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Which professions can qualify as non-medical prescribers?

Nurses, pharmacists and optometrists can all undertake a qualification to allow them to become independent and/or supplementary prescribers. Nurses can also train to become community practitioner nurse prescribers.

Chiropodists/podiatrists, physiotherapists and radiographers can train to become supplementary prescribers.

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What is independent prescribing?

Independent prescribing is prescribing by a practitioner (e.g. doctor, dentist, nurse, pharmacist or optometrist) responsible and accountable for the assessment of patients with undiagnosed or diagnosed conditions and for decisions about the clinical management required, including prescribing.

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What is supplementary prescribing?

Supplementary prescribing is a voluntary partnership between a doctor or dentist and a supplementary prescriber to implement an agreed patient-specific clinical management plan (CMP) with the patient’s agreement.

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What can an independent prescriber prescribe?

Nurse independent prescribers can prescribe any licensed or unlicensed medicine for any condition within their clinical competence, including some controlled drugs (see controlled drugs section below).

Pharmacist independent prescribers can prescribe any licensed or unlicensed medicine for any condition within their clinical competence, excluding controlled drugs (see controlled drugs section below).

Optometrist independent prescribers are able to prescribe any licensed medicine for ocular conditions affecting the eye, and the tissue surrounding the eye, within their recognised area of expertise and competence, except for controlled drugs or medicines for parenteral administration.

Guidance on independent prescribing can be found in the Department of Health document
‘Improving patients' access to medicines: A guide to implementing nurse and pharmacist independent prescribing within the NHS in England’. A note on recent changes to medicines legislation can be found on the Department of Health website: ‘Changes to medicines legislation to enable Mixing of Medicines prior to administration in Clinical Practice’.

A community practitioner nurse prescriber can prescribe from the Nurse Prescribers’ Formulary for Community Practitioners. (See ‘What can a community practitioner nurse prescriber prescribe?’ below).

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What can a community practitioner nurse prescriber prescribe?

Community practitioner nurse prescribers (formerly district nurse and health visitor prescribers) can prescribe from the Nurse Prescribers’ Formulary for Community Practitioners (formerly the Nurse Prescribers’ Formulary for District Nurses and Health Visitors). This formulary includes dressings, appliances and a limited number of medicines relevant to community nursing and specialist community public health nursing practice. The formulary can be found at the back of the BNF or at BNF.org - Nurse Prescribers’ Formulary for Community Practitioners.

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What can a supplementary prescriber prescribe?

A supplementary prescriber can prescribe any licensed or unlicensed medicine, including controlled drugs, for any condition within their competence, as part of a patient-specific, written clinical management plan (CMP) agreed with a doctor, and with the patient’s agreement.

Guidance on supplementary prescribing can be found in the Department of Health document
‘Supplementary Prescribing by Nurses, Pharmacists, Chiropodists/Podiatrists, Physiotherapists and Radiographers within the NHS in England’.

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What is a clinical management plan (CMP)?

A supplementary prescriber may give a prescription for a medicinal product only when they are acting in accordance with the terms of a clinical management plan (CMP).

The Department of Health document -‘Supplementary Prescribing by Nurses, Pharmacists, Chiropodists/Podiatrists, Physiotherapists and Radiographers within the NHS in England’ contains guidance on the CMP (Paragraphs 55-60) and states:

‘Before supplementary prescribing can take place, it is obligatory for an agreed CMP to be in place (written or electronic) relating to a named patient and to that patient's specific condition(s) to be managed by the supplementary prescriber’.

It goes on to list the specific requirements for what a CMP must contain, including patient name, illness and references to medicines that may be prescribed.

This information can also be found in the supplementary prescribing section of the Department of Health website: Clinical Management Plans (CMPs).

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Where can I find examples of clinical management plans (CMPs) used elsewhere?

The National Electronic Library for Medicines’ non-medical prescribing (NMP) community area (http://www.nelm.nhs.uk/en/NeLM-Area/Community-Areas/Non-Medical-Prescribing/Support-Materials/) contains examples of clinical management plans (CMPs) in its ‘support materials’ section. There is also a ‘Clinical Management Plan Library’ at http://www.cmponline.info/.

Both of these resources give non-medical prescribers the opportunity to search though and use examples of CMPs and upload their own.

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What training is involved in becoming an independent or supplementary prescriber?

Guidance on preparation and training can be found on the Department of Health website for both supplementary and independent prescribing and also in the Department of Health guides ‘Improving patients' access to medicines: A guide to implementing nurse and pharmacist independent prescribing within the NHS in England’ and ‘Supplementary Prescribing by Nurses, Pharmacists, Chiropodists/Podiatrists, Physiotherapists and Radiographers within the NHS in England’. Your trust or strategic health authority (SHA) non-medical prescribing (NMP) lead should be able to advise you on where training is available in your area.

