NIHR Signal Nurses and pharmacists can prescribe as effectively as doctors

Published on 21 March 2017

Prescribing by suitably-trained pharmacists and nurses offers similar outcomes to prescribing by doctors, at least in the management of chronic conditions.

This Cochrane review pooled clinical outcomes and patient satisfaction across 45 studies of nurse or pharmacist prescribing compared with doctor prescribing.

Most studies were of chronic disease management in primary care settings in high income countries (25 from the US and six from the UK).

Independent and supplementary prescribers in the NHS include not only the nurses and pharmacists, as covered in this review, but also other professions such as podiatrists, optometrists, and physiotherapists. At a time of high demand for NHS resources, with shortages of doctors in some specialties, prescribing by other professionals may help ease the workload, but safety, time and costs of training need to be considered.

Nurses and pharmacists can prescribe as effectively as doctors

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Why was this study needed?

Prescribing by health professionals other than doctors has been in place in the UK since 2006. Nurses, pharmacists, dentists and some other healthcare professionals are now able to train as independent prescribers, meaning they can prescribe any drug within their competency, including controlled drugs. There are an estimated 19,000 nurse independent prescribers in the UK, and many more supplementary prescribers from other professions such as optometrists, midwives and physiotherapists, who prescribe to protocol or under supervision of a doctor.

Independent and supplementary prescribing has been seen as a way of improving access to medicines, freeing up doctors’ time, and making better use of the skills of professionals such as nurses and pharmacists. This study aimed to investigate whether independent prescribing delivered comparable outcomes to prescribing by doctors.

What did this study do?

This was a Cochrane review of 45 studies that compared prescribing by doctors with prescribing by other healthcare professionals. The focus was on independent prescribers, able to initiate, change or stop medication without close supervision of doctors. Most studies were of chronic disease management in primary care settings.

Forty-four studies were randomised controlled trials; one study was a controlled trial and one a before-and-after study. Prescribers were nurses in 26 studies and pharmacists in the remaining 20.

Twenty-five studies were carried out in the US, six in the UK, with others from Australia, Canada, Ireland and the Netherlands. Four were from lower-income countries, one each from Colombia, South Africa, Uganda and Thailand. Evidence quality of supporting findings was generally considered moderate to high.

What did it find?

  • Patient outcomes after nurse or pharmacist prescribing were similar to those for medical prescribing.
  • Blood pressure: People prescribed drugs by nurses or pharmacists had lower systolic blood pressure than those prescribed drugs by doctors (-5.31mmHg, 95% confidence interval [CI] -6.46 to -4.16; in 12 trials, involving 4,229 participants).
  • Cholesterol: People prescribed drugs by nurses or pharmacists had lower low density lipoprotein cholesterol than those prescribed drugs by doctors (-0.21 mmol/L, 95% CI -0.29 to -0.14; in seven trials, involving 1,469 participants).
  • Blood sugar: People prescribed drugs by nurses or pharmacists had lower glycated haemoglobin (HbA1c, a long-term measure of blood sugar control) than those prescribed drugs by doctors (-0.62%, 95% CI -0.85% to -0.38%; in six trials, with 775 participants).
  • Patient adherence to medication, patient satisfaction and health-related quality of life were also comparable between nurse and pharmacist prescribers and doctor prescribers.
  • There was not enough evidence to reliably say whether independent prescribers used fewer resources, saved medical time, or reduced adverse effects.

What does current guidance say on this issue?

Prescribing in the UK by professions other than doctors, is governed by legislation. The following groups can train on accredited courses as independent prescribers: dentists; nurses and midwives; pharmacists; optometrists; podiatrists; physiotherapists, and therapeutic radiographers.

Independent prescribers can prescribe any drug (with the exception of opiates for treatment of addiction) within their own competencies. The National Prescribing Centre, now a part of NICE, published a guide to non-medical prescribing for commissioners in 2010. The guide says non-medical prescribers can help NHS organisations to meet referral targets, provide urgent and out-of-hours care and meet quality care standards for long term conditions.

What are the implications?

The review provides some reassurance that properly-trained independent prescribers can prescribe as effectively as doctors for patients with long-term conditions. Nurse or pharmacist prescribers may be a useful addition to a chronic disease management service, for example, such as a blood pressure or diabetes clinics.

