Since 1994 there have been considerable additions to the range of health care professionals (HCPs) that can prescribe in the United Kingdom (UK). These HCPs include nurses, pharmacists, radiographers, physiotherapists, podiatrists, chiropodists and optometrists. After a period of specific prescribing training these HCPs are often referred to as non-medical prescribers (NMPs). There has been a limited amount of research that has investigated the influences on the prescribing behaviour of NMPs. Additional research with NMPs would be beneficial to contribute to the currently limited understanding of the prescribing behaviour of NMPs. Knowledge about the influences on NMPs' decisions will also provide further insight into the training and support requirements of these HCPs. A programme of research was conducted to explore the influences on the prescribing behaviour of nurse and pharmacist independent and/or supplementary prescribers working in primary and community care. The research utilised a range of qualitative data collection techniques including interviews, semi-structured interviews, focus groups and the critical incident technique. The Q-method was also used. This allowed perspectives amongst NMPs about prescribing influences to be identified. In total, 104 NMPs took part in this research. This included 31 pharmacist prescribers and 73 nurse prescribers. NMPs were mainly recruited via their primary care trust prescribing lead but pharmacist prescribers were also contacted using the details they provided to their professional body. NMPs in this research occupied a wide range of roles and had diverse demographic characteristics. Relevant ethical approval was obtained before conducting this research. NMPs were motivated by their desire to feel safe, keep it simple and fit in with prescribing culture when prescribing. They also had a code of practice which underlined their rejection of some influences, such as patient pressure and logistical influences, and their acceptance of others, such as guidelines and formularies. The research found that the influences on NMPs' prescribing decisions can be best understood through identifying how and in what circumstances NMPs take responsibility for issuing prescriptions and making prescribing decisions. As well as providing insights into the training and support requirements of NMPs the findings of this research are important to others that may want to research the prescribing influences on NMPs in the future.

The prescribing rights of non-medical healthcare professionals in the United Kingdom (UK) are some of the most extensive in western medical practice. Nurses, pharmacists, physiotherapists, optometrists, chiropodists, podiatrists, therapeutic and diagnostic radiographers and dieticians, with appropriate training have the authority to prescribe. They are often referred to as non-medical prescribers (NMPs). These non-medical healthcare professionals should have a specified number of years of post-registration experience in order to undertake specific training in prescribing. There has been a limited amount of research exploring how non-medical healthcare professionals acquire their expertise during the prescribing programme. In addition, there is a gap in the literature on how NMPs apply their acquired expertise during the process of making clinical prescribing decisions. A programme of research was conducted to explore the learning processes and decision-making skills of pharmacist and nurse independent prescribers working in secondary care. The research used current literature on pharmacist and nurse independent prescribing by conducting a systematic review to assess how their expertise development is reported in the literature. In addition, the learning experiences of secondary care pharmacists and nurses undertaking the independent prescribing programme was explored by employing a novel audio-diary technique followed by semi-structured interviews on 7 nurses and 6 pharmacists. Students were mainly recruited via their non-medical prescribing programme leaders at a number of accredited universities across the UK. There was little opportunity in this study to explore the clinical reasoning processes of students as they were learning to prescribe. Therefore, the final study aimed to explore how secondary care pharmacist and nurse independent prescribers make clinical prescribing decisions. A total of 21 independent prescribers working in secondary care took part in this study, mainly recruited via their non-medical prescribing lead and social media. This study employed a think-aloud protocol method using validated clinical vignettes followed by semi-structured interviews. Students and NMPs occupied a wide range of roles. Ethical approval from the University of Manchester Research Ethics Committee (UREC) and governance approvals from a number of National Health Service (NHS) hospitals were obtained before conducting the research. NMPs were influenced by a number of intrinsic and extrinsic factors during the process of learning to prescribe and when making prescribing decisions. Students also experienced an affective phase of transition in which students became highly metacognitive as they began to form their identities as prescribers and reflect on their confidence and competence. There were notable differences between how pharmacists and nurses learned to prescribe, which were also seen during the process of clinical decision-making as independent prescribers. Despite this, pharmacists and nurses revealed a similar pattern in their decision-making processes as prescribers. Findings from this programme of research provide further insight into the specific training and support requirements of these healthcare professionals. Additional research with NMPs would be beneficial to contribute to the currently limited understanding of the learning and clinical reasoning processes of NMPs.