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What is a designated medical practitioner (DMP)?

A designated medical practitioner (DMP) is a medical practitioner who directs and supervises a non-medical prescriber’s period of learning in practice – a required element of non-medical prescribing (NMP) qualifications. They will also be responsible for assessing whether the learning outcomes have been met and whether the trainee has acquired certain competencies.

The National Prescribing Centre (NPC) have produced guidance for this role:
'Training non-medical prescribers in practice: A guide to help doctors prepare for and carry out the role of designated medical practitioner'. As this guide was published prior to some of the more recent changes in extending prescribing responsibilities legislation, the newer types of prescriber are not reflected in the guide – however the DMP’s roles and responsibilities remain the same.

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What controlled drugs can non-medical prescribers prescribe?

Independent prescribers

Nurse independent prescribers are restricted by current legislation to independently prescribe only certain controlled drugs solely for specified medical conditions (See BNF Nurse Prescribers’ Formulary - Nurse Independent Prescribing).

Pharmacist independent prescribers are not yet able to independently prescribe any controlled drugs.

Optometrist independent prescribers cannot prescribe controlled drugs.

Supplementary prescribers

Nurse, pharmacist, chiropodist / podiatrist, physiotherapist, radiographer and optometrist supplementary prescribers can prescribe any schedule 2-5 controlled drugs for any condition within their competence, as part of a patient specific, written clinical management plan (CMP) agreed with a doctor.

For NPC resources regarding controlled drugs please see: http://www.npc.co.uk/policy/cd/controlled_drugs.htm.

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Can non-medical prescribers prescribe temazepam, diazepam and clonazepam?

Temazepam is a schedule 3 controlled drug, and diazepam and clonazepam are both schedule 4. As such they fall under the restrictions for prescribing controlled drugs (see the question above).

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Can nurse independent prescribers prescribe preparations containing controlled drugs e.g. co-codamol?

Nurse independent prescribers can independently prescribe preparations containing, in combination with other medicines, controlled drugs which are listed in the formulary of controlled drugs which nurse independent prescribers can prescribe from (see BNF Nurse Prescribers’ Formulary - Nurse Independent Prescribing), provided the indication and route of administration is as listed in the table, and that they are working within their competence. This would therefore include, for example, oral co-codamol 30/500.

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Can pharmacist independent prescribers prescribe pharmacy only preparations containing schedule 5 controlled drugs e.g. co-codamol 8/500?

Pharmacist independent prescribers are not currently permitted to independently prescribe, administer in their own right or direct the administration of controlled drugs, including schedule 5 controlled drugs which may appear in pharmacy only preparations that are available for over the counter sale. (See Medicines, Ethics and Practice: A guide for pharmacists and pharmacy technicians. Number 34 July 2010. Section 1.2.14).

The legislation on nurse and pharmacist independent prescribers prescribing controlled drugs is due to change, please see the question below.

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When will the law regarding the non-medical prescribing (NMP) of controlled drugs change?

Following a consultation process conducted in 2007, the Home Office’s Misuse of Drugs regulations relating to non-medical prescribing (NMP) of controlled drugs are set to change. The changes are due to allow pharmacist independent prescribers to prescribe, within competence, schedule 2, 3, 4 and 5 controlled drugs and remove the existing limitations on the prescription and administration of controlled drugs by nurse independent prescribers. An amendment to the Prescription Only Medicines (Human Use) Order 1997 has been made, which came into force on 1 April 2008, and goes part way to achieving these changes. However, a change to the Misuse of Drugs Regulations 2001 is also necessary and is expected to take place later in 2010.

We are not in a position to say exactly when these changes will take place, however we will keep our NMP network informed and website updated when they do.

Until the Misuse of Drugs Regulations 2001 are amended nurse independent prescribers will continue to be limited to the range of controlled drugs they can prescribe for particular indications. Pharmacist independent prescribers will not be able to prescribe controlled drugs. Supplementary prescribers can still prescribe any controlled drug as long as they are part of an agreed clinical management plan (CMP) and the supplementary prescriber is working within his or her level of competence.

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Can non-medical prescribers prescribe unlicensed medicines?

Independent prescribers

Nurse and pharmacist independent prescribers are allowed to prescribe unlicensed medicines within their competence, on the same basis as doctors.

Optometrist independent prescribers are not permitted to prescribe unlicensed medicines.

Supplementary prescribers

Supplementary prescribers are able to prescribe any medicine, including an unlicensed medicine, that is listed in an agreed clinical management plan (CMP).

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Can non-medical prescribers prescribe off-label/off-license medicines?

Yes.

