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Health Policy 85 (2008) 277292

Review

Nurse and pharmacist supplementary prescribing

in the UKA thematic review of the literature
Richard Jason Cooper a, , Claire Anderson a , Tony Avery b , Paul Bissell c ,
Louise Guillaume c , Allen Hutchinson c , Veronica James e , Joanne Lymn e ,
Aileen McIntosh c , Elizabeth Murphy f , Julie Ratcliffe c , Sue Read c , Paul Ward d
b

a Division of Social Research in Medicines and Health, School of Pharmacy, The University of Nottingham, UK
School of Community Health Sciences, The University of Nottingham, University Park, Nottingham NG7 2RD, UK
c School of Health and Related Research, University of Shefeld, UK
d Flinders University, Adelaide, Australia
e School of Nursing, The University of Nottingham, UK
f School of Sociology and Social Policy, The University of Nottingham, UK

Abstract
Objectives: Supplementary prescribing (SP) represents a recent development in non-medical prescribing in the UK, involving a
tripartite agreement between independent medical prescriber, dependent prescriber and patient, enabling the dependent prescriber
to prescribe in accordance with a patient-specific clinical management plan (CMP). The aim in this paper is to review, thematically,
the literature on nurse and pharmacist SP, to inform further research, policy and education.
Methods: A review of the nursing and pharmacy SP literature from 1997 to 2007 was undertaken using searches of electronic
databases, grey literature and journal hand searches.
Results: Nurses and pharmacists were positive about SP but the medical profession were more critical and lacked awareness/understanding, according to the identified literature. SP was identified in many clinical settings but implementation barriers
emerged from the empirical and anecdotal literature, including funding problems, delays in practicing and obtaining prescription
pads, encumbering clinical management plans and access to records. Empirical studies were often methodological weaknesses
and under-evaluation of safety, economic analysis and patients experiences were identified in empirical studies. There was a
perception that nurse and pharmacist independent prescribing may supersede supplementary prescribing.
Conclusions: There is a need for additional research regarding SP and despite nurses and pharmacists enthusiasm, implementation issues, medical apathy and independent prescribing potentially undermine the success of SP.
2007 Elsevier Ireland Ltd. All rights reserved.
Keywords: Nurse; Pharmacist; Supplementary prescribing; Literature review; UK

Corresponding author. Tel.: +44 1142220683/7889 932626.

E-mail address: richard.cooper@nottingham.ac.uk (R.J. Cooper).

0168-8510/$ see front matter 2007 Elsevier Ireland Ltd. All rights reserved.
doi:10.1016/j.healthpol.2007.07.016

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R.J. Cooper et al. / Health Policy 85 (2008) 277292

Contents
1.
2.
3.
4.

5.
6.

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Objectives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Scope and method . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
4.1. Empirical research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
4.1.1. Practitioners perspectives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
4.1.2. Views of other healthcare professionals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
4.1.3. Patients and publics perspectives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
4.1.4. Professional relationships . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
4.1.5. Education and training . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
4.2. Anecdotal literature . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
4.3. Clinical applications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
4.4. Facilitators and barriers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
4.5. Independent prescribing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
4.6. Grey literature . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1. Introduction
Changes within healthcare in recent years have seen
a shift in the traditional roles undertaken by healthcare
professionals and one of the most significant of these
has been the development of non-medical prescribing.
Internationally, several healthcare systems now include
some form of prescribing by non-medical healthcare
professionals, offering potential benefits in terms of
increasing patients continuity of care and access to
medicines, better utilisation of economic and human
resources, reductions in patient waiting times and less
fragmentation of care [1]. The nursing and pharmacy
professions have been at the forefront of these prescribing changes and in the USA, for example, collaborative
prescribing by pharmacists and nurses has been possible since the 1970s and, in the United Kingdom
(UK), district nurses and health visitors have had limited prescribing rights since the late 1990s. A review
of the international pharmacist prescribing literature
identified predominantly US studies which reported
benefits such as improved compliance and disease control measures, fewer drug interactions, better allocation
of resources and economic saving [2], whilst a UK
nurse prescribing literature review identified generally
positive evaluations amongst both patients and nurse