No / In recent years, as the prevalence of prescribers has increased, there has been discord and confusion around exactly how to refer to prescribers who are not doctors (Nuttall and Rutt-Howard, 2020). Professional regulators continue to define prescribers by specific profession, using terms such as ‘nurse prescriber’ (Nursing and Midwifery Council, 2018a), ‘pharmacist prescriber’ (General Pharmaceutical Society, 2018) and ‘allied health professional prescriber’ (Health and Care Professions Council, 2016). However, there is a broader range of literature using the collective term of ‘non-medical prescribers’ (All Wales Medicines Strategy Group, 2017; Department of Health Northern Ireland, 2020; NHS England, 2020; Scottish Government, 2020), highlighting the multidisciplinary nature of contemporary prescribing practices across the UK, and the shared responsibility of prescribers for assuring safe and effective practice. Within this chapter, we refer to prescribers collectively, as non-medical prescribers. Although this chapter has been written with the four countries of the UK in mind, it is important that you consider any country-specific, and profession-specific guidelines.

Yes / Background In the United Kingdom, nurses and pharmacists who have undertaken additional post-registration training can prescribe medicines for any medical condition within their competence (non-medical prescribers, NMPs), but little is known about patients' experiences and perceptions of this service. Objective to obtain feedback from primary care patients on the impact of prescribing by nurse independent prescribers (NIPs) and pharmacist independent prescribers (PIPs) on experiences of the consultation, the patient–professional relationship, access to medicines, quality of care, choice, knowledge, patient-reported adherence and control of their condition. Design Two cross-sectional postal surveys. Setting and participants Patients prescribed for by either NIPs or PIPs in six general practices from different regions in England. Results 30% of patients responded (294/975; 149/525 NIPs; 145/450 PIPs). Most said they were very satisfied with their last visit (94%; 87%), they were told as much as they wanted to know about their medicines (88%; 80%), and felt the independent prescriber really understood their point of view (87%; 75%). They had a good relationship with (89%; 79%) and confidence in (84%; 77%) their NMP. When comparing NMP and doctor prescribing services, most patients reported no difference in their experience of care provided, including access to it, control of condition, support for adherence, quality and safety of care. Discussion and conclusions Patients had positive perceptions and experience from their NMP visit. NMPs were well received, and patients' responses indicated the establishment of rapport. They did not express a strong preference for care provided by either their non-medical or medical prescriber. / Policy Research Programme in the Department of Health

No / Aim. To determine the adequacy of initial nurse independent prescribingeducation and identify continuing professional development and clinicalgovernance strategies in place for non-medical prescribing.Background. In 2006, new legislation in England enabled nurses with anindependent prescribing qualification to prescribe, within their competence. In 2006,non-medical prescribing policies released by the Department of Health outlinedthe recommendations for education, continuing professional development andgovernance of non-medical prescribing; however, there was no evidence on a nationalscale about the exte nt of implementation and effectiveness of these strategies.Design. National surveys of: (i) nurse independent prescribers; and (ii) non-medical prescribing leaders in England.Methods. Questionnaire surveys (August 2008–February 2009) coveringeducational preparation, prescribing practice (nurse independent prescribers) andstructures/processes for support and governance (non-medical prescribing leaders).Results. Response rates were 65% (976 prescribers) and 52% (87 leaders). Mostnurses felt their prescribing course met their learning needs and stated courseoutcomes and that they had adequate development and support for prescribing tomaintain patient safety. Some types of community nurse prescribers had less accessto support and development. The prescribing leaders reported lacking systems toensure continuity of non-medical prescribing and monitoring patient experience.Conclusion. Educational programmes of preparation for nurse prescribing werereported to be operating satisfactorily and providing fit-for-purpose preparationfor the expansion to the scope of nurse independent prescribing. Most clinicalgovernance and risk management strategies for prescribing were in place inprimary and secondary care. / Department of Health (UK)