However, we don’t know from the review whether prescribing by these professions saves overall costs when time and training are factored in. While numbers of adverse events between medical and independent prescribing groups were similar, information on adverse events was limited.

Also, a variety of resource use measures were included in the studies, making it hard to compare them across the board.

Citation and Funding

Weeks G, George J, Maclure K, Stewart D. Non-medical prescribing versus medical prescribing for acute and chronic disease management in primary and secondary care. Cochrane Database Syst Rev. 2016;(11):CD011227

The Australian Satellite of the Effective Practice and Organisation of Care (EPOC) Group, which carried out the review, receive funding from the National Health and Medical Research Council (NHMRC), Australia.

Bibliography

British National Formulary (BNF). Non-medical prescribing. London: Royal Pharmaceutical Society of Great Britain/BMJ; 2017.

National Prescribing Centre. Non-medical prescribing by nurses, optometrists, pharmacists, physiotherapists, podiatrists and radiographers: A quick guide for commissioners. Liverpool: National Prescribing Centre; 2010.

Royal College of Nursing. Fact Sheet: Nurse Prescribing in the UK. London: Royal College of Nursing; 2014.

Why was this study needed?

Prescribing by health professionals other than doctors has been in place in the UK since 2006. Nurses, pharmacists, dentists and some other healthcare professionals are now able to train as independent prescribers, meaning they can prescribe any drug within their competency, including controlled drugs. There are an estimated 19,000 nurse independent prescribers in the UK, and many more supplementary prescribers from other professions such as optometrists, midwives and physiotherapists, who prescribe to protocol or under supervision of a doctor.

Independent and supplementary prescribing has been seen as a way of improving access to medicines, freeing up doctors’ time, and making better use of the skills of professionals such as nurses and pharmacists. This study aimed to investigate whether independent prescribing delivered comparable outcomes to prescribing by doctors.

What did this study do?

This was a Cochrane review of 45 studies that compared prescribing by doctors with prescribing by other healthcare professionals. The focus was on independent prescribers, able to initiate, change or stop medication without close supervision of doctors. Most studies were of chronic disease management in primary care settings.

Forty-four studies were randomised controlled trials; one study was a controlled trial and one a before-and-after study. Prescribers were nurses in 26 studies and pharmacists in the remaining 20.

Twenty-five studies were carried out in the US, six in the UK, with others from Australia, Canada, Ireland and the Netherlands. Four were from lower-income countries, one each from Colombia, South Africa, Uganda and Thailand. Evidence quality of supporting findings was generally considered moderate to high.

What did it find?

  • Patient outcomes after nurse or pharmacist prescribing were similar to those for medical prescribing.
  • Blood pressure: People prescribed drugs by nurses or pharmacists had lower systolic blood pressure than those prescribed drugs by doctors (-5.31mmHg, 95% confidence interval [CI] -6.46 to -4.16; in 12 trials, involving 4,229 participants).
  • Cholesterol: People prescribed drugs by nurses or pharmacists had lower low density lipoprotein cholesterol than those prescribed drugs by doctors (-0.21 mmol/L, 95% CI -0.29 to -0.14; in seven trials, involving 1,469 participants).
  • Blood sugar: People prescribed drugs by nurses or pharmacists had lower glycated haemoglobin (HbA1c, a long-term measure of blood sugar control) than those prescribed drugs by doctors (-0.62%, 95% CI -0.85% to -0.38%; in six trials, with 775 participants).
  • Patient adherence to medication, patient satisfaction and health-related quality of life were also comparable between nurse and pharmacist prescribers and doctor prescribers.
  • There was not enough evidence to reliably say whether independent prescribers used fewer resources, saved medical time, or reduced adverse effects.

What does current guidance say on this issue?

Prescribing in the UK by professions other than doctors, is governed by legislation. The following groups can train on accredited courses as independent prescribers: dentists; nurses and midwives; pharmacists; optometrists; podiatrists; physiotherapists, and therapeutic radiographers.

Independent prescribers can prescribe any drug (with the exception of opiates for treatment of addiction) within their own competencies. The National Prescribing Centre, now a part of NICE, published a guide to non-medical prescribing for commissioners in 2010. The guide says non-medical prescribers can help NHS organisations to meet referral targets, provide urgent and out-of-hours care and meet quality care standards for long term conditions.

