With independent prescribing a major step closer, Matthew Limb assesses the implications.
A ‘monumental milestone for the profession’. That’s how CSP professional adviser Pip White describes the recent Department of Health scoping project recommendation for physiotherapy to move towards independent prescribing rights. ‘It’s right up there with 1977, when we achieved autonomy,’ she says. ‘This is another key step that moves the whole profession forward.’ Darryn Marks, the consultant physiotherapist who was seconded to the DH to lead the scoping project, concurs, saying: ‘Now the DH non-medical prescribing board has endorsed the recommendations and the report has had ministerial sign-off, we are in a significantly different situation than we were before.’ However, he reminds colleagues that although the report did not foresee any potential pitfalls ahead, the journey is not yet complete: several important developments will need to take place before physiotherapists are legally permitted to prescribe independently, and it could be another two years or more before the law change is finally enacted.
Looking ahead in hope, the implications of gaining autonomy in terms of medicines use for patients, practitioners and the profession are immense. Professionally it further raises the profile of physiotherapy and put physiotherapists on an equal footing with other professions who can presently prescribe independently. ‘I believe there would be massive benefits for patients, in terms of creating greater choice and improved care, and for the profession as a whole,’ says Darryn Marks. For patients, he believes, it would ‘allow them to get the care they need from their professional care giver, regardless of professional background’. But, he adds, that does not mean every physiotherapist would have to be a prescriber. What is important about the project’s recommendation that physiotherapists be given independent prescribing rights is the professional flexibility it enables. If all goes well over the next two years, physiotherapists will have a choice – to prescribe or not, and to be an independent or a supplementary prescriber, to suit their particular mode of practice. Pip White says: ‘Members would need to think about the clinical setting they work in, then pick the medicines and prescribing framework that will work best for that setting.’
Potential settings for independent prescribing
She thinks independent prescribing would work well in settings where physiotherapists work independently and/or where they are not in close contact with doctors. Examples might include physios working in the community who run asthma management services, those specialising in women’s health running continence clinics and the many CSP members in private practice. Qualifying as independent prescribers would be a big help to private practitioners as they could then provide a complete range of treatment. Musculoskeletal consultant physio Darryn Marks is assistant director of therapy services with Barnsley primary care trust and is qualified as a supplementary prescriber, which means he needs a doctor to approve a clinical management plan for individual patients. He prescribes medicines such as analgesics, non-steroidal anti-inflammatories and pain modulating medications, and describes the supplementary model in his situation as ‘bordering on unworkable’ because it doesn’t deliver the care patients need. He explains: ‘It’s very difficult to administer because I don’t always work alongside a medic. It delays patient care, duplicates professional time and increases costs when I have to involve doctors in the process.’ If doctors aren’t available to agree the CMP, it can result in having to send patients away without them having had the treatment Darryn Marks feels they need, and then re-book them for an ‘unnecessary’ follow-up appointment. Looking to the future, he says: ‘As an independent non-medical prescriber, I would be able to deliver the pharmaceutical care patients need immediately, without delays and without unnecessarily burdening other professionals.’
Self referral boosted
Both Pip White and Darryn Marks highlight independent prescribing could also boost the further expansion of physiotherapy self referral. Darryn Marks elaborates: ‘Independent prescribing is the best mechanism within a self referral model, because it allows patients to receive all the care they need from the physiotherapist without delay.’ The potential for independent prescribing to work well with self referral was acknowledged in the DH’s scoping project report which said: ‘Independent prescribing is the most appropriate mechanism for patients in many physiotherapy care pathways, particularly those that involve first contact, diagnostics, self referral and community care.’
Where supplementary prescribing works
Bhanu Ramaswamy, a consultant physiotherapist in intermediate care for Derbyshire County primary care trust, says supplementary prescribing still works well in specific settings. Many of her elderly patients take a variety of medication for multiple illnesses that can pose particular challenges for prescribers. ‘The supplementary element works really well in that there’s always a medic to guide me through, and we discuss the issues and the clinical management plan.’ But, she says: ‘In specific clinical areas, such as musculoskeletal, cardiac rehabilitation or respiratory, it can be more advantageous to be an independent prescriber.’
Independent training possibilities
It is unclear at this stage what form new training for independent prescribing would take, but if it follows the model now in place for other non-medical prescribers, such as nurses, it need not be too onerous or time-consuming. At present, health professionals training to be both supplementary and independent prescribers can follow the same course at a higher education institute, with the supplementary prescribers completing their course a couple of days before the independent prescribers. Physiotherapist Dena Ediker, who works for a community respiratory team in North Derbyshire, recently qualified as a supplementary prescriber alongside nurse colleagues. She says: ‘There was only one session of the whole programme that differentiated between the supplementary and independent prescriber. You are basically sitting the same exam.’ Bhanu Ramaswamy hopes there could be provision to allow existing supplementary prescribers to submit portfolios demonstrating their current competence and how they planned to work as independent prescribers. Currently 135 physiotherapists are registered with the Health Professions Council as supplementary prescribers and the CSP is now undertaking a survey of these individuals to find out more about them: the kind of clinical areas they work in, the medicines they are using and what they see as their development needs. This will inform a programme of work to support members who wish to go on to prescribe independently. A lot of work will be taking place over the next two years, but the hope is that at the end of it all, physios will gain independent prescribing rights. That’s something to look forward to. FL
Allied health professions prescribing and medicines supply mechanisms scoping project report, Department of Health.
Prescribing: the story so far
Physiotherapists have been using medicines for injection therapy since the early 1990s through patient-specific directions. PSDs require direct instruction from an independent prescriber, normally a doctor. Since 2000, physios have been able to supply and administer medicines through patient group directions, which need local approval. Injection therapists, for example, use PGDs extensively for medicines such as local anaesthetics and corticosteroids. For a condition such as back pain, as many as 10 PGDs may be required for the different medicines involved. In 2005, physiotherapists, podiatrists and radiographers were approved as supplementary prescribers. Supplementary prescribing requires a link with a doctor to approve a clinical management plan for an individual patient.
In 2008, the DH set up a national scoping project, led by physiotherapist Darryn Marks, to examine whether the existing ‘complex’ arrangements by which allied health professionals prescribe and supply medicines best served the needs of patients. The group reviewed the evidence and found greater flexibility of prescribing and medicines supply by AHPs had the potential to reduce treatment delays, and improve patient safety, access and choice. Its report, published in July 2009, concluded there was a ‘strong case for progression to independent prescribing for physiotherapists and podiatrists’, and it found supplementary prescribing was too restricted to be of use in certain care pathways. However, further steps are required before independent prescribing by physios becomes a reality. The DH is expected to set a timetable shortly for the further work it sees as necessary and will outline the process expected to lead ultimately to a change in the law. It is likely this will include developing a business case and a period of public consultation, perhaps led by the Medicines and Healthcare Products Regulatory Agency.
What about support workers?
Physiotherapy support workers cannot prescribe because the law requires the prescriber to be a registered health professional, but in future they could be asked by a physiotherapist prescriber to administer medicines to a patient, such as helping someone use a nebuliser. The CSP’s Pip White says: ‘Support workers are part of the medicines agenda as well. They will need to understand that as they may start to work with more and more physiotherapists who prescribe, they might be getting instructions from physios about medicines, which may feel unusual for them at first, but would be perfectly appropriate.’
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