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Supplementary prescribing: Patient, podiatrist and professor perspectives

Over the past 20 years, the healthcare work force has been transformed. For eligible allied healthcare professions, non-medical prescribing has been introduced. This move has given fast and safe access to appropriate medicines for a range of patients.

Supplementary prescribing rights were extended to include the podiatry profession in 2005, but few podiatrists have taken on this role. At present, around just 120 UK podiatrists are qualified supplementary prescribers (Health Professions Council, 2010). With so few practising supplementary prescribers in podiatry, it is perhaps unsurprising that their impact – on the health service, patient care and, ultimately, outcomes – may be considered minimal. 

So what are the benefits of non-medical prescribing, and what value does it add to the health service? More specifically, how does supplementary prescribing improve outcomes in the management of people with long-term conditions, such as diabetes and diabetes-related complications of the foot?

Here, the authors offer various perspectives – that of the patient (Umberto Saoncella), the professor and physician (Philip Wiles) and the podiatrists (Louise Stuart, Martin Fox) – on the benefits of supplementary prescribing. In conclusion, Alan Borthwick looks at the possibilities of independent prescribing for podiatrists and projects currently under way to determine the best path forward.

Background
The vast majority of podiatrists access medicines for their patients via statutory exemptions, Patient Group Directions or rely on prescriptions written by medical colleagues. Those who have successfully undertaken the supplementary prescriber course can prescribe medicines for an individual within an agreed clinical management plan between reviews by the independent prescriber – most often a physician. Podiatrists are not yet able to prescribe independently, unlike appropriately qualified nurses and pharmacists (Department of Health, 2006).

The patient’s perspective
Umberto Saoncello has been receiving care for active Charcot foot disease and foot ulceration for the past 3 years in Manchester. During this time he has regularly attended the hospital-based multidisciplinary diabetic foot team, which includes a podiatrist supplementary prescriber. When asked to comment on his experiences he said:

“The diabetic foot clinic has been a beacon of hope for me over the past 3 years. Before being managed in the clinic, I struggled to obtain specialist care for my foot problems. In the past 2 years I have swiftly received antibiotics, prescribed by my podiatrist, as well as my diabetologist, when they have been needed.

“It seems logical to me as a patient that a podiatrist prescriber offers joined-up care. I fail to understand why, at the most important juncture of my care, the pen could be taken from the hand of the person who knows me best and thrust into the hand of another professional who, in some cases, may know little about my condition.

“I was dealt with competently, kept informed of all aspects of my care and had full confidence in the podiatrist prescribing for me. There was a totality of care given, not fragmented management. My GP was kept fully informed of my treatment and continued to prescribe in the community in line with advice given by the podiatrist and my diabetologist.

“I would argue that people with diabetes-related foot problems need more specialists able to prescribe medicines appropriately in all locations, not just hospitals. At times, my care – particularly outside of the hospital – has not been provided by those sufficiently knowledgeable or skilled to manage my foot problems.”

The professor’s perspective
Philip Wiles is Honorary Professor, University of Salford and a jobbing general diabetes consultant working in a large district general hospital diabetes centre. Having mentored and worked with both independent and supplementary prescribers, Philip had this to say on his experiences: 

“By far the greatest impact made by the introduction of supplementary prescribing at our hospital has been on the diabetic foot service. In that environment clinical problems are dynamic and the pace frequently frenetic, making non-medical prescribing completely practical. As a result, clinics run more smoothly and the patients leave for home more quickly. 

“Supplementary prescribing is underpinned by a robust governance process that applies structure and scrutiny to prescribing. Best practice has extended into the community, where I have seen a more rational approach to antibiotic prescribing in primary care settings as a consequence of contact with a prescribing podiatrist.

“Personally, I have benefited from the case discussions and the need to explain prescribing decisions. Supplementary prescribing has also released some of my time to spend on other aspects of patients’ general care and diabetes management.

“Podiatrists cannot, as yet, prescribe independently. Supplementary prescribing is fine within a clinic environment, but the lack of independence is a hindrance when trying to manage foot ulceration in the community. Neither my podiatry colleagues, nor our patients, have the luxury of time to waste. I look forward to the extension of full independent prescriber status to appropriately trained podiatrists.”

The prescribing podiatrists’ perspective
Louise Stuart MBE and Martin Fox describe the supplementary prescribing course for podiatrists as the most useful one they have undertaken since qualifying. If readers think that writing a prescription is the only benefit, they urge them to think again:

“Penning the prescription is the tip of the iceberg; we review medicines in every patient we see. This allows us to provide a safer, more informed and holistic service for people with diabetes-related foot complications. But apart from our anecdotal experiences, what evidence is there that supplementary podiatrist prescribers add value to the health service and improve patient experience and outcomes?

“In 2009, the North-West Allied Healthcare Professions Non-Medical Prescribing Network (AHP NMP) undertook an audit of allied healthcare professional prescribing practices. To the best of our knowledge, it is the largest audit of its kind. The aim was to assess the impact of supplementary prescribing on patient care.

