The complex challenge of prescribing as an advanced clinical practice physiotherapist

The complexity of the UK advanced clinical practitioner role

Within the UK, advanced clinical practitioner (ACP) roles are open to all professionally-registered health care staff aligned to clinical areas where there is a demonstratable need for advanced practice input. This includes advanced paediatric critical care practitioners (APCCP) (Morris and Fortune, 2022). As part of this role, skills to assess, diagnose and treat children in critical care are developed and honed, with close input from consultant intensivists and university education. Practitioners are expected to successfully complete the v300 non-medical prescribing (NMP) course, which leads to annotation as a prescriber on the relevant professional regulatory register.

Globally, NMP has developed rapidly to allow several registered professions to prescribe medications. Each country holds its own legal context of prescribing, alongside professional regulations. Nations which permit forms of non-medical prescribing include the US, UK, Canada, Netherlands, New Zealand, Australia, Sweden, Norway, Ireland, Denmark, Finland, Cyprus, Poland, Spain, Estonia, France and Switzerland (Weeks et al, 2016; Maier, 2019). This list is not exhaustive, and many more countries are reviewing policies to allow more professions the right to become non-medical prescribers.

British laws around NMP have been developing since the 1990s and have progressed rapidly in the last decade to include several allied health professionals (AHPs), as well as nurses and pharmacists (Cope et al, 2016). As a Health and Care Professions Council (HCPC) registrant and physiotherapist, the rights to prescribe medicine as an adjunct to care are underpinned by key laws outlined by the Chartered Society of Physiotherapy (CSP) (CSP, 2018a), and are intrinsically linked to the protected title of physiotherapist. Each HCPC-regulated profession has different prescribing rights (HCPC, 2023). Legally, physiotherapists can independently prescribe seven controlled drugs (CDs) (Table 1) via specified routes of administration (CSP, 2018b; HCPC, 2023). Additional caution must be taken to the specifics of ‘injection’ and ‘infusion’ routes. These terms are not interchangeable and represent different modes of administration.

The Medicines and Healthcare Products Regulatory Agency (MHRA) have clarified, in legal terms, that injections involve the breaching of skin and administration of single or multiple doses, whereas ‘infusion’ involves continuous administration (intravenous, intrathecal, continuous syringe drivers, intraspinal or epidural administration) (CSP, 2022). As such, physiotherapy prescribers, irrespective of role or job, are not legally allowed to independently prescribe controlled drugs for administration via these routes. It is also worth noting that not all HCPC registrants can prescribe CDs independently, and no HCPC registrants can independently prescribe unlicenced medication (HCPC, 2021; Pharmaceutical Services Negotiating Committee (PSNC), 2022).

Often, higher education institutions (HEIs) offer NMP education to multiple professional groups, working in a wide variety of clinical settings together. These courses are individually appraised and approved by the NMC, HCPC and General Pharmaceutical Council depending on the student groups who will access them. The NMP course outlines the vast area of pharmacy, applying key differences to practice, namely around independent (IP) and supplementary (SP) prescribing. As an IP, clinicians are responsible and accountable for assessment, diagnosis, and subsequent treatment decisions, which may include a prescription for a person (Montgomery et al, 2020). A SP works in partnership with a patient (parents/guardian) and IP (who must be a doctor or dentist) to formulate an agreed plan of treatment documented in a bespoke, patient-specific clinical management plan (CMP) (HCPC, 2021; HCPC, 2023). Both IP and SP annotations are registrable on the associated professional register upon completion of the V300 course for most professions; dieticians and diagnostic radiographers can only practice as SP at this time (HCPC, 2023).

Prescribing complexities in paediatric intensive care

Cases within the paediatric intensive care unit (PICU) are complex, with multi-system involvement, often with respiratory or cardio-vascular instability, requiring close monitoring from the multi-disciplinary team (MDT). Regardless of previous professional background, within the APCCP training, the scope of practice and educational development is rooted in the pathophysiology and management of multi-organ conditions such as cardiac disorders, postoperative care, respiratory disease and neurocritical care, as well as skills to locate and place intravascular (IV) access and advanced paediatric life support (APLS) for managing cardio-respiratory deterioration. An example of this skill acquisition is the rapid sequence induction for intubation using fentanyl, ketamine or sequential midazolam or IV morphine.