Independent and supplementary prescribing are the two main forms of non-medical prescribing (NMP) that have been practised in the UK since 2006. Most available studies have qualitatively investigated the impact of NMP, especially in primary care. This may be due to the fact that prescriptions are issued mainly by general practitioners in primary care. This PhD thesis aimed at investigating the clinical effectiveness of independent pharmacist and diabetes specialist nurse (DSN) prescribers in the management of patients with type 2 diabetes at outpatient clinics in hospitals. A literature review was firstly conducted to explore the current research on NMP around the world and the UK. A systematic review of the previously published randomised control trials (RCT) and non-RCT studies that focused on prescribing interventions of nurses and pharmacist was also conducted to explore the impact of their prescribing interventions in treating type 2 diabetes using HbA1c level as the primary outcome. A programme of work of three retrospective comparative database analytical studies was then carried out to investigate the impact of independent NMPs in type 2 diabetes care. This programme of work used electronic medical records of patients attending outpatient clinics of diabetes centres in two teaching hospitals in Manchester; one employed an independent pharmacist and the other employed DSN prescribers. A group of subjects seen by an NMP in place of a doctor during the study period were the study group and the control group were those who seen only by doctors. The primary outcome was the average yearly change of HbA1c amongst the two groups. Secondary outcomes were yearly change of total cholesterol, blood pressure and serum creatinine as well as body mass index. Five statistical models, which included multivariable regression, propensity score matching and sensitivity analyses, were utilised to control for confounding effects, and the nature of selection bias in the retrospectively comparative effectiveness research using secondary database resources. A total of 330 patients seen by a team including a pharmacist versus 975 by doctors only between January 2006 and January 2013 at one site; and 656 by a team including DSNs versus 3,746 patients seen by doctors only between January 2007 to December 2013 at the other. The studies found both prescribing pharmacists and DSNs are capable of achieving at least non-inferior improvements in diabetes outcome compared to doctors. The pharmacist achieved a mean 0.01% reduction in HbA1c level versus doctors who achieved slight increase (p<0.4). DSNs also achieved a mean 0.07% reduction compared to doctors. However, after adjustment with multivariate and propensity score as well as with propensity score matching, there were no significant differences between the two groups. These findings were consistent with the findings in the systemic review. Although an RCT is the only method that by definition would produce unbiased treatment effects, the use of propensity score methods here, have reduced the potential for bias that may remain unaccounted for in multivariate models without propensity scores. Adjusting for propensity scores using two different methods also gives more confidence that the results are as unbiased as possible. Nonetheless, caution in generalising the results is necessary because of the retrospective nature of the studies and deficiencies in the database used.

Background: Increased pressure, rising demand and cost constraints have driven a need for radical service re-design in the NHS. To deliver re-design objectives it is necessary to understand how they are perceived by service users and providers. Aim: To investigate the views of patients and health care professionals (HCP) on aspects of health policy and service re-design affecting primary care. Setting: Patients and HCPs from one geographical area in England. Method: Themes from phase one qualitative interviews were explored quantitatively using a questionnaire in phase two and a discrete choice experiment (DCE) in phase three. Factor analysis was used to explore HCP responses in phase two. In phase three the DCE was administered to explore patients‟ relative priorities of a range of attributes. Results: HCPs had concerns that the Quality Outcomes Framework (QOF) detracted from the patient‟s agenda and did not improve health outcomes. GPs felt continuity of care was important Monday through Friday but were not keen on its provision out of hours. Neither did they feel nurses could run chronic disease management clinics without a GP present. Patients felt continuity could be provided by different HCPs for different conditionsPatients stated continuity of care and consultation duration were the most important attributes in a primary care service. However, in the DCE they prioritised both being seen on the day and by a GP over longer appointments. Patient preference to be seen by a GP may reflect the low uptake of non-medical prescribing in the area. Conclusion: Continuity of care, while remarked as being important to both HCPs and patients, appears less important when weighted against other primary care service attributes. HCPs appear to want longer consultations whereas patients saw time as encompassing both the time to wait for an appointment and consultation length. For patients, the quality of the time with a HCP may be more important than its duration, additionally patients appear to want choice but not necessarily to choose.

