanne Lymn 3,
Elizabeth Murphy 4,
Julie Ratcliffe 5,
Paul Ward 6


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 with43 purposively sampled UK stakeholders, including pharmacistand nurse supplementary prescribers, doctors, patient groupsrepresentatives, academics and policy developers. Analysis oftranscribed interviews was undertaken using a process of constantcomparison and framework analysis, with coding of emergent themes.

Results: Stakeholders generally viewed SP positively and perceived benefitsin terms of improved access to medicines and fewer delays, alongwith a range of facilitators and barriers to the implementationof this form of non-medical prescribing. Stakeholders’ viewson the economic impact of SP varied, but safety concerns werenot considered significant. Future challenges and implicationsfor policy included SP being potentially superseded by independentnurse and pharmacist prescribing, and the need to improve awarenessof SP. Several potential tensions emerged including nurses’versus pharmacists’ existing skills and training needs, supplementaryversus independent prescribing, SP theory versus practice andprescribers versus non-prescribing peers.

Conclusion: SP appeared to be broadly welcomed by stakeholders and was perceivedto offer patient benefits. Several years after its introductionin the UK, stakeholders still perceived several implementationbarriers and challenges and these, together with various tensionsidentified, might affect the success of supplementary and otherforms of non-medical prescribing.





Introduction

Go to previous sectionTop

 Introduction
Go to next sectionMethod

Go to next sectionResults

Go to next sectionDiscussion

Go to next sectionAcknowledgements

Go to next sectionReferences

 

Supplementary prescribing (SP) represents one of several non-medical prescribing models to have been introduced internationally in recent years that are re-defining how patients access medicines from health care professionals.1 Introduced in the UK in 2003 in the nursing and pharmacy professions, SP is a dependent model of prescribing which involves a tripartite arrangement between a non-medical supplementary prescriber, a doctor and a patient. Following an initial medical diagnosis, SP allows suitably trained pharmacists and nurses to take prescribing responsibility for patients in accordance with a patient-specific clinical management plan (CMP) for a full range of medicines, including unlicensed and controlled drugs.2 With aims of improving patients’ access to medicines, making better use of the skills of non-medical health care professionals and reducing waiting times,3,4 SP is considered particularly suitable for the many patients with long-term conditions such as asthma, diabetes and hypertension. SP is intended to complement not only existing prescribing by doctors – who, it is envisaged, may be able to spend more time on complex conditions and patients as a result of SP – but also previous developments such as patient group directions and, more recently, independent prescribing (IP) by nurses and pharmacists. IP differs from SP in that IP involves nurses and pharmacists not only prescribing, but also diagnosing without direct medical involvement or a CMP, whereas patient group directions tend to be for specific medicines but not specific patients. SP shares many similarities with IP, however, and this is reflected in the identification of similar implementation problems for both forms of prescribing among nurse prescribers, including restrictive local arrangements, problems generating computer prescriptions, lack of peer support, and objections by doctors and pharmacists.5 A further similarity is reflected in the development of a combined prescribing training course for nurses and pharmacists in the UK in both SP and IP, reflecting considerable overlap in indicative course content between SP and IP. Many UK higher education institutions offer SP and IP courses and these are accredited by relevant professional bodies, provide general training and are usually funded by the prescriber’s employer. More specialized experience in a specific clinical area is obtained through working alongside a doctor – known as designated medical practitioners (DMPs) – in a mandatory period of learning practice. Such training may be contrasted with some dependent prescribing undertaken internationally, where entirely local assessment of competency is undertaken instead,1 although the adequacy of such training and also nurse prescribers’ pharmacological knowledge have been criticized.6

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 involvedin the training, development, implementation and practice ofSP in the UK for pharmacists and nurses to offer insights intohow the development of his form of non-medical prescribing hasproceeded, to indicate possible benefits and challenges, andto 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 mayalso be used to inform other forms of prescribing, such as IP,given the similarities identified in terms of training and implementationproblems.





