In 1986 a committee headed by Baroness Cumberlege stated “The Department of Health and Social Security (DHSS) should agree a limited list of items and simple agents which may be prescribed by nurses as part of a nursing care programme, and issue guidelines to enable nurses to control drug dosage in well-defined circumstances” (DHSS 1986). After 8 years of political and professional negotiation, district nurses (DNs) and health visitors (HVs) began prescribing in 1994. The Advisory Group on Nurse Prescribing made specific recommendations to the government on prescribing by DNs and HVs in 1989 (DH 1989, Crown Report I). The necessary legislation enabling nurse prescribing was provided in the Medicinal Products: Prescribing by Nurses etc. Act. This Act was passed in 1992 and was implemented in 1994. DNs and HVs have since been able to prescribe a limited range of products approved by the DHSS/DH and listed in the British National Formulary (BNF) as the Nurse Prescribers’ Formulary (NPF). In developing the non-medical prescribing agenda, the government built on the prescribing experience acquired by nurses who possessed the DN and HV qualifications.

In 1997, under “new labor,” the government’s strategy document The NHS Plan (Department of Health 1997, 2000a) integrated the main principles of the modernization of the NHS. The principal aim of the reform was to provide high-quality, accessible healthcare, designed and delivered around the needs of its users. An important part of the reform, and one of the tools designed to achieve its aims, was the goal to redesign the NHS workforce to develop and utilize the skills and abilities of the NHS staff.

Within this document, the chief nursing officer defined ten key roles for the profession, one of which included prescribing (Department of Health 2000a). Following The NHS Plan, the Department of Health (DH), in collaboration with professional bodies, detailed changes to the NHS workforce in a range of specific documents (Department of Health 2000b, 2001, 2002); nurses and other allied health professionals were encouraged to expand their clinical roles, particularly in chronic disease management, and were empowered to prescribe medicines (Department of Health 2000c).

In developing the non-medical prescribing agenda, the Department of Health (2001) built on the prescribing experience acquired by nurses who possessed the district nurse (DN) and health visitor (HV) qualifications. However, the “Nurse Prescribers’ Formulary (NPF) for DNs and HVs” or “limited” NPF was quickly criticized by nurses as being too limited, and despite having prescribing rights, very few nurses were actually prescribing (Luker 1997). These reactions led to the extension of prescribing rights (DH 1999), and following the second Crown Report (II) (DH 1999), recommendations were made to extend nurse prescribing. After a lengthy consultation process, a formulary was drawn up from four areas of clinical practice: minor injury, minor ailments, health promotion, and palliative care. Eighty medical conditions and 180 prescription-only medicines (POMs) were selected for nurses to prescribe from a nurse’s formulary known as the Nurse Prescribers’ Extended Formulary.

Following further public consultation, a proposal was made to introduce “supplementary” prescribing for nurses and pharmacists. In 2003 alterations were made to the NHS regulations and the prescription-only medicines order to allow implementation of supplementary prescribing by nurses and pharmacists (DH 2003a). Supplementary prescribing is based on a voluntary agreement between a medical independent prescriber (doctor/dentist), the patient, and the supplementary prescriber (nurse) (DH 2003a, b). This agreement is recorded as a clinical management plan (CMP). The CMP is a legal document that has to be complied, agreed, and signed by both the independent prescriber and the supplementary prescriber before supplementary prescribing can take place. Each patient for whom supplementary prescribing is used will have their own CMP, although each CMP can encompass a number of disease states.

Several key factors have to be incorporated into the CMP to fulfill the legal requirements. These include clinical outcomes, name(s) of the medication(s), when the patient should be referred back to the independent prescriber, and review dates and plan for reporting adverse drug reactions. The ideal CMP should consider evidence-based prescribing and clinical governance and reflect the supplementary prescribers’ level of competency. The CMP can be cancelled at any time, either by the independent prescriber, by the supplementary prescriber, or by the patient. While giving the non-medical prescriber the opportunity to prescribe any medicine within their area of clinical competence, supplementary prescribing was viewed as being time-consuming and limited autonomy among nurses (Courtney et al. 2007).

From 1 May 2006, the Nurse Prescribers’ Extended Formulary was discontinued, and all independent nurse prescribers received prescriptive authority to prescribe any drug from the BNF (including some controlled drugs), providing it was within their scope of professional practice (DH 2006). This development was welcomed by the nursing profession enabling nurses to become autonomous and responsible for their prescribing decisions and in many cases complete a package of care for the patient without having to liaise with a doctor. From this time, the only restrictions were schedule 4 and 5 controlled drugs.

From 23 April 2012, legislative changes to the Misuse of Drugs (amendment 2) (England, Wales, and Scotland) Regulations 2012 have enabled independent nurse and pharmacist prescribers to prescribe, administer, and give directions for the administration of schedule 2, 3, 4, and 5 controlled dugs (DH 2012). This means that all nurses with the appropriate prescribing qualification can now prescribe any medicines from the BNF on the same terms as a medical professional.