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285
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prescribers but identified concerns involving pharmacological knowledge and limitations in prescribable
medicines [3].
Rapid changes within healthcare, though, have
meant that these reviews did not include more recent
non-medical prescribing models such as supplementary prescribing (SP). Introduced in the UK in 2003,
this model is a key part of the UK governments plans
to revolutionise the delivery of healthcare and offers
prescribing rights for several healthcare professions,
including nurses, pharmacists and, most recently, physiotherapists, radiographers and optometrists. SP is a
dependent model of prescribing, involving a tripartite
arrangement between the supplementary prescriber, an
independent prescribing doctor and the patient. Following an initial medical diagnosis, SP allows suitably
trained healthcare professionals to take prescribing
responsibility for patients in accordance with a specific clinical management plan (CMP) [4]. Such is the
pace of healthcare reforms in the UK that, as well as SP,
nurses and pharmacists can now also undertake independent prescribing (IP). Non-medical training in the
UK now involves, for nurses, a single post-graduate
independent, extended and supplementary prescribing
(IESP) qualification whilst pharmacists, at the time
of writing, complete either a SP or an IP conversion

R.J. Cooper et al. / Health Policy 85 (2008) 277292

course. Despite the development of IP, SP is intended to

have a central role in UK healthcare and is argued to be
particularly suited to the many patients who have stable,
long-term conditions such as cardiovascular disease
and diabetes. Safety is paramount in SP, by virtue of
continued medical supervision and the guidelines of the
CMP. Such safeguards have meant that SP can be from
a full medicines formulary, including controlled and
unlicensed drugs. There are around 1200 SP qualified
pharmacists (Personal communication, Royal Pharmaceutical Society of Great Britain 2007) and around
10,000 nurses qualified to undertake SP or IP [5].

2. Objectives
The aim in this paper is to review the extant literature
relating to nurse and pharmacist SP, given its importance to changing UK healthcare roles and National
Health Service (NHS) aims. Specific objectives were to
consider issues surrounding the implementation of SP
and how it has been perceived and experienced by various healthcare professionals and to describe relevant
empirical research relating to SP and identify where
additional research is needed. In so doing, it is hoped
that this review can inform further research and policy,
not only in the UK but also internationally.

3. Scope and method

The intention in this review is to consider both
empirical pharmacist and nurse SP research and also
opinion and commentary and the grey literature relating to SP. The reason for including such potentially
diverse literatures is due mainly to SP being a relatively
recent development with as associated lack of empirical
research, as previous non-medical prescribing reviews
have found [3]. Hence, a thematic rather than systematic review was considered most appropriate and
including the grey literature offered the opportunity not
only of identifying research that would not otherwise
be found (such as from conferences, non-peer reviewed
publications and commissioned and policy documents)
but also of considering more broadly how SP is perceived from the perspectives of the nursing, pharmacy
and medical professions. Searches were made of that
literature from 1997 to 2007 using combinations of

279

the following keywords: supplementary prescriber,

supplementary prescribing, nurs* and prescrib*,
pharmac* and prescrib*. These search criteria were
used to allow for the inclusion of papers on non-medical
prescribing more generally if these were relevant to SP,
especially since the IESP status of many UK nurses
means that research may have been undertaken using
such nurse samples without specific reference to SP.
Although SP was only introduced in 2003, the earlier
search date was used to allow for early consultation
or policy documents or reflection on the proposed use
of SP. Exclusion criteria included papers relating to
specific but non-supplementary forms of prescribing
such as patient group directions [3] and independent
prescribing. The following electronic databases were
searched: MEDLINE, EMBASE, CINAHL, ISI Web of
Knowledge and Zetoc. In addition, on-line searches of
The Pharmaceutical Journal, International Journal of
Pharmacy Practice, Journal of Clinical Nursing, Journal of Advanced Nursing, Nurse Prescriber, Nursing
Times and Department of Health websites were made.