Method

Go to previous sectionTop

Go to previous sectionIntroduction

 Method
Go to next sectionResults

Go to next sectionDiscussion

Go to next sectionAcknowledgements

Go to next sectionReferences

 

Using purposive sampling, 52 individuals or organizations in the UK were initially approached to reflect key stakeholder groups and from these, 43 individual stakeholders were subsequently interviewed during 2006 (Table 1). These stakeholders were identified primary through contacts of the authors, in terms of their involvement currently or previously in the training, research, practice and implementation of SP in both primary (community and general medical practice) and secondary (hospital) care settings. Insights from patient groups and the nursing, pharmacy and medical professions were also considered desirable, and recruitment of stakeholders from appropriate organizations was also undertaken, again using contacts of the authors. In several cases, stakeholders were no longer directly involved in SP, but were recruited based upon their previous experience of SP. Qualitative, semi-structured interviews were undertaken mainly by telephone, as this overcame the problems of interviewing a relatively large number of interviewees across many locations in the UK, in the relatively short timescale permitted. Although such interviews may lead to less interaction and rapport, this was not considered an issue in this research. A small number of interviews, however, were conducted in person. An interview guide was developed, based upon a review of the literature11 and discussions among the authors (Box 1). Interviews variedin duration from 21 to 82 minutes with a mean of 42 minutes.



View this table:
[in this window]
[in a new window]
Table 1 Details of stakeholder sample



Box 1 Examples of interview schedule questions

What do you see as the key issues for SP in nursing and pharmacy and non-medical prescribing more generally?
What is your overall view of how SP has been implemented?
What is your view on the appropriateness of SP training and ongoing support?
How do you think SP has developed over time?
How do you see SP developing in the future?
Do you think SP raises particular issues in relation to safety and, if so, what are these?
Do you think SP raises particular issues in relation to multi-disciplinary working and, if so, what are these?
What impact do you think that SP is going to have or already has had upon prescribing costs?
Do you think that SP might raise issues about professional rivalry or boundary encroachment?
What is your view about the development and use of CMPs?
How might CMPs be improved?

 

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.13A second researcher undertook additional open and axial coding,together with the process of constant comparison, with transcriptsbeing re-read until all emergent themes had been coded. Independentethics review was obtained from the University of Sheffield.





Results

Go to previous sectionTop

Go to previous sectionIntroduction

Go to previous sectionMethod

 Results
Go to next sectionDiscussion

Go to next sectionAcknowledgements

Go to next sectionReferences

 

Analysis of interviews revealed several broad themes which,due to the relatively structured nature of many of the interviewsconducted, corresponded closely to the questions asked. Hence,issues relating to SP in practice, training, safety and economicconcerns were all identified. It was apparent that stakeholders’background and expertise affected their responses and, for example,those involved in research, teaching or policy tended to considerSP in terms of training and competency, whereas practitionersfocused more upon barriers and problems in practice. However,in other respects, the views of different stakeholders werebroadly similar, as will be indicated in relation to perceptionsof professional competencies. The key emergent themes are nowpresented in turn, leaving the implications of these data tobe considered more fully in the discussion, where it will beargued that a number of tensions and differences are apparent.


Training and education

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 skilland experience was needed by students before undertaking a prescribingcourse. Academic and lecturer stakeholders warned, however,that early ‘pioneering’ student cohorts may representthe most motivated and clinically competent but future cohortsmight 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 professionaldevelopment (CPD) once qualified. Concerns were raised thatongoing training was limited and restricted to individual professions,and that this might lead to prescribers being unaware of currentclinical knowledge, to the detriment of patients.


Implementation and practice

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 largelyunaware of SP, representing not only a barrier to the implementationof SP, but also, as a patient group representative noted, reflectinga broader concern about SP having being introduced without adequatepatient consultation and information. Several stakeholders perceivedthere to be overall benefits from SP in terms of reducing doctors’workloads and also in encouraging greater interaction and understandingbetween 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 CMPsoffered in terms of a formalized care plan informed by currentguidelines and the practical expediencies of prescribing ina limited time for patients with multiple diseases. The CMPwas also believed to be less suitable for patients with co-morbiditiesand more complex presentations, and was frequently describedas being restrictive in nature resulting in inflexible prescribingthat 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 animportant facilitator and was often described by supplementaryprescribers, offering reassurance and a forum for addressingconcerns in their practice. Access to appropriate informationtechnology (IT) and facilities were identified as further facilitatorsand were argued to make the SP process easier, as was a pre-existingworking relationship between a doctor and a supplementary prescriber.Some argued that a prior relationship meant that a doctor wouldhave gained confidence in the capabilities of the prescriber,but in contrast to nurses – who have increasingly workedalongside doctors in both primary and secondary care –pharmacists, and especially those working in the community,were perceived as being more isolated and lacking close medicalcontact.