No / The United Kingdom is considered to be the world leader in nurse prescribing, no other country having the same extended non-medical prescribing rights. Arguably, this growth has outpaced research to evaluate the benefits, particularly in areas of clinical practice where patients have complex co-morbid conditions such as palliative care. This is the first study of non-medical prescribing in palliative care in almost a decade. AIM: To explore the current position of nurse prescribing in palliative care and establish the impact on practice of the 2012 legislative changes. DESIGN: An online survey circulated during May and June 2013. PARTICIPANTS: Nurse members (n = 37) of a regional cancer network palliative care group (61% response rate). RESULTS: While this survey found non-medical prescribers have embraced the 2012 legislative changes and prescribe a wide range of drugs for cancer pain, we also identified scope to improve the transition from qualified to active non-medical prescriber by reducing the time interval between the two. CONCLUSION: To maximise the economic and clinical benefit of non-medical prescribing, the delay between qualifying as a prescriber and becoming an active prescriber needs to be reduced. Nurses who may be considering training to be a non-medical prescriber may be encouraged by the provision of adequate study leave and support to cover clinical work. Further research should explore the patients' perspective of non-medical prescribing.

Introdução. Desde a promulgação da Constituição Federal de 1988 no Brasil, que consolida a saúde como um direito social, a ser garantido de forma integral e universal pelo Estado brasileiro, os cidadãos passaram a reivindicar este direito em juízo, acionando legitimamente o Estado para a garantia de suas pretensões sanitárias. E, neste sentido, o número de ações que demandam medicamentos vem crescendo de forma exponencial no Brasil, impactando diretamente a política pública de saúde, e suscitando debates sobre a segurança sanitária dos medicamentos dispensados em juízo. Objetivo. Evidenciar de que forma as questões técnicas e políticas que envolvem o direito social à assistência farmacêutica vem sendo debatidas dentro de processos judiciais que tem por objeto a solicitação de medicamentos em face do Estado. Isto para que se possa relacionar estes resultados aos atuais debates sobre o papel do Poder Judiciário em face da garantia do direito à saúde, e seu impacto perante a política pública de saúde. E, também, aos atuais debates político-sanitários sobre a prescrição médica, e sua importância para o exercício do direito em foco. Método. A metodologia de pesquisa revestiu-se em duas etapas distintas. A primeira etapa consistiu na análise de processos judiciais que versavam sobre a demanda de medicamentos em face do Estado, provenientes de quatro Tribunais Estaduais do país, em primeira instância: São Paulo, Minas Gerais, Rio Grande do Sul e Rio de Janeiro. Os processos foram analisados através do uso da Metodologia Qualiquantitativa do Discurso Coletivo. A segunda etapa consistiu na pesquisa de artigos científicos, nas principais bases de dados de periódicos científicos de saúde pública, que tivessem relação com a pergunta de pesquisa: Como hoje estrutura-se a discussão político-sanitária em torno da prescrição médica? Resultados. Pela análise dos processos judiciais, evidencia-se que as demandas que envolvem pedidos de medicamento em juízo vêm sendo deferidas pelos juízes, prioritariamente, com base nas prescrições médicas individuais e com base na leitura pura do ordenamento jurídico, sem considerar as dimensões técnicas e políticas que envolvem o direito à assistência farmacêutica. A análise dos artigos científicos nos demonstra a vasta discussão técnica acerca da prescrição médica e suas implicações sanitárias, e aponta a necessidade de contraditar esses documentos e investir em educação e informação médicas, em prol da segurança sanitária dos pacientes-cidadãos. Conclusão. O direito à saúde é um direito complexo, que requer, para a sua adequada proteção e garantia, que ultrapassemos o paradigma positivista, com sua leitura exclusivamente normativa e dogmática, em prol de um novo paradigma que permita maior penetração de questões e saberes técnicos e políticos no âmbito do direito. Tanto judicial quanto extrajudicialmente precisam ser criados caminhos de proteção à saúde, que abriguem todos os profissionais