4. Results
Thirty-five empirical research papers were identified: 20 relating to pharmacy [625] (Table 1 ), 15
nursing [2640] (Table 2) and 3 papers that concerned
both [4143] (Table 3). However, several publications
reported different aspects of one overall study and data
set [12,13,2931,37,38]. A further 25 nurse SP papers
and 5 pharmacist SP papers were identified offering
anecdotal opinions and experiences of SP practice. One
book was identified [44] and 20 policy documents and
a number of anonymous journalistic reports on SP in
publications such as The Pharmaceutical Journal and
Nursing Times. Several broad categories of literature
were identified: empirical research papers (from both
peer reviewed journals and the grey literature), anecdotal or opinion pieces, governmental and professional
body policy documents and general journalistic reporting on SP. It was apparent from this review that this is
still an area of healthcare in its infancy and the literature
was frequented by phrases such as rst wave, early
experiences and references to the potential of SP. The
results and emergent themes of the empirical research
papers identified are described first, before a consideration of other identified literature forms anecdotal and

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R.J. Cooper et al. / Health Policy 85 (2008) 277292

Table 1
Pharmacy supplementary (or relevant other) prescribing studies
Author(s)

Study aims/results

Method/sample

Candlish et al. [6]

SP pharmacist and barriers survey. 50% of pharmacists

practicing SP. Community a problem due to prescription pad
delays and IT issues. Most wanted to train and practice IP.
Hospital argued to be more conducive to SP due to existing
relationships, access to medical records and pads
Pilot study of pharmacists and mentors experiences of SP:
relationships, responsibilities and professional progression
were all emergent issues

Fifty-four pharmacists who had

completed SP training at one
university returned postal
questionnaire from sample of 107
(50%)
Three focus groups with total of 17
hospital pharmacists and
semi-structured interviews with 11
mentors
Questionnaire using convenience
sample of hospital doctors,
pharmacists and nurses in five UK
hospitals
Questionnaire using convenience
sample of hospital doctors in five UK
hospitals

Cassidy et al. [7]

Child et al. [8]

Few doctors or nurses had experienced pharmacist prescribing

but positive if training, communication skills, resources and
liability issues addressed

Child and Cantrill [9]

Doctors perceived barriers to pharmacist prescribing:

communication, pharmacists clinical/patient knowledge,
doctors initial prescription-writing and mechanisms for
treatment review
Nurses perceived pharmacist prescribing positively if training,
communication skills, resources and liability issues addressed

Child [10]

Dawoud et al. [11]

George et al. [12]

Pharmacists views after SP training courses: less

pharmacology and more examination, consultation training
needed. 88% perceived themselves already competent. 82%
foresaw SP problems in co-morbidity, 51% CMP difficulties,
and 48% thought pharmacists and not nurses most appropriate
to prescribe
SP pharmacists reported benefits as patient management, job
satisfaction and self-confidence but challenges due to lack of:
funding, IT support, awareness by others

George et al. [13]

Early experiences of SP pharmacists: only half trained SP

pharmacists actually practicing

Hobson and Sewell [14]

Implementation of SP in UK: more barriers to SP in primary

care SP, whereas secondary care SP formalising existing
practices

Hughes and McCann [15]

Perceived barriers between pharmacist and GPs: doctors

shopkeeper perception of pharmacists and issues of access,
hierarchies and lack of SP awareness were all inter-professional
barriers
Baseline survey of implementation of SP in PCTs revealed
perceived training issues, greater nurse SP due to existing
infrastructure and pragmatic uptake
Pharmacist stakeholders views on SP. Positive view of SP
emerged, but training and GP relationships an issue

Jackson [16]

Jones et al. [17]

Lloyd and Hughes [18]

Pharmacists and mentors views of SP: broadly welcomed by

both but issues of deskilling, IP threat, boundary encroachment
identified. Some pharmacists cautious about competency &
necessary relationships

One hundred and fifteen hospital

nurses from five UK hospital
completed questionnaire about
pharmacist prescribing
Thirty-five self-response
questionnaires returned from sample
of 41 (85%) first cohort pharmacists
from two universities

Four hundred and one questionnaire

responses from postal survey of all
488 (allowing for 30 pilot) UK SP
pharmacists (82.2%)
Four hundred and one questionnaire
responses from postal survey of all
518 (less 30 pilot) UK SP
pharmacists (82.2%)
Postal survey of pharmacists in PCTs
responsible for implementing SP (97
secondary, 187 primary care
responses)
Six focus groups involving 22 GPs
and 31 pharmacists from three areas
of Northern Ireland
One hundred and ninety two postal
questionnaire returned from sample
of all 302 UK PCTs (63.5%)
Semi-structured interviews with 14
stakeholders: SP trainee pharmacists,
education providers, policy makers
Nine focus groups involving SP
pharmacists and 35 semi-structured
interviews with medical mentors

