R22 - Who can prescribe ?

What is independent prescribing?

Independent prescribing is when a qualified prescriber is responsible for:

• Assessing a patient.

• Diagnosing their condition.

• Deciding on appropriate treatment.

• Prescribing medicines.

The prescriber is fully responsible and accountable for their prescribing decisions.

Who can prescribe medicines independently?

Independent prescribers include:

• Doctors and dentists.

• Pharmacists.

• Nurses and midwives.

• Paramedics.

• Physiotherapists.

• Optometrists.

• Podiatrists.

• Therapeutic radiographers.

What is the difference between medical and non-medical independent prescribers?

• Medical prescribers: Doctors and dentists can prescribe on registration.

• Non-medical prescribers: Qualified healthcare professionals, such as pharmacists and nurses, who have the required prescribing training and authority.

What is a community practitioner nurse prescriber?

A specially trained nurse, such as a district nurse, health visitor or school nurse, who can prescribe from a limited formulary called the Nurse Prescribers' Formulary for Community Practitioners.

What is supplementary prescribing?

Supplementary prescribing is when a qualified non-medical prescriber prescribes medicines according to an agreed Clinical Management Plan (CMP).

The plan is agreed between:

• The independent prescriber (doctor or dentist).

• The supplementary prescriber.

• The patient.

Who can become a supplementary prescriber?

According to the lecture, eligible professions include:

• Pharmacists.

• Nurses and midwives.

• Physiotherapists.

• Paramedics.

• Podiatrists.

• Optometrists.

• Dietitians.

• Therapeutic and diagnostic radiographers.

The lecture identifies dietitians and diagnostic radiographers as professions that can undertake supplementary but not independent prescribing.

What is the main difference between independent and supplementary prescribing?

Independent prescribing (IP)	Supplementary prescribing (SP)
Prescriber assesses and makes treatment decisions independently	Prescriber follows an agreed CMP
Can assess diagnosed or undiagnosed conditions	Manages conditions covered by the CMP
Does not require a CMP	Requires a CMP
Prescriber is accountable for clinical decisions	SP is accountable for prescribing within the CMP

When is supplementary prescribing most appropriate?

Supplementary prescribing is particularly suitable for:

• Stable, long-term conditions.

• Patients requiring ongoing treatment.

• Situations where the independent and supplementary prescribers work closely together.

• Some circumstances involving controlled drugs or unlicensed medicines where independent prescribing is restricted.

It is not suitable for unplanned urgent or acute prescribing situations.

. What is a Clinical Management Plan (CMP)?

A CMP is an agreed, patient-specific plan that allows a supplementary prescriber to prescribe medicines for a particular condition.

It sets out which medicines can be prescribed and how the patient's treatment should be managed.

What information is included in a Clinical Management Plan?

A CMP includes:

• Patient details.

• Independent and supplementary prescriber details.

• Medical condition being treated.

• Aim of treatment.

• Medicines that can be prescribed.

• Dose schedules.

• Circumstances requiring referral back to the independent prescriber.

Why must the independent and supplementary prescribers have a close working relationship?

Because they need to:

• Communicate about the patient's treatment.

• Share access to clinical records.

• Monitor the patient's progress.

• Ensure prescribing follows the agreed CMP.

• Refer the patient back when necessary.

How would a supplementary prescriber prescribe an inhaler for a patient with stable asthma?

The lecture uses the example of Amelia, whose asthma is well-controlled but who is running out of her inhaler.

The supplementary prescriber should:

1. Check the patient's CMP.

2. Confirm the inhaler is included in the plan.

3. Check the prescribed strength, dose and frequency.

4. Confirm that treatment remains appropriate.

5. Write the prescription according to the CMP.

What is a Patient Specific Direction (PSD)?

A PSD is a written instruction from a prescriber allowing a medicine to be supplied or administered to a named patient.

The prescriber must have assessed the patient individually before issuing the direction.

When would a Patient Specific Direction be used?

Examples include:

• A hospital inpatient medication chart directing medicine administration.

• A GP authorising vaccination for named patients attending a clinic.

A PSD is appropriate when the patient has already been individually assessed by a prescriber.

What information must a PSD contain?