“Nurse and pharmacist independent prescribers may prescribe medicines independently for uses outside their licensed indications/UK marketing authorisation (so called ‘off-licence’ or ‘off-label’). They must, however, accept professional, clinical and legal responsibility for that prescribing, and should only prescribe ‘off-label’ where it is accepted clinical practice.
A local policy for the use of off-label medicines should be approved through mechanisms such as drug and therapeutic committees or the equivalent. The prescriber should explain the situation to the patient/guardian, where possible, but where a patient is unable to agree to such treatment, the prescriber should act in accordance with best practice in the given situation and within the policy of the employing organisation”. (‘Improving patients' access to medicines: A guide to implementing nurse and pharmacist independent prescribing within the NHS in England’ - Paragraph 54).

“Optometrist independent prescribers should not normally prescribe off-licence. However, when working within the limits of their own experience and competence optometrists may occasionally encounter situations in which it would be desirable to prescribe a drug for an unlicensed indication.” If they do so they must ensure they are “satisfied that it would better serve the patient’s needs than an appropriately licensed alternative” and “that there is a sufficient evidence base and/or experience of using the medicine to demonstrate its safety and efficacy.” They should “explain to the patient or parent/carer, in broad terms, the reasons why medicines are not licensed for their proposed use. If optometrists intend to prescribe off-licence they are advised to obtain the written consent of the patient”, and they must “make a clear, accurate, and legible record of all medicines prescribed and the reasons for prescribing an ‘off-licence’ medicine.” (The College of Optometrists ‘Guidance for optometrist prescribers’ – Section 1, P17).

Supplementary prescribers may prescribe products used outside their UK licensed indications (i.e. “off-label” use). Such use must have the joint agreement of both prescribers and the status of the drug should be recorded in the clinical management plan (CMP). (‘Supplementary Prescribing by Nurses, Pharmacists, Chiropodists/Podiatrists, Physiotherapists and Radiographers within the NHS in England’ – Paragraphs 61-62).

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Can non-medical prescribers mix medicines and instruct others to mix medicines?

Nurse and pharmacist independent prescribers are allowed to mix medicines prior to administration and provide written directions for others to do so.

Supplementary prescribers are allowed to mix medicines prior to administration and provide written directions for others to do so, only when that preparation forms part of the clinical management plan for an individual patient.

Optometrist independent prescribers are not allowed to mix medicines or direct others to do so.

Guidance from the Royal Pharmaceutical Society states: ‘The mixing of drugs should be avoided unless essential to meet the needs of the patient, and that those involved in both the prescribing and actual mixing should be competent to do so and take full professional and clinical responsibility for their actions. In addition such actions must be within the governance structures and guidance of the employing authority and of the relevant statutory bodies.’ Law and Ethics Bulletin: Mixing of Medicines

The MHRA has already issued a statement advising that it would not consider taking enforcement action against those prescribing and administering mixtures of licensed medicines in clinical practice, unless it would be in the public interest to do. This includes controlled drugs and the Home Office is aware of the position.

The MHRA has also approached the Home Office and the Advisory Council for the Misuse of Drugs (ACMD) with the Commission on Human Medicines’ recommendations that corresponding amendments for mixing of controlled drugs are made to the Misuse of Drugs Regulations.  Meantime, existing good practice arrangements should continue on mixing before administration which includes a controlled drug.

Further information on mixing of medicines can be found on the website of the Medicines and Healthcare products Regulatory Agency at http://www.mhra.gov.uk/Publications/Consultations/Medicinesconsultations/MLXs/CON033523

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How do non-medical prescribers obtain prescription pads?

Non-medical prescribers should speak to the NMP lead in their trust about obtaining their prescription pad. Prescription forms are not sent out automatically, trusts must order FP10 prescriptions from the supplier, and re-order as and when required.

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Can non-medical prescribers use the same prescription pad in all work settings/employers?

Non-medical prescribers who work for more than one employer or in more than one setting (e.g. PCT directly employed prescriber, providing services to patients in the PCT and the same prescriber providing services to patients outside the PCT area, through a contract) must have separate prescription pads for each organisation or use FP10SS prescriptions, printed with the correct organisation details in the prescriber details area of the prescription form.

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Is it necessary to have specific prescriber details – e.g. name, registration number - on a prescription?

The Department of Health (DH) guide - ‘Improving patients' access to medicines: A guide to implementing nurse and pharmacist independent prescribing within the NHS in England’ states (Paragraph 66) that:
“In primary care, a nurse or pharmacist should only write prescriptions on a prescription pad bearing his/her own unique Nurse and Midwifery Council’s (NMC’s)/Royal Pharmaceutical Society of Great Britain (RSPGB) registration number”.