“The AHP NMP audit revealed the immediate access to medicines provided by non-medical prescribing, with a prescription being drawn in 80% of all emergency appointments. The follow-on effect of this is the prompt treatment for the patient, the prevention of referrals and a cost saving to hospital-based emergency care that would otherwise have been engaged.

“The audit also revealed that a review of patients’ medicines took place in 97% of cases. The impact of the medicines review led to the recognition of sub-therapeutic doses and inappropriate regimens, which were subsequently red-flagged to independent prescribers. In one in ten cases the non-medical prescriber identified inappropriate repeat prescriptions, the correction of which would result in cost savings and a reduction in medicines waste.

“Few studies have critically examined the impact of non-medical prescribing and, in the absence of evidence, the effectiveness of prescribing is assessed by the surrogate, and less than ideal, measure of number of prescriptions issued. The assumption that the success of non-medical prescribing lies in the number of prescriptions written was refuted by the AHP NMP audit. There are multiple benefits to prescribing, not only in improved patient care but also in terms of ensuring the appropriate use of scarce NHS resources.”

Independent prescribing: The way forward?
In its report of July 2009, the Department of Health’s Allied Health Professions Prescribing and Medicines Supply Mechanisms Scoping Project recommended two additional implementation phases designed to enhance access to, and up-take of, non-medical prescribing across a range of allied healthcare professions. In February 2010, the Allied Healthcare Professions Medicines Project was established with a view to enacting the first of the two recommended phases and is presently preparing for public consultation on extending independent prescriber status to the podiatry and physiotherapy professions. Although there has been unavoidable uncertainty around the policy priorities of the new coalition Government, the work of the project continues apace.

As was the case in nursing, pharmacy and optometry, a range of prescribing activity options are being considered for podiatrists. Would limited prescribing within a set formulary be sufficient, or would freedom to prescribe where relevant be preferable? Might it be effective to prescribe within a limited range of conditions, or would this create more problems for patients than even the current system allows?

Answers to these, and related, questions will determine the case for independent prescribing status for the podiatry profession. As evidence grows that supplementary prescribing benefits patients, makes services more responsive and reduces the burden on GPs and hospital physicians, the case for independent prescribing for the podiatry profession will strengthen.

Over the past 20 years, the healthcare work force has been transformed. For eligible allied healthcare professions, non-medical prescribing has been introduced. This move has given fast and safe access to appropriate medicines for a range of patients.

Supplementary prescribing rights were extended to include the podiatry profession in 2005, but few podiatrists have taken on this role. At present, around just 120 UK podiatrists are qualified supplementary prescribers (Health Professions Council, 2010). With so few practising supplementary prescribers in podiatry, it is perhaps unsurprising that their impact – on the health service, patient care and, ultimately, outcomes – may be considered minimal. 

So what are the benefits of non-medical prescribing, and what value does it add to the health service? More specifically, how does supplementary prescribing improve outcomes in the management of people with long-term conditions, such as diabetes and diabetes-related complications of the foot?

Here, the authors offer various perspectives – that of the patient (Umberto Saoncella), the professor and physician (Philip Wiles) and the podiatrists (Louise Stuart, Martin Fox) – on the benefits of supplementary prescribing. In conclusion, Alan Borthwick looks at the possibilities of independent prescribing for podiatrists and projects currently under way to determine the best path forward.

Background
The vast majority of podiatrists access medicines for their patients via statutory exemptions, Patient Group Directions or rely on prescriptions written by medical colleagues. Those who have successfully undertaken the supplementary prescriber course can prescribe medicines for an individual within an agreed clinical management plan between reviews by the independent prescriber – most often a physician. Podiatrists are not yet able to prescribe independently, unlike appropriately qualified nurses and pharmacists (Department of Health, 2006).

The patient’s perspective
Umberto Saoncello has been receiving care for active Charcot foot disease and foot ulceration for the past 3 years in Manchester. During this time he has regularly attended the hospital-based multidisciplinary diabetic foot team, which includes a podiatrist supplementary prescriber. When asked to comment on his experiences he said:

“The diabetic foot clinic has been a beacon of hope for me over the past 3 years. Before being managed in the clinic, I struggled to obtain specialist care for my foot problems. In the past 2 years I have swiftly received antibiotics, prescribed by my podiatrist, as well as my diabetologist, when they have been needed.

“It seems logical to me as a patient that a podiatrist prescriber offers joined-up care. I fail to understand why, at the most important juncture of my care, the pen could be taken from the hand of the person who knows me best and thrust into the hand of another professional who, in some cases, may know little about my condition.

“I was dealt with competently, kept informed of all aspects of my care and had full confidence in the podiatrist prescribing for me. There was a totality of care given, not fragmented management. My GP was kept fully informed of my treatment and continued to prescribe in the community in line with advice given by the podiatrist and my diabetologist.

“I would argue that people with diabetes-related foot problems need more specialists able to prescribe medicines appropriately in all locations, not just hospitals. At times, my care – particularly outside of the hospital – has not been provided by those sufficiently knowledgeable or skilled to manage my foot problems.”