What are the implications?

The review provides some reassurance that properly-trained independent prescribers can prescribe as effectively as doctors for patients with long-term conditions. Nurse or pharmacist prescribers may be a useful addition to a chronic disease management service, for example, such as a blood pressure or diabetes clinics.

However, we don’t know from the review whether prescribing by these professions saves overall costs when time and training are factored in. While numbers of adverse events between medical and independent prescribing groups were similar, information on adverse events was limited.

Also, a variety of resource use measures were included in the studies, making it hard to compare them across the board.

Citation and Funding

Weeks G, George J, Maclure K, Stewart D. Non-medical prescribing versus medical prescribing for acute and chronic disease management in primary and secondary care. Cochrane Database Syst Rev. 2016;(11):CD011227

The Australian Satellite of the Effective Practice and Organisation of Care (EPOC) Group, which carried out the review, receive funding from the National Health and Medical Research Council (NHMRC), Australia.

Bibliography

British National Formulary (BNF). Non-medical prescribing. London: Royal Pharmaceutical Society of Great Britain/BMJ; 2017.

National Prescribing Centre. Non-medical prescribing by nurses, optometrists, pharmacists, physiotherapists, podiatrists and radiographers: A quick guide for commissioners. Liverpool: National Prescribing Centre; 2010.

Royal College of Nursing. Fact Sheet: Nurse Prescribing in the UK. London: Royal College of Nursing; 2014.

Non-medical prescribing versus medical prescribing for acute and chronic disease management in primary and secondary care

Published on 23 November 2016

Weeks, G.,George, J.,Maclure, K.,Stewart, D.

