Nonmedical prescribing has been allowed in the United Kingdom (UK) since 1992. Its development over the past 24 years has been marked by changes in legislation, enabling the progression towards independent prescribing for nurses, pharmacists and a range of allied health professionals. Although the UK has led the way regarding the introduction of nonmedical prescribing, it is now seen in a number of other Western-European and Anglophone countries although the models of application vary widely between countries. The programme of study to become a nonmedical prescriber (NMP) within the UK is rigorous, and involves a combination of taught curricula and practice-based learning. Prescribing is a complex skill that is high risk and error prone, with many influencing factors. Literature reports regarding the impact of nonmedical prescribing are sparse, with the majority of prescribing research tending to focus instead on prescribing by doctors. The impact of nonmedical prescribing however is important to evaluate, and can be carried out from several perspectives. This review takes a brief look back at the history of nonmedical prescribing, and compares this with the international situation. It also describes the processes required to qualify as a NMP in the UK, potential influences on nonmedical prescribing and the impact of nonmedical prescribing on patient opinions and outcomes and the opinions of doctors and other healthcare professionals.

https://journals.sagepub.com/doi/pdf/10.1177/2042098616646726

Nonmedical prescribing: where are we now?

Objectives Non-medical prescribers, including pharmacists, have been found to achieve comparable clinical outcomes with doctors for certain health conditions. Legislation supporting pharmacist prescribing (PP) has been implemented in the United Kingdom (UK), Canada and New Zealand (NZ); however, to date, Australian pharmacists have not been extended prescribing rights. The purpose of this review was to describe the barriers to PP found in the literature from the UK, Canada, NZ and Australia, and examine the implications of these for the development of PP in Australia. Methods We conducted a scoping review, which included peer-reviewed and grey literature, and consultation with stakeholders. Sources - Scopus, PubMed and CINAHL; Google Scholar, OpenGrey and organisational websites from January 2003 to March 2018 in the UK, Canada, NZ and Australia. Inclusion criteria - articles published in English, related to implementation of PP and articulated barriers to PP. Key findings Of 863 unique records, 120 were reviewed and 64 articles were eligible for inclusion. Three key themes emerged: (1) Socio-political context, (2) Resourcing issues and (3) Prescriber competence. The most common barriers were inadequate training regarding diagnostic knowledge and skills, inadequate support from authorities and stakeholders, and insufficient funding/reimbursement. Conclusions If implementation of PP is to occur, attention needs to be focused on addressing identified barriers to PP implementation, including fostering a favourable socio-political context and prescriber competence. As such, a concerted effort is required to develop clear policy pathways, including targeted training courses, raising stakeholder recognition of PP and identifying specific funding, infrastructure and resourcing needs to ensure the smooth integration of pharmacist prescribers within interprofessional clinical teams.

https://onlinelibrary.wiley.com/doi/epdf/10.1111/ijpp.12557

Barriers to pharmacist prescribing: a scoping review comparing the UK, New Zealand, Canadian and Australian experiences

Residential Aged Care Medication Review to Improve the Quality of Medication Use: A Systematic Review

AIMS Pharmacists have been contributing to the care of residents in nursing homes and play a significant role in ensuring quality use of medicine. However, the changing role of pharmacist in nursing homes and their impact on residents is relatively unknown. METHODS Six electronic databases were searched from inception until November 2018 for articles published in English examining the services offered by pharmacists in nursing homes. Studies were included if it examined the impact of interventions by pharmacists to improve the quality use of medicine in nursing homes. RESULTS Fifty-two studies (30 376 residents) were included in the current review. Thirteen studies were randomised controlled studies, while the remainder were either pre-post, retrospective or case-control studies where pharmacists provided services such as clinical medication review in collaboration with other healthcare professionals as well as staff education. Pooled analysis found that pharmacist-led services reduced the mean number of falls (-0.50; 95% confidence interval: -0.79 to -0.21) among residents in nursing homes. Mixed results were noted on the impact of pharmacists' services on mortality, hospitalisation and admission rates among residents. The potential financial savings of such services have not been formally evaluated by any studies thus far. The strength of evidence was moderate for the outcomes of mortality and number of fallers. CONCLUSION Pharmacists contribute substantially to patient care in nursing homes, ensuring quality use of medication, resulting in reduced fall rates. Further studies with rigorous design are needed to measure the impact of pharmacist services on the economic benefits and other patient health outcomes.

https://bpspubs.onlinelibrary.wiley.com/doi/pdf/10.1111/bcp.14101

Pharmacist services in nursing homes: A systematic review and meta-analysis.

In recent years a number of countries have extended prescribing rights to pharmacists in a variety of formats. The latter includes independent prescribing, which is a developing area of practice for pharmacists in secondary care. Potential opportunities presented by wide scale implementation of pharmacist prescribing in secondary care include improved prescribing safety, more efficient pharmacist medication reviews, increased scope of practice with greater pharmacist integration into acute patient care pathways and enhanced professional or job satisfaction. However, notable challenges remain and these need to be acknowledged and addressed if a pharmacist prescribing is to develop sufficiently within developing healthcare systems. These barriers can be broadly categorised as lack of support (financial and time resources), medical staff acceptance and the pharmacy profession itself (adoption, implementation strategy, research resources, second pharmacist clinical check). Larger multicentre studies that investigate the contribution of hospital-based pharmacist prescribers to medicines optimisation and patient-related outcomes are still needed. Furthermore, a strategic approach from the pharmacy profession and leadership is required to ensure that pharmacist prescribers are fully integrated into future healthcare service and workforce strategies.

