Evidence
Alert

Nurses and pharmacists can prescribe as effectively as doctors

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.

 

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.

Produced by the University of Southampton and Bazian on behalf of NIHR through the NIHR Dissemination Centre

 

Definitions

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.

Commentaries

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