Cochrane Database Syst Rev Volume 11 , 2016

BACKGROUND: A range of health workforce strategies are needed to address health service demands in low-, middle- and high-income countries. Non-medical prescribing involves nurses, pharmacists, allied health professionals, and physician assistants substituting for doctors in a prescribing role, and this is one approach to improve access to medicines. OBJECTIVES: To assess clinical, patient-reported, and resource use outcomes of non-medical prescribing for managing acute and chronic health conditions in primary and secondary care settings compared with medical prescribing (usual care). SEARCH METHODS: We searched databases including CENTRAL, MEDLINE, Embase, and five other databases on 19 July 2016. We also searched the grey literature and handsearched bibliographies of relevant papers and publications. SELECTION CRITERIA: Randomised controlled trials (RCTs), cluster-RCTs, controlled before-and-after (CBA) studies (with at least two intervention and two control sites) and interrupted time series analysis (with at least three observations before and after the intervention) comparing: 1. non-medical prescribing versus medical prescribing in acute care; 2. non-medical prescribing versus medical prescribing in chronic care; 3. non-medical prescribing versus medical prescribing in secondary care; 4 non-medical prescribing versus medical prescribing in primary care; 5. comparisons between different non-medical prescriber groups; and 6. non-medical healthcare providers with formal prescribing training versus those without formal prescribing training. DATA COLLECTION AND ANALYSIS: We used standard methodological procedures expected by Cochrane. Two review authors independently reviewed studies for inclusion, extracted data, and assessed study quality with discrepancies resolved by discussion. Two review authors independently assessed risk of bias for the included studies according to EPOC criteria. We undertook meta-analyses using the fixed-effect model where studies were examining the same treatment effect and to account for small sample sizes. We compared outcomes to a random-effects model where clinical or statistical heterogeneity existed. MAIN RESULTS: We included 46 studies (37,337 participants); non-medical prescribing was undertaken by nurses in 26 studies and pharmacists in 20 studies. In 45 studies non-medical prescribing as a component of care was compared with usual care medical prescribing. A further study compared nurse prescribing supported by guidelines with usual nurse prescribing care. No studies were found with non-medical prescribing being undertaken by other health professionals. The education requirement for non-medical prescribing varied with country and location.A meta-analysis of surrogate markers of chronic disease (systolic blood pressure, glycated haemoglobin, and low-density lipoprotein) showed positive intervention group effects. There was a moderate-certainty of evidence for studies of blood pressure at 12 months (mean difference (MD) -5.31 mmHg, 95% confidence interval (CI) -6.46 to -4.16; 12 studies, 4229 participants) and low-density lipoprotein (MD -0.21, 95% CI -0.29 to -0.14; 7 studies, 1469 participants); we downgraded the certainty of evidence from high due to considerations of serious inconsistency (considerable heterogeneity), multifaceted interventions, and variable prescribing autonomy. A high-certainty of evidence existed for comparative studies of glycated haemoglobin management at 12 months (MD -0.62, 95% CI -0.85 to -0.38; 6 studies, 775 participants). While there appeared little difference in medication adherence across studies, a meta-analysis of continuous outcome data from four studies showed an effect favouring patient adherence in the non-medical prescribing group (MD 0.15, 95% CI 0.00 to 0.30; 4 studies, 700 participants). We downgraded the certainty of evidence for adherence to moderate due to the serious risk of performance bias. While little difference was seen in patient-related adverse events between treatment groups, we downgraded the certainty of evidence to low due to indirectness, as the range of adverse events may not be related to the intervention and selective reporting failed to adequately report adverse events in many studies.Patients were generally satisfied with non-medical prescriber care (14 studies, 7514 participants). We downgraded the certainty of evidence from high to moderate due to indirectness, in that satisfaction with the prescribing component of care was only addressed in one study, and there was variability of satisfaction measures with little use of validated tools. A meta-analysis of health-related quality of life scores (SF-12 and SF-36) found a difference favouring usual care for the physical component score (MD 1.17, 95% CI 0.16 to 2.17), but not the mental component score (MD 0.58, 95% CI -0.40 to 1.55). However, the quality of life measurement may more appropriately reflect composite care rather than the prescribing component of care, and for this reason we downgraded the certainty of evidence to moderate due to indirectness of the measure of effect. A wide variety of resource use measures were reported across studies with little difference between groups for hospitalisations, emergency department visits, and outpatient visits. In the majority of studies reporting medication use, non-medical prescribers prescribed more drugs, intensified drug doses, and used a greater variety of drugs compared to usual care medical prescribers.The risk of bias across studies was generally low for selection bias (random sequence generation), detection bias (blinding of outcome assessment), attrition bias (incomplete outcome data), and reporting bias (selective reporting). There was an unclear risk of selection bias (allocation concealment) and for other biases. A high risk of performance bias (blinding of participants and personnel) existed. AUTHORS' CONCLUSIONS: The findings suggest that non-medical prescribers, practising with varying but high levels of prescribing autonomy, in a range of settings, were as effective as usual care medical prescribers. Non-medical prescribers can deliver comparable outcomes for systolic blood pressure, glycated haemoglobin, low-density lipoprotein, medication adherence, patient satisfaction, and health-related quality of life. It was difficult to determine the impact of non-medical prescribing compared to medical prescribing for adverse events and resource use outcomes due to the inconsistency and variability in reporting across studies. Future efforts should be directed towards more rigorous studies that can clearly identify the clinical, patient-reported, resource use, and economic outcomes of non-medical prescribing, in both high-income and low-income countries.

There are two types of non-medical prescribers in the NHS: independent prescribers and supplementary prescribers. This review focused on independent prescribers.

Independent prescribers are practitioners responsible and accountable for the assessment of patients with previously undiagnosed or diagnosed conditions and for decisions about the clinical management required, including prescribing. They are recommended to prescribe generically, except where this would not be clinically appropriate or where there is no approved non-proprietary name.

Supplementary prescribing is a partnership between an independent prescriber (a doctor or a dentist) and a supplementary prescriber to implement an agreed Clinical Management Plan for an individual patient with that patient's agreement.

Expert commentary

This review confirms what many people have long believed from practice. Nurses and pharmacists, trained as independent prescribers, produce comparable clinical outcomes to doctors, when caring for patients with long-term conditions. Now, a wider group of healthcare professionals work as independent prescribers in even more settings.

Independent prescribers, for example, are working as advanced clinical practitioners in acute and emergency practice. The challenge to researchers over the next few years is to generate further robust evidence as to the impact of these independent prescribers in the latest cutting-edge practice.

Dr Mary Tully, Reader in Pharmacy Practice in the Division of Pharmacy and Optometry, University of Manchester