Pharmacist independent prescribing in secondary care: opportunities and challenges.

Objectives Suitably qualified pharmacists in the UK are able to prescribe all medicines. While doctors’ prescribing errors are well documented, there is little information on the rate and nature of pharmacists’ prescribing errors. Our aim was to measure the prevalence of prescribing errors by pharmacists. Methods Prescribing by pharmacists, for inpatients admitted to three hospitals in North East England was studied. Part one measured the extent of prescribing by pharmacists as a proportion of all prescribing on a single day. The number of medication orders, reason for prescribing and therapeutic category were collected by the researcher (OC). In part two, pharmacist prescribing was reviewed for safety and accuracy by ward-based clinical pharmacists over 10 days; errors were documented and categorised as per EQUIP study. Results Part 1: Pharmacists prescribed one or more medication orders for 182 (39.8%) of 457 patients, accounting for 12.9% (680 from 5274) of all medication orders prescribed on a single census day. Pharmacists prescribed medicines from 12 out of 15 British National Formulary categories (no prescribing of drugs used in malignancy, immunology and anaesthetics). Part 2: 1415 pharmacist-prescribed medication orders were checked by clinical pharmacists, with four errors (0.3%) reported. Conclusions This study suggests that prescribing pharmacists can provide a valuable role in safely prescribing for a broad range of inpatients in UK general hospitals.

https://ejhp.bmj.com/content/ejhpharm/22/2/79.full.pdf

Pharmacist prescribing within a UK NHS hospital trust: nature and extent of prescribing, and prevalence of errors

Residents in care homes are more likely to be prescribed multiple medicines yet often have little involvement in these prescribing decisions. Reviewing and stopping inappropriate medicines is not currently adopted across the health economy. This Health Foundation funded Shine project developed a pragmatic approach to optimising medicines in care homes while involving all residents in decision making. The pharmacist undertook a detailed medication review using primary care records. The results were discussed at a multidisciplinary team (MDT) meeting involving the care home nurse and the resident’s general practitioner (GP), with input from the local psychiatry of old age service (POAS) where appropriate. Suggestions for medicines which should be stopped, changed or started, and other interventions (eg monitoring) were discussed with the resident and/or their family. Over 12 months 422 residents were reviewed, and 1346 interventions were made in 91% of residents reviewed with 15 different types of interventions. The most common intervention (52.3%) was to stop medicines; 704 medicines stopped in 298 residents (70.6%). On average, 1.7 medicines were stopped for every resident reviewed (range zero to nine medicines; SD=1.7), with a 17.4% reduction in medicines prescribed (3602 medicines prescribed before and 2975 after review). The main reasons for stopping medicines were: no current indication (401 medicines; 57%), resident not wanting medicine after risks and benefits were explained (120 medicines; 17%), and safety concerns (42 medicines; 6%). The net annualised savings against the medicines budget were £77,703 or £184 per person reviewed. The cost of delivering the intervention was £32,670 (pharmacist, GP, POAS consultant, and care home nurse time) for 422 residents; for every £1 invested, £2.38 could be released from the medicines budget. This project demonstrated that a multidisciplinary medication review with a pharmacist, doctor, and care home nurse can safely reduce inappropriate medication in elderly care home residents.

https://bmjopenquality.bmj.com/content/bmjqir/3/1/u203261.w2538.full.pdf

A clinico-ethical framework for multidisciplinary review of medication in nursing homes.

Objectives
The potential harm from omitted and delayed medicines for hospital inpatients was highlighted by the National Patient Safety Agency (NPSA). Despite evidence of omitted doses, few interventional studies have been reported on preventing the problem. This study aimed to assess the impact on omitted doses when medicine administration was supported by pharmacy assistants (PAs).

Methods
PAs were trained to support nurses on medicine administration rounds. Using stratified random sampling, two intervention and control wards were selected. Three study groups were defined: (A) intervention group (PA-supported medicine administration); (B) intra-ward control group; and (C) inter-ward control group. Primary outcome measure was number of patients with unacceptable omitted doses (UODs) in group A versus C. Secondary outcome measures were patients with critical UOD (cUOD), as defined by the NPSA, in groups A, B and C and UODs in group B versus A and C. Data were collected over 2 weeks (December 2011 and February 2012).

Key findings
Using aggregated data over 2 weeks, 778 patients were assessed; 308 were male (40%). The overall proportion of patients with ≥1 UOD was 12.4% (n = 96). The proportion of patients with ≥1 UOD was 1.1% (n = 2) in group A (intervention) and 18.5% (n = 68) in group C (control). There were significantly fewer patients with cUOD in group A (1.1%; n = 2) compared with group C (7.4%; n = 27).

Conclusion
PA-supported medication rounds can significantly reduce the rate of omitted doses. This study provides evidence for a potential solution to the problem of omitted doses for hospital inpatients.

Wasim Baqir

Papers

Pharmacist prescribing within a UK NHS hospital trust: nature and extent of prescribing, and prevalence of errors

Pharmacist independent prescribing in secondary care: opportunities and challenges.

A clinico-ethical framework for multidisciplinary review of medication in nursing homes.

Reducing unacceptable missed doses: pharmacy assistant-supported medicine administration.