R.J. Cooper et al. / Health Policy 85 (2008) 277292

281

Table 1 (Continued )
Author(s)

Study aims/results

Method/sample

Lloyd, McNally and Hughes [19]

Nurses saw pharmacists as most knowledgeable about

medicines but not best for prescribing. Pharmacist SP not a
threat to nursing but might de-skill doctors
Doctors had good relationships with pharmacists, agreed that
SP could reduce their workload and errors but were unaware of
SP and felt doctors best prescribers
SP pharmacists more likely than and doctors to comply with
guideline drug dosing for haemofiltration

Questionnaires completed by 205

from sample of 820 randomly
selected nurses in 11 UK hospitals
Questionnaire sent to all 516 junior
and senior house officers in 11 UK
hospitals. 115 responses
Retrospective analysis of medication
details of 145 ICU patients requiring
haemofiltration
Convenience sample of patients from
one UK SP hypertension clinic:
111/127 returned questionnaire
Thirty-eight pharmacists who had
completed SP training given postal
questionnaire and interviewed
Twenty-three semi-structured
pharmacist SP interviews and 5 case
studies involving interviews with 7
doctors, 5 pharmacists, 3 nurses, 10
patients and other staff
127/238 (53.4%) pharmacists from 5
PCT areas responded to self-report
postal questionnaire Postal
questionnaire survey

Lloyd, McHenry and Hughes [20]

Shulman and Jani [21]

Smalley [22]

Warchal et al. [23]

Weiss et al. [24]

While et al. [25]

Patients experiences of pharmacist-led SP included: better

understanding of their condition, better care and involvement in
their treatment
Pharmacists skills, challenge, patient and profession benefits all
reasons for taking SP course but access to records a barrier. IP
an eventual aim and a threat to SP
Pharmacists positive about SP as challenge and benefit for
patient but communication issues, clinical examination skills,
doctors and patients lack of awareness of SP and delays in
prescribing all concerns
Community pharmacists views on SP positive in increasing
knowledge, job satisfaction, patient benefits but time and
medical record access concerns

additional grey literature and broader themes such as

clinical applications, facilitators and barriers and IP.
4.1. Empirical research
A range of methodological approaches was found
in the empirical studies and although qualitative focus
groups, semi-structured interviews and observational
approaches were found, quantitative postal self-report
questionnaires were the most frequently used method.
Many of the quantitative studies involved convenience,
rather than randomised, samples from particular geographical locations such as health areas, NHS trusts or
individual hospitals and these methodological limitations were often recognised by authors as preventing
generalisations from being made and are considered
again in the discussion. Key themes to emerge from
the empirical research literature involved the differing
sample groups (nurses, pharmacists, other healthcare
professionals, patients), training and relationships, and
these are considered first, before describing the other
emergent themes, which overlapped somewhat more
with the anecdotal literature such as clinical applications, facilitators and barriers and IP.

4.1.1. Practitioners perspectives

The most common focus in empirical research concerned the experiences, perceptions and opinions of
either nurse or pharmacist SP practitioners or trainees,
often using self-report questionnaire methods. In the
pharmacy literature, George et al. [12] reported on the
early experiences of SP pharmacists and on the benefits and challenges to SP [13] using the same data from
a postal questionnaire sent to all UK SP pharmacists.
This was the only national survey of SP pharmacists
identified in this review. The studies by George et al.
identified themes that were recurrent in this literature
review such as prescribers confidence and increased
job satisfaction and independence and their perception
that patients were more satisfied and better managed
with SP arrangements. Pharmacists views were also
sought in a study in the grey literature by Weiss et al.
[24] which reported similar themes to those identified
above, in that SP pharmacists perceived many patient
benefits such as being able to spend more time with
patients and give more medicines information than doctors. Lloyd and Hughes [18] reported that a sample of
the first Northern Ireland pharmacist SP cohorts were
generally positive about SP as a professional devel-

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R.J. Cooper et al. / Health Policy 85 (2008) 277292

Table 2
Nurse supplementary (and relevant other) prescribing studies
Author(s)

Study description/results

Method

Avery et al. [26]