All non-medical prescribers in the United Kingdom are required to undertake a specific educational program provided by approved universities and validated by the regulatory bodies: the Nursing Midwifery Council (NMC), General Pharmaceutical Council (GPhC), and Health Care Professional Council (HCPC). The NMC Standards of Proficiency for Nurse and Midwife Prescribers (NMC 2006) forms the structure of this generic non-medical prescribing program, with the GPhC and HCPC requiring additional learning outcomes that are professional specific. Core standards for the educational program set by the regulatory bodies include entry requirements, core curriculum content, and core assessment criteria (NMC 2006; HCPC 2013). The program is offered by most universities as an integrated program with other non-medical prescribers such as pharmacists, physiotherapists, podiatrists, and radiographers.

The Department of Health (2006) also specified specific entry criteria for health professionals wishing to undertake the non-medical prescribing programs, which include:

Key principles should be considered when selecting students to undertake the non-medical prescribing program and include patient safety, benefit to the patient in terms of quicker and more efficient access to medicines, and a better use of skills (DH 2004a). Throughout the program, all students are required to apply the principles of prescribing to their practice and reflect on this through a learning log or portfolio. However, they may not prescribe until they have successfully completed the program and the relevant qualification has been recorded with the regulatory body.

Supervised clinical practice is a crucial element of the non-medical prescribing educational program. Each student is required to identify a designated medical practitioner (DMP), (a doctor), who will provide the student with supervision, support, and the opportunities to develop the competencies required to become a safe, cost-effective, and competent prescriber. The time spent with the DMP and the range of activities undertaken within the supervised clinical practice will depend on the individual student and their clinical relevant experience. However, as guidance, time should be spent observing consultations with patients, discussion of differential diagnoses, clinical reasoning in relation to the patient presentation, and discussion and analysis of the patient treatment/management plan. Non-medical prescribers who have achieved prescriptive authority as a result of successfully completing the non-medical prescribing program must aim to maintain their standard of competence through regular CPD.

The NMC (2006) (due for revision in 2017) and HCPC (2013) have both published standards for prescribing. Although the GPhC does not have specific standards for prescribing in England, the Pharmaceutical Society of Northern Ireland has published standards and guidance for pharmacist prescribers, which are widely used in England. Each of these regulatory standards for prescribing has documented core learning outcomes for the educational programs for non-medical prescribing and specific standards of professional conduct that non-medical prescribers must adhere to ensure integrity. It is important that the standards are adhered to and practitioners practice lawfully, safely, and effectively. Although worded differently, the core standards for prescribing include (NMC 2006; HCPC 2013):

*The following standards have been taken from the NMC (2006) Standards of Proficiency for Nurse and Midwife Prescribers

There are several components to the English legal system that must be understood as all non-medical prescribers are accountable for their prescribing decisions. All prescribers are accountable to the public through criminal law, the patient through civil law, the employer through your contract of employment, and your profession through the professional code of conduct (Armstrong 2011)

All non-medical prescribers are accountable to civil law with regard to the scope of their practice and must prescribe only in areas that they are deemed to be competent. In cases where a non-medical prescriber may want to expand the scope of clinical practice by increasing his/her area of competence, it is important that this is done within the framework of clinical governance.

Patient consent is a fundamental principle of healthcare law and is based on the legal and ethical principle that a patient has a right to decide what will happen to their body. Provision of information is core to the consent process, and it is the non-medical prescriber’s responsibility to provide the patient with correct information regarding any treatment that is prescribed (Dimond 2009). Non-medical prescribers should confirm that their patients know and understand what their treatment is for, how it works, and any risks or possible adverse reactions. Patients should also be given advice as to what to do if they experience any adverse reactions.

Non-medical prescribers are encouraged to adopt good record keeping practice and maintain records that are “unambiguous and legible” (DH 2006). Records should contain details of the prescription as well as a documented record of the consultation. Ideally, any information given to the patient should be documented in the patients’ notes. Neighbour (1987) described this as “safety netting” and considers it to be an integral part of the consultation process. This should include advice given to patients about when and how to seek further medical attention if symptoms deteriorate. Records should be written immediately after the consultation or as soon as possible afterwards (NMC 2015).

In the United Kingdom, vicarious liability in healthcare means that healthcare professionals have legal exemption from liability for damages or claims made by patients and resulting from performing duties specified in their job description. However, despite this, many professional organizations now insist that practitioners have their own professional indemnity insurance. The NMC (2015) code of professional standards of practice and behavior for nurses and midwives suggests that while employers have vicarious liability for acts of omission/negligence of their employees, this would not cover independent practice and some areas of advanced practice. It is the individual’s responsibility to establish their insurance status and take appropriate action. All non-medical prescribers should ensure that they have personal professional indemnity insurance through professional organizations such as the Royal College of Nursing, Pharmacist Defence Association, and Chartered Society of Physiotherapist. All non-medical prescribers must ensure that their job description reflects any extended role, including prescribing.