The professor’s perspective
Philip Wiles is Honorary Professor, University of Salford and a jobbing general diabetes consultant working in a large district general hospital diabetes centre. Having mentored and worked with both independent and supplementary prescribers, Philip had this to say on his experiences: 

“By far the greatest impact made by the introduction of supplementary prescribing at our hospital has been on the diabetic foot service. In that environment clinical problems are dynamic and the pace frequently frenetic, making non-medical prescribing completely practical. As a result, clinics run more smoothly and the patients leave for home more quickly. 

“Supplementary prescribing is underpinned by a robust governance process that applies structure and scrutiny to prescribing. Best practice has extended into the community, where I have seen a more rational approach to antibiotic prescribing in primary care settings as a consequence of contact with a prescribing podiatrist.

“Personally, I have benefited from the case discussions and the need to explain prescribing decisions. Supplementary prescribing has also released some of my time to spend on other aspects of patients’ general care and diabetes management.

“Podiatrists cannot, as yet, prescribe independently. Supplementary prescribing is fine within a clinic environment, but the lack of independence is a hindrance when trying to manage foot ulceration in the community. Neither my podiatry colleagues, nor our patients, have the luxury of time to waste. I look forward to the extension of full independent prescriber status to appropriately trained podiatrists.”

The prescribing podiatrists’ perspective
Louise Stuart MBE and Martin Fox describe the supplementary prescribing course for podiatrists as the most useful one they have undertaken since qualifying. If readers think that writing a prescription is the only benefit, they urge them to think again:

“Penning the prescription is the tip of the iceberg; we review medicines in every patient we see. This allows us to provide a safer, more informed and holistic service for people with diabetes-related foot complications. But apart from our anecdotal experiences, what evidence is there that supplementary podiatrist prescribers add value to the health service and improve patient experience and outcomes?

“In 2009, the North-West Allied Healthcare Professions Non-Medical Prescribing Network (AHP NMP) undertook an audit of allied healthcare professional prescribing practices. To the best of our knowledge, it is the largest audit of its kind. The aim was to assess the impact of supplementary prescribing on patient care.

“The AHP NMP audit revealed the immediate access to medicines provided by non-medical prescribing, with a prescription being drawn in 80% of all emergency appointments. The follow-on effect of this is the prompt treatment for the patient, the prevention of referrals and a cost saving to hospital-based emergency care that would otherwise have been engaged.

“The audit also revealed that a review of patients’ medicines took place in 97% of cases. The impact of the medicines review led to the recognition of sub-therapeutic doses and inappropriate regimens, which were subsequently red-flagged to independent prescribers. In one in ten cases the non-medical prescriber identified inappropriate repeat prescriptions, the correction of which would result in cost savings and a reduction in medicines waste.

“Few studies have critically examined the impact of non-medical prescribing and, in the absence of evidence, the effectiveness of prescribing is assessed by the surrogate, and less than ideal, measure of number of prescriptions issued. The assumption that the success of non-medical prescribing lies in the number of prescriptions written was refuted by the AHP NMP audit. There are multiple benefits to prescribing, not only in improved patient care but also in terms of ensuring the appropriate use of scarce NHS resources.”

Independent prescribing: The way forward?
In its report of July 2009, the Department of Health’s Allied Health Professions Prescribing and Medicines Supply Mechanisms Scoping Project recommended two additional implementation phases designed to enhance access to, and up-take of, non-medical prescribing across a range of allied healthcare professions. In February 2010, the Allied Healthcare Professions Medicines Project was established with a view to enacting the first of the two recommended phases and is presently preparing for public consultation on extending independent prescriber status to the podiatry and physiotherapy professions. Although there has been unavoidable uncertainty around the policy priorities of the new coalition Government, the work of the project continues apace.

As was the case in nursing, pharmacy and optometry, a range of prescribing activity options are being considered for podiatrists. Would limited prescribing within a set formulary be sufficient, or would freedom to prescribe where relevant be preferable? Might it be effective to prescribe within a limited range of conditions, or would this create more problems for patients than even the current system allows?

Answers to these, and related, questions will determine the case for independent prescribing status for the podiatry profession. As evidence grows that supplementary prescribing benefits patients, makes services more responsive and reduces the burden on GPs and hospital physicians, the case for independent prescribing for the podiatry profession will strengthen.

Department of Health (2006) Improving Patients’ Access to Medicines: A Guide to Implementing Nurse and Pharmacist Independent Prescribing within the NHS in England. DH, London
Department of Health (2009) Allied Health Professions Prescribing and Medicines Supply Mechanisms Scoping Project Report. DH, London
Health Professional Council (2010) Health Professional Council Podiatrist Register Data. HPC, London. Available at: www.hpc-uk.org (password protected)
North West Allied Health Professional Network (2009) North West Allied Health Professional Non-Medical Prescribing Audit.AHPN, Salford. Available at: www.ahpnw.nhs.uk (password protected)

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