Elsevier

Health Policy

Volume 85, Issue 3, March 2008, Pages 277-292
Health Policy

Review
Nurse and pharmacist supplementary prescribing in the UK—A thematic review of the literature

https://doi.org/10.1016/j.healthpol.2007.07.016Get rights and content

Abstract

Objectives

Supplementary prescribing (SP) represents a recent development in non-medical prescribing in the UK, involving a tripartite agreement between independent medical prescriber, dependent prescriber and patient, enabling the dependent prescriber to prescribe in accordance with a patient-specific clinical management plan (CMP). The aim in this paper is to review, thematically, the literature on nurse and pharmacist SP, to inform further research, policy and education.

Methods

A review of the nursing and pharmacy SP literature from 1997 to 2007 was undertaken using searches of electronic databases, grey literature and journal hand searches.

Results

Nurses and pharmacists were positive about SP but the medical profession were more critical and lacked awareness/understanding, according to the identified literature. SP was identified in many clinical settings but implementation barriers emerged from the empirical and anecdotal literature, including funding problems, delays in practicing and obtaining prescription pads, encumbering clinical management plans and access to records. Empirical studies were often methodological weaknesses and under-evaluation of safety, economic analysis and patients’ experiences were identified in empirical studies. There was a perception that nurse and pharmacist independent prescribing may supersede supplementary prescribing.

Conclusions

There is a need for additional research regarding SP and despite nurses’ and pharmacists’ enthusiasm, implementation issues, medical apathy and independent prescribing potentially undermine the success of SP.

Introduction

Changes within healthcare in recent years have seen a shift in the traditional roles undertaken by healthcare professionals and one of the most significant of these has been the development of non-medical prescribing. Internationally, several healthcare systems now include some form of prescribing by non-medical healthcare professionals, offering potential benefits in terms of increasing patients’ continuity of care and access to medicines, better utilisation of economic and human resources, reductions in patient waiting times and less fragmentation of care [1]. The nursing and pharmacy professions have been at the forefront of these prescribing changes and in the USA, for example, collaborative prescribing by pharmacists and nurses has been possible since the 1970s and, in the United Kingdom (UK), district nurses and health visitors have had limited prescribing rights since the late 1990s. A review of the international pharmacist prescribing literature identified predominantly US studies which reported benefits such as improved compliance and disease control measures, fewer drug interactions, better allocation of resources and economic saving [2], whilst a UK nurse prescribing literature review identified generally positive evaluations amongst both patients and nurse prescribers but identified concerns involving pharmacological knowledge and limitations in prescribable medicines [3].

Rapid changes within healthcare, though, have meant that these reviews did not include more recent non-medical prescribing models such as supplementary prescribing (SP). Introduced in the UK in 2003, this model is a key part of the UK government's plans to revolutionise the delivery of healthcare and offers prescribing rights for several healthcare professions, including nurses, pharmacists and, most recently, physiotherapists, radiographers and optometrists. SP is a dependent model of prescribing, involving a tripartite arrangement between the supplementary prescriber, an independent prescribing doctor and the patient. Following an initial medical diagnosis, SP allows suitably trained healthcare professionals to take prescribing responsibility for patients in accordance with a specific clinical management plan (CMP) [4]. Such is the pace of healthcare reforms in the UK that, as well as SP, nurses and pharmacists can now also undertake independent prescribing (IP). Non-medical training in the UK now involves, for nurses, a single post-graduate independent, extended and supplementary prescribing (IESP) qualification whilst pharmacists, at the time of writing, complete either a SP or an IP conversion course. Despite the development of IP, SP is intended to have a central role in UK healthcare and is argued to be particularly suited to the many patients who have stable, long-term conditions such as cardiovascular disease and diabetes. Safety is paramount in SP, by virtue of continued medical supervision and the guidelines of the CMP. Such safeguards have meant that SP can be from a full medicines formulary, including controlled and unlicensed drugs. There are around 1200 SP qualified pharmacists (Personal communication, Royal Pharmaceutical Society of Great Britain 2007) and around 10,000 nurses qualified to undertake SP or IP [5].

Section snippets

Objectives

The aim in this paper is to review the extant literature relating to nurse and pharmacist SP, given its importance to changing UK healthcare roles and National Health Service (NHS) aims. Specific objectives were to consider issues surrounding the implementation of SP and how it has been perceived and experienced by various healthcare professionals and to describe relevant empirical research relating to SP and identify where additional research is needed. In so doing, it is hoped that this

Scope and method

The intention in this review is to consider both empirical pharmacist and nurse SP research and also opinion and commentary and the grey literature relating to SP. The reason for including such potentially diverse literatures is due mainly to SP being a relatively recent development with as associated lack of empirical research, as previous non-medical prescribing reviews have found [3]. Hence, a thematic rather than systematic review was considered most appropriate and including the grey

Results

Thirty-five empirical research papers were identified: 20 relating to pharmacy [6], [7], [8], [9], [10], [11], [12], [13], [14], [15], [16], [17], [18], [19], [20], [21], [22], [23], [24], [25] (Table 1), 15 nursing [26], [27], [28], [29], [30], [31], [32], [33], [34], [35], [36], [37], [38], [39], [40] (Table 2) and 3 papers that concerned both [41], [42], [43] (Table 3). However, several publications reported different aspects of one overall study and data set [12], [13], [29], [30], [31],

Discussion

A descriptive analysis of the SP literature reveals a trend that SP nurse and pharmacist practitioners were positive and generally confident about SP and that it has been successfully implemented in a range of clinical setting in the UK. However, other healthcare professionals and especially doctors appeared more qualified in their assent and also lacked awareness of SP and a range of implementation barriers and challenges were also identified. However, a critical analysis of the emergent

Conclusions

This review of the SP literature has revealed that SP is a model of non-medical prescribing that, although welcomed by non-medical professionals, faces a number of challenges. Some relate to implementation barriers that may be resolved at a local policy level but others such as the development of IP and the apathy of the medical profession, represent more significant threats to the success of this prescribing initiative. Further research is urgently needed in this area of rapid change in

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