Although indemnity protects the prescriber in case of patient legal claims, any claims would be reviewed with respect to contractual law. This demands that practitioners adhere to all policies and procedures laid down by their employer. Practitioners must then act within the context of these policies and within the parameters of their employment contract and job description. Prescriptive authority is a good example of how advanced practice is developing. However, through expansion of responsibility, there is also the risk of the expansion of liability.

Healthcare professionals have a duty of care and are responsible for the well-being of their patients. Clinical governance is a well-embedded tool, which can be used to achieve this and to provide safe, effective, and high-quality patient-centered care (DH 2004b). Organizations and their employees are responsible for ensuring that their work conforms to principles of clinical governance. This has clear implications for non-medical prescribing practice. Non-medical prescribing practice should be subjected to regular audits and evaluations and be part of risk assessment frameworks established by employer organizations (DH 2004a). In order to maintain competence and keep abreast of current research, practitioners should implement the skills acquired during their prescribing course. Critical appraisal skills are particularly useful in evaluating the validity and usefulness of newly published research before considering its implementation. It is important to join with other practitioners in prescribing forums, study groups, and professional teams to assess evidence also. Developing critical appraisal skills comes with practice and peer support is also valuable. Sharing opinions and experience is invaluable.

A variety of evidence-based resources exist for prescribers to use, including a range of national service frameworks which all support good practice. The National Institute for Health and Clinical Excellence (NICE) produces evidence-based guidelines for use by prescribers on a regular basis. On a more local level, health Trusts produce formularies and clinical guidelines for practitioners to use. Once they become confident, non-medical prescribers can participate in the development of such tools as clinical guidelines (Chapman 2008). A pharmacy lead in a primary care or an acute trust can be very helpful in offering guidance on local prescribing issues, especially around local formulary usage.

Developed by the National Prescribing Centre in 2012, the single competency framework provided an outline of common prescribing competencies to enable all prescribers to become and remain effective prescribers in their area of practice (NPC 2012). The competency framework (see Fig. 6.3 and Table 6.1) has been updated by the Royal Pharmaceutical Society (RPS) in 2016. The competency framework (see Fig. 6.3) sets out what good prescribing looks like. There are ten competencies split into two domains (see Table 6.1). Within each of the ten competency dimensions, there are statements, which describe the activity, or outcomes prescribers should be able to demonstrate. All of these statements MUST be completed and signed off to pass the portfolio.

Since 1994 the scope and practice of nurse prescribing have steadily grown (NPC 2012). Advances in prescriptive authority may have seemed slow and frustrating at times, but by 2012 legislation had been amended to enable independent nurse and pharmacist prescribers to prescribe all medicines the same as doctors (DH 2012) and other non-medical prescribers (the exception being controlled drugs and unlicensed drugs). It is now widely accepted that prescribing is a core component of the advanced practice role. With the advent of independent non-medical prescribing, the principles for NHS reform set out in the NHS plan of 2000 (DH 2000a, b, c), to improve patient care, choice and access to health professionals, patient safety, better use of health professional’s skills, and more flexible working, have been fulfilled. However, Anguita (2012), discussing the evidence for non-medical prescribing, suggests that although the published literature concludes a high level of patient satisfaction from nurse prescribers, the evidence for nurse prescribing must increase and focus on clinical, economic, and humanistic outcomes. Cope et al. (2016) conclude that nurse and pharmacist independent prescribing is becoming well-integrated and an established component of patient management. Latter et al. (2011) also suggest that education for non-medical prescribing is fit for purpose and prescribing by nurses is safe and clinically appropriate with most Trusts having core clinical governance and strategies for prescribing. The numbers of registered nurse independent/supplementary prescribers has been rising steadily and, by February 2016, was approximately 28,000. Latter et al. (2011) found that the majority of nurse independent prescribers had used their prescribing qualification and that most were currently prescribing. At the time of this evaluation, the majority of independent nurse prescribers were working in primary care; however, more recently nurses working in all areas of clinical practice are undertaking the non-medical prescribing programs.

This section on non-medical prescribing for nurses in the United Kingdom has explored the history, legislation, education, legal, and professional issues that surround the complexity of nurse prescribing in the twenty-first century. The road to full prescribing rights for nurses has been a long and arduous one. Although prescribing is firmly embedded within the advanced practice role, the future may see prescribing as an integral component of preregistration nursing and become the norm for routine nursing practice. However, before this can be achieved, the pioneers of nurse prescribing will need to have their prescribing habits evaluated and audited to ensure that nurse prescribing is improving the health outcomes and meeting the needs of the patients (Anguita 2012; Cope et al. 2016).

Nurses have always been responsible for the administration of medicines, but it is the new role of nurse prescribing that is challenging. The different programs and formularies that encompass non-medical prescribing are complex and have the potential to be very confusing for the patient. The added accountability and responsibility that non-medical prescribers have can be daunting at first. However, with confidence develops competence and as the numbers of non-medical prescribers increase, attitudes toward non-medical prescribing will become more positive.