jurídicos, políticos e técnicos envolvidos na temática, rumo à construção interdisciplinar do direito à saúde e da cidadania sanitária no Brasil / Introduction. Since the enactment of the 1988 Federal Constitution in Brazil, that consolidates health as a social right, the citizens began to demand this right in court, lawfully driving the state to guarantee their health claims. And, in this sense, the number of actions that require medicines is growing exponentially in Brazil, which impact directly the public health policy, and stimulate discussions about the safety of drugs dispensed by the courts. Objective. Show how the technical and political issues, involving the social right to pharmaceutical assistance has been debated in legal proceedings whose objective is the solicitation of drugs against the State. This to be able to relate these findings to the current debates about the role of the judiciary, in view of the guaranteed of right to health and its impact on the public health policy. And, also, to the current political debates about health prescription, and its importance for the right in focus. Method. The research methodology is coated in two stages. The first step was the analysis of court cases that focused the drug demand against the State, from Four State Courts in Brazil: Sao Paulo, Minas Gerais, Rio Grande do Sul and Rio de Janeiro. The processes were analyzed through the use of qualitativequantitative methodology of collective discourse. The second step consisted in the search of scientific articles in major databases of scientific journals of public health, that were related to the following research question: How today\'s discussion is structured around the political health context of the medical prescription? Results. The analysis of court proceedings, results clear that the demands that involve medication in court have been deferred by the judges, primarily, based on the individual medical prescriptions, and based on the pure reading of the legal system, without considering the technical and political dimensions that involve the right to pharmaceutical assistance. The analysis of scientific articles shows us the extensive technical discussion about the prescription and its health implications, and highlights the need to contradict these documents, and invest in education and medical information, towards the safety of patients-citizens. Conclusion. The right to health is a complex right, which requires for its adequate protection and security, that we move beyond the positivist paradigm, with its exclusively normative reading and dogmatic rules, towards a new paradigm which allows greater penetration of issues and political and technical knowledge within the law. Both judicial and extrajudicial ways need to be created to protect health, involving all legal, politicians and technicians professionals involved in the matter, toward interdisciplinary construction of the right to health and health citizenship in Brazil

Introdução. Desde a promulgação da Constituição Federal de 1988 no Brasil, que consolida a saúde como um direito social, a ser garantido de forma integral e universal pelo Estado brasileiro, os cidadãos passaram a reivindicar este direito em juízo, acionando legitimamente o Estado para a garantia de suas pretensões sanitárias. E, neste sentido, o número de ações que demandam medicamentos vem crescendo de forma exponencial no Brasil, impactando diretamente a política pública de saúde, e suscitando debates sobre a segurança sanitária dos medicamentos dispensados em juízo. Objetivo. Evidenciar de que forma as questões técnicas e políticas que envolvem o direito social à assistência farmacêutica vem sendo debatidas dentro de processos judiciais que tem por objeto a solicitação de medicamentos em face do Estado. Isto para que se possa relacionar estes resultados aos atuais debates sobre o papel do Poder Judiciário em face da garantia do direito à saúde, e seu impacto perante a política pública de saúde. E, também, aos atuais debates político-sanitários sobre a prescrição médica, e sua importância para o exercício do direito em foco. Método. A metodologia de pesquisa revestiu-se em duas etapas distintas. A primeira etapa consistiu na análise de processos judiciais que versavam sobre a demanda de medicamentos em face do Estado, provenientes de quatro Tribunais Estaduais do país, em primeira instância: São Paulo, Minas Gerais, Rio Grande do Sul e Rio de Janeiro. Os