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 severalstakeholders and this involved practical issues such as notbeing able to print prescriptions and more general problemssuch 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)

 


Safety

Overall, there was a perception that SP might offer an inherentlysafer framework than IP because of the need for a patient-specificCMP, because of the joint decision-making by non-medical prescriberand doctor, and because SP involves patients with less complexmedical conditions. There was also a perception, particularlyamong course providers and policy-makers, that safety couldbe ensured by adequate training, and subsequent auditing andreview of practice. However, stakeholders believed lack of accessto IT, and especially a common, electronic patient record, mightaffect the safety of SP because of potential multiple recordsand delays in updating records as more and varied prescribersprovided care for one patient. Fragmentation of care was considereda concern. Access to patients’ records was believed to be moreproblematic for those working in remote sites (such as communitypharmacists and midwives), threatening their involvement inSP. The competency of non-medical prescribers was identifiedas a possible safety concern and stakeholders involved in policywarned of the need for prescribers to recognize their clinicallimitations and for their competency to be formally auditedand assessed. Differences between nurses and pharmacists wereagain raised, and several stakeholders remarked that pharmacists’understanding of pharmacology might lead to safer prescribing,but other stakeholders argued that nurses’ diagnostic trainingcould provide an additional safety check.


Economic aspects of SP

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 prescribersdemanded higher salaries, although SP nurses reported colleaguesbeing dissuaded from prescribing due to meagre salary increasesrelative to the extra responsibility. Several stakeholders referredto 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, eitherbecause SP represented such a small percentage of overall NHSprescribing, or because SP was perceived as substitute prescribing.However, several stakeholders believed prescribing costs woulddecrease because of nurses’ and pharmacists’ more recent training,guideline-based CMPs, a perception that pharmacists were veryaware of medicine costs and patients’ increased compliance throughbetter information provision with SP. A minority of stakeholders,however, believed that SP would result in increased prescribingcosts due to perceptions of supplementary prescribers beinginfluenced by pharmaceutical companies, nurses being unawareof medicine costs and the sheer numbers of additional prescribersincreasing overall prescribing. Several stakeholders commentedon a number of indirect costs associated with SP, such as thoseassociated with training nurses and pharmacists, and concernsabout perceived longer consultation times involving nurses andpharmacists, all of which could result in increased overallSP costs.


Independent prescribing

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 innot requiring a CMP; it would improve access to medicines, byaddressing delays in appointments for acute treatment by doctors;and it represented a more prestigious and more autonomous prescribingmodel for non-medical prescribers. However, these perceivedbenefits were countered by a number of concerns which SP wasargued to address, such as that IP might be a greater threatto medical dominance, that IP might not suit less confidentnon-medical prescribers, that IP might increase prescribingcosts, that IP could lead to prescribing beyond nurses’ andpharmacists’ competencies, and that their diagnostic skillsmight be inadequate for some presenting conditions.


Future challenges

Stakeholders were also asked to comment upon the future of SP,and although some believed it would become an integral partof nurses’ and pharmacists’ roles and ultimately undergraduatetraining, others argued that it might be superseded by IP. Inaddition, a minority of stakeholders believed recent changesrelating to non-medical prescribing had been too rapid and thata more conservative approach to policy in this area was needed.Key challenges were perceived to be increasing awareness ofSP, introducing local strategies for implementing SP more effectively,addressing deficiencies in CPD and training in consultationand therapeutic skills, undertaking more research into non-medicalprescribing and addressing access to patients’ medical records.