According to the lecture:

• Patient name or identifying details.

• Medicine name, form and strength.

• Route of administration.

• Dose.

• Frequency.

• Start and finish dates.

• Prescriber's signature.

What is a Patient Group Direction (PGD)?

A PGD is a written legal direction allowing authorised healthcare professionals to supply or administer specified medicines to a defined group of patients without an individual prescription.

Patients must meet the criteria stated in the PGD.

When can Patient Group Directions be used?

Examples include:

• Vaccination clinics.

• Community pharmacy services.

• Pharmacy First.

• Pharmacy Contraception Service.

• Minor injury units.

• Sexual health services.

PGDs are particularly suitable when patient assessment and treatment follow a predictable pattern.

Who can legally work under a PGD?

Healthcare professionals must:

• Belong to an eligible profession listed in the Human Medicines Regulations 2012.

• Be registered, trained and competent.

• Be individually authorised to work under that PGD.

• Be accountable for their decisions.

Eligible professionals include pharmacists and pharmacy technicians.

What information must a PGD contain?

A PGD must specify:

• Qualifications and training required for staff.

• Condition being treated.

• Inclusion and exclusion criteria.

• Medicine name, strength and formulation.

• Dose, route, frequency and duration.

• Contraindications, cautions and interactions.

• Possible adverse drug reactions.

• Patient advice and follow-up arrangements.

• Documentation requirements.

What is the difference between a PSD and a PGD?

Feature	PSD	PGD
Applies to	Named patient(s)	Defined group of eligible patients
Individual prescriber assessment first?	Yes	Not required
Written by	Authorised prescriber	Developed and authorised through a formal PGD process
Patient eligibility	Individually assessed	Must meet PGD criteria
Example	Named patient receiving a vaccination	Eligible patients receiving vaccination under a clinic PGD

Why should PGDs only be used when another suitable mechanism is unavailable?

Because individualised prescribing or a PSD is generally preferred.

PGDs should be used when they offer a safe and effective way to provide treatment without compromising patient safety.

They are not intended to replace individual prescribing unnecessarily.

How are PGDs used in the Pharmacy First service?

The lecture states that Pharmacy First covers seven clinical conditions, supported by 23 PGDs.

PGDs allow authorised pharmacists to supply prescription-only medicines to eligible patients following the relevant clinical pathway.

PGDs are not needed for medicines classified as Pharmacy (P) or General Sales List (GSL) when supplied through the usual legal routes.

What are the Human Medicines Regulations 2012 (HMR 2012)?

The Human Medicines Regulations 2012 are UK legislation governing the regulation, sale, supply and administration of human medicines.

They establish legal requirements for prescribing and other mechanisms for supplying prescription-only medicines.

What other legal mechanisms allow POM medicines to be supplied without an individual prescription?

The lecture identifies:

• Emergency supplies.

• Optometrist- or podiatrist-signed patient orders.

• Supply of salbutamol inhalers to schools.

• Supply of adrenaline auto-injectors to schools.

• Supply of naloxone by authorised organisations and healthcare professionals.

• Orthoptist exemptions for certain ocular medicines.

• Specific exemptions for the owner or master of a ship.

These are permitted under particular legal conditions.

How do you decide the most appropriate legal mechanism for supplying a POM?

Consider:

1. Clinical situation: Does the patient require individual assessment?

2. Professional role: Is the healthcare professional legally authorised?

3. Prescribing qualification: Can they prescribe independently or supplementarily?

4. Existing directions: Is there an appropriate PSD or PGD?

5. Legal exemptions: Does another provision of HMR 2012 apply?

Individual prescribing is generally preferred, followed by a PSD where appropriate. A PGD or another legal exemption may be used when suitable.

summary

Key term	Simple definition
IP	Prescribes independently and is accountable for treatment decisions
SP	Prescribes according to an agreed Clinical Management Plan
CMP	Patient-specific plan used in supplementary prescribing
PSD	Written direction for a named patient after individual assessment
PGD	Written direction for eligible patients meeting predefined criteria
POM	Prescription-only medicine
HMR 2012	Legislation governing human medicines
Clinical competence	Having the knowledge and skills to prescribe safely within your area of practice