processos foram analisados através do uso da Metodologia Qualiquantitativa do Discurso Coletivo. A segunda etapa consistiu na pesquisa de artigos científicos, nas principais bases de dados de periódicos científicos de saúde pública, que tivessem relação com a pergunta de pesquisa: Como hoje estrutura-se a discussão político-sanitária em torno da prescrição médica? Resultados. Pela análise dos processos judiciais, evidencia-se que as demandas que envolvem pedidos de medicamento em juízo vêm sendo deferidas pelos juízes, prioritariamente, com base nas prescrições médicas individuais e com base na leitura pura do ordenamento jurídico, sem considerar as dimensões técnicas e políticas que envolvem o direito à assistência farmacêutica. A análise dos artigos científicos nos demonstra a vasta discussão técnica acerca da prescrição médica e suas implicações sanitárias, e aponta a necessidade de contraditar esses documentos e investir em educação e informação médicas, em prol da segurança sanitária dos pacientes-cidadãos. Conclusão. O direito à saúde é um direito complexo, que requer, para a sua adequada proteção e garantia, que ultrapassemos o paradigma positivista, com sua leitura exclusivamente normativa e dogmática, em prol de um novo paradigma que permita maior penetração de questões e saberes técnicos e políticos no âmbito do direito. Tanto judicial quanto extrajudicialmente precisam ser criados caminhos de proteção à saúde, que abriguem todos os profissionais jurídicos, políticos e técnicos envolvidos na temática, rumo à construção interdisciplinar do direito à saúde e da cidadania sanitária no Brasil / Introduction. Since the enactment of the 1988 Federal Constitution in Brazil, that consolidates health as a social right, the citizens began to demand this right in court, lawfully driving the state to guarantee their health claims. And, in this sense, the number of actions that require medicines is growing exponentially in Brazil, which impact directly the public health policy, and stimulate discussions about the safety of drugs dispensed by the courts. Objective. Show how the technical and political issues, involving the social right to pharmaceutical assistance has been debated in legal proceedings whose objective is the solicitation of drugs against the State. This to be able to relate these findings to the current debates about the role of the judiciary, in view of the guaranteed of right to health and its impact on the public health policy. And, also, to the current political debates about health prescription, and its importance for the right in focus. Method. The research methodology is coated in two stages. The first step was the analysis of court cases that focused the drug demand against the State, from Four State Courts in Brazil: Sao Paulo, Minas Gerais, Rio Grande do Sul and Rio de Janeiro. The processes were analyzed through the use of qualitativequantitative methodology of collective discourse. The second step consisted in the search of scientific articles in major databases of scientific journals of public health, that were related to the following research question: How today\'s discussion is structured around the political health context of the medical prescription? Results. The analysis of court proceedings, results clear that the demands that involve medication in court have been deferred by the judges, primarily, based on the individual medical prescriptions, and based on the pure reading of the legal system, without considering the technical and political dimensions that involve the right to pharmaceutical assistance. The analysis of scientific articles shows us the extensive technical discussion about the prescription and its health implications, and highlights the need to contradict these documents, and invest in education and medical information, towards the safety of patients-citizens. Conclusion. The right to health is a complex right, which requires for its adequate protection and security, that we move beyond the positivist paradigm, with its exclusively normative reading and dogmatic rules, towards a new paradigm which allows greater penetration of issues and political and technical knowledge within the law. Both judicial and extrajudicial ways need to be created to protect health, involving all legal, politicians and technicians professionals involved in the matter, toward interdisciplinary construction of the right to health and health citizenship in Brazil