Discussion

Go to previous sectionTop

Go to previous sectionIntroduction

Go to previous sectionMethod

Go to previous sectionResults

 Discussion
Go to next sectionAcknowledgements

Go to next sectionReferences

 

Overall, SP appeared to be viewed positively by stakeholders, and their perceptions and experiences suggest that SP has the potential to fulfil the UK Government’s aims of improving patients’ access to medicines, reducing delays in seeing health care professionals, and providing a legally and procedurally reassuring framework for novice prescribers.2,3 Despite these perceived benefits, however, some aspects of training, implementation and practice were viewed more negatively, and issues remain in relation to the differing educational needs of pharmacists and nurses, raising awareness of non-medical prescribing, accessing IT and a common electronic medical record, CMP difficulties and the role of IP, as other research has also identified.11,14 With the exception of the last two, these concerns also represent barriers to IP, and threaten further developments of non-medical prescribing more generally. These may be relevant to the continued low volume of nurse and pharmacist SP and IP prescribing overall which in primary care in England in 2006 amounted to only 0.85% and 0.004%, respectively, of prescribing (doctors being the main prescribing group).15

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

Pharmacists and nurses – in their different training needs, existing competencies (e.g. pharmacology) and potential boundary encroachment
SP and IP – in that while SP was perceived to be safer than IP, it was also less flexible and an introductory or transitional prescribing model
SP theory and practice – in that despite anticipated timesaving and procedural and legal certainty, SP might result in time-intensive initial setting-up, CMP development and consultations
Student and course providers – in terms of training needs and requirements
Prescribers and non-prescribers in a profession – in that, instead of being role models, prescribers may be resented or not understood by their own colleagues in nursing and pharmacy
Community and primary care – due to community difficulties in accessing patients’ medical records and developing medical relationships
Practitioners and policy-makers/educators – due to differing emphases upon practical difficulties and competency/training, respectively

 

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 potentiallyundertaking SP due to their relative isolation, and lack ofmedical 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 couldinclude more advertising of SP and IP as prescribing modelsand their potential benefits to the medical profession in termsof reducing workloads and costs, and in meeting performancetargets for general practitioners in primary care. This mayalso encourage more doctors to undertake DMP roles, though remunerationmay 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 featuresare not associated with SP and this may have contributed toa perception of relative safety. However, further empiricalresearch is required to complement stakeholders’ perceptionsand experiences. Similarly, although a range of economic issuesemerged – with some conflicting views about whether SPwill lead to increased NHS costs – further research isneeded to explore the costs of SP.

Study limitations involved the possibility that stakeholders’views were not necessarily representative of SP stakeholdersnationally. For example, the doctors interviewed had all experiencedSP to some extent, in contrast to other members of their profession.It was not possible to recruit patients for this study and despitethe use of patient group representatives as proxies, furtherresearch is needed to consider patients’ views and experiencesmore fully. Finally, the study relied upon stakeholders’ perceptionsof SP and this may differ from actual practice; some stakeholdersnot involved in practice, for example, appeared to espouse receivedwisdom or offered responses that reflected what they had readin the literature.

In conclusion, SP represents a novel approach to providing patientswith medicines and appears to be broadly welcomed by stakeholders.Several years after its introduction in the UK, however, implementationproblems and challenges, together with a number of tensionsremain, and these potentially threaten the success of supplementaryand other forms of non-medical prescribing.

 




Acknowledgements

Go to previous sectionTop

Go to previous sectionIntroduction

Go to previous sectionMethod

Go to previous sectionResults

Go to previous sectionDiscussion

 Acknowledgements
Go to next sectionReferences

 

The authors would like to thank all the stakeholders who participated,the Journal’s peer reviewers for their helpful comments, andthe Department of Health for funding.




Footnotes


Richard J Cooper PhD, Research Fellow, Claire Anderson PhD, Professor of Social Pharmacy, Centre for Pharmacy, Health and Society, University of Nottingham, University Park, Nottingham, NG7 2RD, UK; Tony Avery DM, Professor in Primary Care, Community Health Sciences, Queen’s Medical Centre, University of Nottingham, Nottingham, UK; Paul Bissell PhD, Senior Lecturer in Public Health, Louise Guillaume PhD, Research Associate, Allen Hutchinson MB BS, Section of Public Health, ScHARR, University of Sheffield, Sheffield, UK; Joanne Lymn PhD, Associate Professor, School of Nursing, University of Nottingham, Nottingham, UK; Elizabeth Murphy PhD, Professor of Medical Sociology, School of Sociology & Social Policy, University of Nottingham, Nottingham, UK; Julie Ratcliffe PhD, Associate Research Professor, School of Nursing and Midwifery, University of South Australia, Adelaide, Australia; Paul Ward PhD, Associate Professor of Public Health Research, School of Medicine, Flinders University, Bedford Park, Australia.