Here, the ability to prescribe and administer medication make up an aspect of a skilled task for endotracheal intubation. Medical registrars and APCCPs have competencies for these practices, however, the APCCP with HCPC registration is unable to prescribe the full remit of required drugs for this practice (APLS, 2017; CSP, 2018a). Alternatively, an APCCP who is a registered nurse, can prescribe schedule 2–5 CDs and unlicensed medicines (PSNC, 2022; Joint Formulary Committee (JFC), 2023a; JFC, 2023b). This presents the HCPC APCCP with a unique problem, which can be source of professional frustration and inequality among team members.

Status epilepticus (SE), with worsening seizure symptoms, is common in PICU. Often, the escalation of anti-epileptic drugs (AEDs) is required, as per the SE algorithm (Bacon et al, 2021). However, combinations of specific legislation—such as the Misuse of Drugs Act (1971), the Misuse of Drugs Regulations (2001) and the Human Medicines Regulations (2012)— restricts HCPC members prescribing rights to certain CDs, two of which, Lorazepam and Diazepam by oral administration (CSP, 2018a), are included in the entitlements but not via the correct route of administration as per the SE guidance, requiring IV or rectal, respectively.

In this situation, if the APCCP wishes to prescribe, they would need to employ supplementary prescribing and formally enter the SP process with a medical IP and the patient/guardian. In situations where prescribing needs can be anticipated and planned for, this may be a realistic solution; however, complexity is seen in dealing with emergency or rapidly evolving situations, which may move past the parameters of the agreed CMP.

In addition, in PICU, prescribing unlicensed or licensed medicines off-label is common due to the way in which medicines are licenced and the limited research trials into the medicines used specifically in paediatric populations. Thus, significant proportions of medicines used lack authorisation from Medicines and Healthcare products Regulatory Agency (Medicines for Children, 2020). Therefore, it could be argued that HCPC NMPs, being competent, confident and practiced in SP, may be intrinsic to current APCCP practice.

Discussion

The complexity and distinctions between the underpinning of professional registration of the ACP, and the legal context of prescribing, appears to be not well understood in practice. There is a risk of professional confusion, which could unintentionally set practitioners apart or place challenges on service provision, as two practitioners with the same defined role, scope of practice, education and skills, may not be able to manage and support the same prescribing activity and patient needs. The HCPC ACP, with the same prescribing education and professional annotations, may have to revert to asking medical colleagues to assess, diagnose and prescribe appropriate medication. This is in opposition to the purpose of ACP roles and NMP, which was to alleviate the workload of the medical staff (Graham-Clarke et al, 2019), and to provide better and more responsive care to patients.

Although most clinicians who have completed NMP education successfully continue to prescribe within their role (Maddox et al, 2016), the emergence of new, advancing roles are evolving in response to increased need for efficient and effective delivery of health and care services (HEE, 2018). While many registrants from many professional groups can undertake ACP education and roles, legal constraints and variation across professions hold back equality within the MDT.

The Royal Pharmaceutical Society (RPS) (2021) competency framework for all prescribers forms the basis of NMP education, and all clinicians—irrespective of professional background—must achieve the same competencies. Standards for prescribing education set by the NMC and HCPC (2018) are upheld by HEIs admission criteria, and all echo each other in that clinicians must have prerequisite skills aligned to their scope of practice prior to undertaking the NMP course. Therefore, it seems outdated to limit the scope of practice for HCPC registrants who have undertaken the same ACP and NMP education, as their NMC registered peers.

That said, significant progress has been made regarding the inclusion of CDs for some HCPC registrant prescribing rights, and it is hoped that legal reforms are underway to expand the prescribing rights of some HCPC registrants to include CDs.

Conclusion

Ultimately, the RPS (2021) framework serves as a basis for developing practice, but also as a tool for future-proofing practitioners such as AHPs. As illustrated with the development of rights from the initial restrictive formularies in the 1990s-early 2000s, NMP's entitlements grew to include scheduled and unlicensed medicines; the subsequent quick inclusion of AHPs in 2015 and 2018 could herald a succession of provisions for HCPC registrants in the future (Graham-Clarke et al, 2019), which would be vital for equality between new APCCP roles and enable fluid team work within the PICU (Morris and Fortune, 2022). The question remains, which will come first, legislative change for HCPC registrant or a new professional regulatory body for all ACPs, which will encompass equally the abilities of the generic NMP course? For now, the author is having to co-assess and assign prescriptions with staff while on shift, as plans are drawn up with consultants and Trust pharmacists to use supplementary prescribing or patient group directives as they are able.

KEY POINTS

CPD / Reflective Questions