Introduction

Dilyse Nuttall and Jane Rutt-Howard

The Textbook of Non-medical Prescribing has been developed to provide the reader with an insight into the key issues relating to prescribing in the UK today. The book's team of authors have vast experience in the development and delivery of non-medical prescribing programmes. This book has been developed in response to the needs of health professionals undertaking non-medical prescribing programmes and to the views of qualified non-medical prescribers and their colleagues.

The aim of the book is to

1. provide a foundation on which non-medical prescribing students (V100, V150 and V300 including nurses, pharmacists and allied health professionals) can build their knowledge around the key areas and principles of prescribing
2. act as a continued source of information for qualified non-medical prescribers
3. provide a key source of information for non-prescribing health professionals who must learn about the concept and context of prescribing in the modern healthcare (e.g. pre-registration student nurses, pre-registration paramedics) arena
4. provide a key source of information for prescribing health professionals, including doctors considering acting as designated medical practitioners, who need to understand more about their role and the context of non-medical prescribing.

This book provides information essential to enable safe and effective prescribing. It also supports and directs the development and expansion of the reader's knowledge base using generic principles to underpin specialist practice. The introduction has a dual purpose: to introduce the reader to the evolvement of non-medical prescribing and its position in a modern, multidisciplinary health service and to provide guidance on using the book effectively.

The development of prescribing

It had long been recognised that nurses spent a significant amount of time visiting general practitioner (GP) surgeries and/or waiting to see the doctor in order to get a prescription for their patients. Although this practice produced the desired result of a prescription being written, it was not an efficient use of either the nurses' or the GPs' time. Furthermore, it was an equally inefficient use of their skills, exacerbated by the fact that the nurse had usually themselves assessed and diagnosed the patient and decided on an appropriate treatment plan. The situation was formally acknowledged in the Cumberlege Report (Department of Health and Social Security 1986), which initiated the call for nurse prescribing and recommended that community nurses should be able to prescribe from a limited list, or formulary. Progress was somewhat measured, but The Crown Report of 1989 (Department of Health (DH) 1989) considered the implications of nurse prescribing and recommended suitably qualified registered nurses (district nurses (DN) or health visitors (HV)) should be authorised to prescribe from a limited list, namely, the nurse prescribers' formulary (NPF).

Although a case for nurse prescribing had been established, progress relied on legislative changes to permit nurses to prescribe. Progress continued to be cautious with the decision made to pilot nurse prescribing in eight demonstration sites in eight NHS regions. In 1999, The Crown Report II (DH 1999) reviewed more widely the prescribing, supply and administration of medicines and, in recognition of the success of the nurse prescribing pilots, recommended that prescribing rights be extended to include other groups of nurses and health professionals. By 2001, DNs and HVs had completed education programmes through which they gained V100 prescribing status, enabling them to prescribe from the NPF. The progress being made in prescribing reflected the reforms highlighted in The NHS Plan (DH 2000), which called for changes in the delivery of healthcare throughout the NHS, with nurses, pharmacists and allied health professionals being among those professionals vital to its success. The publication of Investment and Reform for NHS Staff - Taking Forward the NHS Plan (DH 2001) stated clearly that working in new ways was essential to the successful delivery of the changes. One of these new ways of working was to give specified health professionals the authority to prescribe, building on the original proposals of The Crown Report (DH 1999). Indeed, The NHS Plan (DH 2000) endorsed this recommendation and envisaged that, by 2004, most nurses should be able to prescribe medicines (either independently or supplementary) or supply medicines under patient group directions (PGDs) (DH 2004).

After consultation in 2000, on the potential to extend nurse prescribing, changes were made to the Health and Social Care Act 2001. The then Health Minister, Lord Philip Hunt, provided detail when he announced that nurse prescribing was to include further groups of nurses. He also detailed that the NPF was to be extended to enable independent nurse prescribers to prescribe all general sales list and pharmacy medicines prescribable by doctors under the NHS. This was together with a list of prescription-only medicines (POMs) for specified medical conditions within the areas of minor illness, minor injury, health promotion and palliative care. In November 2002, proposals were announced by Lord Hunt, concerning 'supplementary' prescribing (DH 2002). The proposals were to enable nurses and pharmacists to prescribe for chronic illness management using clinical management plans. The success of these developments prompted further regulation changes, enabling specified allied health professionals to train and qualify as supplementary prescribers (DH 2005).

From May 2006, the nurse prescribers' extended formulary was discontinued, and qualified nurse independent prescribers (formerly known as extended formulary nurse prescribers) were able to prescribe any licensed medicine for any medical condition within their competence, including some controlled drugs. Further legislative changes allowed pharmacists to train as independent prescribers (DH 2006) with optometrists gaining independent prescribing rights in 2007. The momentum of non-medical prescribing continued, with 2009 seeing a scoping project of allied health professional prescribing, recommending the extension of prescribing to other professional groups within the allied health professions and the introduction of independent prescribing for existing allied health professional supplementary prescribing groups, particularly physiotherapists and podiatrists (DH 2009). In 2013, legislative changes enabled independent prescribing for physiotherapists and podiatrists. As the benefits of non-medical prescribing are demonstrated in the everyday practice of different professional groups, the potential to expand this continues, with consultation currently under way to consider the potential for enabling other disciplines to prescribe.

Using the textbook of non-medical prescribing

Overview

Each of the nine chapters contained within this book addresses a different issue; all of the issues are directly relevant to non-medical prescribing, so it is therefore recommended that the reader peruses all the chapters to gain a full insight into non-medical prescribing. However, it is not necessary to read the chapters in numerical order. The issues and principles considered within each chapter are generic to all prescribing, and it is anticipated that the reader will apply this theory to his or her own practice. This will be helped by undertaking the activities incorporated within each chapter. Where appropriate, and in order to support the reader's understanding, references are made within individual chapters to other chapters in the book.

Core themes

The book has four core themes - public health, social and cultural issues, prescribing principles and continuing professional development and competence - which are considered significant both to safe and effective prescribing and to modern healthcare in the UK. The core themes are incorporated into the main body of each chapter and considered at the end of every chapter in a key themes and considerations box. Continuing professional development and competence is a new core theme including within this second edition of the textbook. The core themes are:

• Public health
• Social and cultural issues
• Prescribing principles
• Continuing professional development and competence

It is pertinent at this point to introduce the prescribing principles (National Prescribing Centre (NPC) 1999) because it is recognised that this may be a new concept to the reader. These were developed originally to support the first nurse prescribers in their decision-making but have continued to be an essential tool in supporting prescribers from all health professional groups able to prescribe. The 'seven good principles of prescribing' were developed by the NPC (1999) with the aim of providing a structured approach to the process of prescribing.

The principles are 'a stepwise approach' and are widely used both theoretically and practically. They are diagrammatically represented within the original Prescribing Nurse Bulletin (NPC 1999) as a pyramid, commencing at the base and working upwards. All the principles of prescribing are as important as each other, and therefore, an alternative representation could...