References

Go to previous sectionTop

Go to previous sectionIntroduction

Go to previous sectionMethod

Go to previous sectionResults

Go to previous sectionDiscussion

Go to previous sectionAcknowledgements

 References

 

  1. Emmerton L, Marriott J, Bessell T, Nissen L, Dean L. Pharmacists and prescribing rights: review of international developments. J Pharm Pharmaceut Sci 2005;8:217–25[Medline]
  2. Department of Health. Supplementary prescribing by nurses, pharmacists, chiropodists/podiatrists, physiotherapists and radiographers within the NHS in England: a guide for implementation – updated May 2005. London: Department of Health, 2005
  3. Department of Health. The NHS Plan. London: Department of Health, 2000
  4. Cooper RJ, Anderson C, Avery T, et al. Non-medical prescribing in the UK – developments and stakeholder interests. J Ambul Care Manage 2008;31:243–51
  5. Courtenay M, Carey N. Nurse independent prescribing and nurse supplementary prescribing practice: national survey. J Adv Nurs 2008;61:291–9[Medline]
  6. Avery AJ, James V. Developing nurse prescribing in the UK. BMJ 2007;335:316[Free Full Text]
  7. Anon. Numbers of nurse prescribers rises. Nursing Times 2006;102:2
  8. Personal communication. Royal Pharmaceutical Society of Great Britain. January 2008
  9. George J, McCaig D, Bond C, et al. Benefits and challenges of prescribing training and implementation: perceptions and experiences of RPSGB prescribers. Int J Pharm Pract 2007;15:23–30
  10. Courtenay M, Carey N, Burke J. Independent extended and supplementary nurse prescribing practice in the UK: a national questionnaire survey. Int J Nurs Stud 2007;44:1093–101[Medline]
  11. Cooper RJ, Anderson C, Avery T, et al. Nurse and pharmacist supplementary prescribing in the UK – a thematic review of the literature. Health Policy 2008;85:277–92[Medline]
  12. Horton R. Nurse-prescribing in the UK: right but also wrong. Lancet 2002;359:875–6
  13. King N. Template analysis. In: Symon G, Cassell C, eds. Qualitative Methods and Analysis in Organizational Research. A Practical Guide. London: Sage Publications, 1998:118–34
  14. Weiss M, Sutton J, Adams C. Exploring innovations in pharmacy practice: a qualitative evaluation of supplementary prescribing by pharmacists. Bath University: Department of Pharmacy and Pharmacology, 2006
  15. Guillaume L, Cooper RJ, Avery A, et al. Supplementary prescribing by community and primary care pharmacists: an analysis of PACT data, 2004–2006. J Clin Pharm Ther 2008;33:11–16[Medline]
  16. Warchal S, Brown S, Tomlin M, Portlock J. Attitudes of successful candidates of supplementary prescribing courses to their training and their extended roles. Pharmaceut J 2006;276:348–52
  17. Keighley B. Should nurses prescribe? B J Gen Pract 2006;56:68


CiteULike    Complore    Connotea    Del.icio.us    Digg    Reddit    Technorati    What’s this?






This article has been cited by other articles:

Home page JAMAHome page

M. O. Baerlocher and A. S. Detsky
Professional Monopolies in Medicine
JAMA,

February 25, 2009;
301(8):
858 – 860.

[Full Text]
[PDF]


 

This Article
Right arrow
Abstract

Freely available
Right arrow

Full Text (PDF)

Right arrow
Alert me when this article is cited
Right arrow
Alert me if a correction is posted
Services
Right arrow
Email this article to a friend
Right arrow

Similar articles in this journal

Right arrow

Similar articles in Web of Science

Right arrow
Similar articles in PubMed
Right arrow
Alert me to new issues of the journal
Right arrow
Download to citation manager
Right arrow
Citing Articles
Right arrow
Citing Articles via HighWire
Right arrow

Citing Articles via Web of Science (1)

Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow
Articles by Cooper, R.
Right arrow
Articles by Ward, P.
Right arrow Search for Related Content
PubMed
Right arrow
PubMed Citation
Social Bookmarking

What’s this?