“All prescription forms require information to be entered on them (by printing or writing or a combination of both). In addition to the correct dispensing of the items prescribed, this allows for prescribing information and costs to be attributed to the correct prescriber and/or organisation, as well as to the correct prescribing budget”.

Pre-printed FP10P prescription forms “will be overprinted to identify the Nurse or Pharmacist Independent Prescriber”. (Annex E – DH guide ‘Improving patients’ access to medicines').

For the overprint specifications for computer-generated prescriptions please see the relevant question later in this section.

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Is it necessary to have a non-medical prescriber’s qualification on their prescription forms?

The Department of Health (DH) guide - ‘Improving patients' access to medicines: A guide to implementing nurse and pharmacist independent prescribing within the NHS in England’ states, in paragraph 96-97:
“The dispensing pharmacist will need to be sure that the prescriber has qualified as a nurse or pharmacist independent prescriber. The prescription form will indicate whether a prescriber is a nurse or pharmacist independent prescriber”.

Pre-printed FP10P prescription forms “will be overprinted to identify the type of independent prescriber e.g. Nurse Independent/Supplementary Prescriber”. (Annex E – DH guide ‘Improving patients’ access to medicines').

For the overprint specifications for computer-generated prescriptions please see the next question.

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What are the requirements for printing prescriptions using IT systems?

The NHS Business Services Authority website contains guidance on prescription forms including specifications which describe the specific print requirements for prescription form and non-FP10 supply form overprinting that will allow prescribers to print prescriptions using GP/pharmacy/out of hours and hospital prescribers IT systems. NHS Business Services Authority - Prescription Forms Overprint Specifications.

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Where can further guidance regarding prescription pads/forms be found?

The Prescription Services section of the NHS Business Services Authority website - www.nhsbsa.nhs.uk/PrescriptionServices.aspx - contains guidance on prescription forms, prescribing and dispensing.

Annex E of the Department of Health guide - ‘Improving patients' access to medicines: A guide to implementing nurse and pharmacist independent prescribing within the NHS in England’ contains guidance regarding prescription forms and prescribing in both primary care and hospitals.

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What guidance is there for prescribing without a patient’s notes being available (i.e. at a walk-in-centre/community pharmacy)?

Practice Standard 3 of the Nursing and Midwifery Council’s (NMC’s) ‘Standards of proficiency for nurse and midwife prescribers, 2006' states:
“In order to prescribe for a patient/client you must satisfy yourself that you have undertaken a full assessment of the patient/client, including taking a thorough history and, where possible, accessing a full clinical record”.

The emphasis is on ensuring a full assessment.

There is also a requirement to “inform, where relevant, anyone else who may be in a position to prescribe for that patient/client of your actions in order to avoid prescribing errors. This is most likely to be the patient/client’s general/medical practitioner, but may also include other non-medical prescribers’ (Standard 5).
Standard 6 states: “You have a responsibility to communicate effectively with other practitioners involved in the care of the patient/client”.

The Royal Pharmaceutical Society of Great Britain’s ‘Professional Standards and Guidance for Pharmacist Prescribers’ states:
“In order to prescribe for a patient you must satisfy yourself that you have undertaken an adequate assessment of the patient by taking a history, performing an appropriate examination and/or by accessing the appropriate parts of their clinical records. You are accountable for your decision to prescribe and must prescribe only where you have relevant knowledge of the patient’s health and medical history and of the medicines required for treating their condition(s)”. [Mandatory Professional Standard]

“Whenever possible, when prescribing for a patient you should have concurrent access to the patient’s full health records.’ [Good Practice Guidance]

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What guidance is available regarding having prescribing duties included in your job description?

The Department of Health document ‘Improving patients' access to medicines: A guide to implementing nurse and pharmacist independent prescribing within the NHS in England’ states (Paragraph 89-90):
“Both the employer and employee (or contractor) should ensure that the employee’s job description (or contractor’s agreed arrangements) includes a clear statement that prescribing is required as part of the duties of that post or service. Where a nurse, midwife or pharmacist is appropriately trained and qualified and prescribes as part of their professional duties with the consent of their employer, the employer is held vicariously liable for their actions”.

Paragraph 60 states that the organisation’s clinical governance framework should include systems to ensure “that the parameters of an individual’s prescribing are agreed between the prescriber, their manager or local professional lead (e.g. the PCT pharmaceutical adviser in the case of a community pharmacist), and their employer” and the first good practice example of non-medical prescribing (NMP) clinical governance frameworks in Annex F states that “The trust should demonstrate job descriptions are amended to account for prescribing responsibilities”.

Practice Standard 1 of the Nurse and Midwifery Council’s (NMC’s) ‘Standards of proficiency for nurse and midwife prescribers, 2006' states that “The ability to prescribe is a privilege granted to you by legislation and your employer, and should be seen in this light”.

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