Doctors views on supervision of nurse prescribers:

positive impressions but concerns about
time/remuneration emerged. pre-existing nurse/doctor
relationships helped
Lecturers experiences of teaching nurse prescribing.
Concerns raised about selection criteria, pharmacology
knowledge and integrating SP to course.
Student/lecturer feedback needed
Attitudes and informational needs of public in relation
to nurse SP. Public had confidence of nurse SP but
wanted medicines information, esp. side effects
Preparing nurse prescribers to prescribe for
dermatological conditions: only 36.7% of nurses
practicing SP and specialist training considered
advantageous
Nurse prescribers confident in mentoring prescribing
students. Sample mostly primary care IP nurses with
degrees and >10 years experience, but few doing SP
Nurse prescribers practices and factors influencing and
inhibiting prescribing: IT access, CMP problems and
lack of access to continuing professional development
Directors positive about nurse SP but questioned
training and readiness of mentors. Perceived medical
acceptance
All broadly supportive of nurse SP but confused over
roles, implementation and disruption to team
functioning. Perception SP formalises existing hospital
practices
Perceptions and demographic details of mental health
nurses considering SP training

Structured telephone interviews with six hospital

doctors and six GPs

Bradley et al. [27]

Berry et al. [28]

Courtenay et al. [29]

Courtenay et al. [30]

Courtenay et al. [31]

Gray et al. [32]

Hay et al. [33]

Hemingway [34]

Hobson and Sewell [35]

James [36]

Jones [37]

Jones [38]

Jones et al. [39]

Skingsley et al. [40]

Implementation of SP. Nurse SP slower in secondary

care but many involved in primary care. No national
strategy
SP for hospital diabetic patients led to reduced waiting
times, less variability in healthcare professional seen by
patient. No errors were reported for 51 prescriptions
Potential reform of hospital psychiatric care using nurse
SP: nurses and psychiatrists positive about SP but new
partnerships and organisational change needed
SP nurse and psychiatrist relationships: new one
needed, based on mutual respect and task delegation.
Paradoxical nurse policing but medical control
perceived with SP
Service users thought nurses listened, gave medicines
info and allowed focus on collaboration; psychiatrics
felt less pressure and thought teams more
knowledgeable
Training mental health nurse prescribers about
neuropharmacology led to increased understanding and
confidence but that prescribing generally needed
existing skills such as communication and empathy

Qualitative semi-structured interviews with eight

lecturers from four HEI institutions

Questionnaires completed by convenience sample of

74 members of UK public (with no previous
experience of nurse prescribing)
868/1187 (73%) postal questionnaire responses
from convenience sample of IESP nurses

868/1187 (73%) postal questionnaire responses

from convenience sample of IESP nurses
868/1187 (73%) postal questionnaire responses
from convenience sample of IESP nurses
Postal questionnaire involving 45 NHS trust
directors of nursing in England, focusing upon SP in
psychiatric setting
Five focus groups with 46 clinical teams members:
22 nurses, 8 doctors, 8 occupational therapists, 6
psychologists and 2 social workers
Opportunistic sampling of 89 nurses (from a UK
conference and from universities providing SP
training)
Postal questionnaire of chief pharmacists in 186
primary and 97 secondary care settings
Convenience sample of 42 inpatients over 6 months
on one ward. 9 patient, 19 staff questionnaires
returned and some clinical glycaemic outcome
measures recorded
Six focus groups involving 19 nurses and 7
psychiatrists from one psychiatric hospital unit
Six focus groups involving 19 nurses and 7
psychiatrists from one psychiatric hospital unit

Unspecified interviews to elicit experiences of 11

mental health service users, 12 psychiatrists and 11
nurse prescribers regarding SP
Undisclosed method collected feedback from
undisclosed number of nurses completing
prescribing course

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283

Table 3
Nurse and pharmacist supplementary (and relevant other) prescribing studies
Author(s)

Study aims/results

Method

Buckley et al. [41]

Hospital stakeholders perspectives on nurse and

pharmacist prescribing: all broadly supportive
but nurses lacking pharmacology skills,
pharmacists diagnostic skills/patient knowledge

Hobson and Sewell [42]

Pharmacists perceived risks and concerns about

SP included training needs, competencies,
responsibilities and positive implementation
approach
CMPs should refer to protocols/guidelines and
have to be simple and quick else SP not worth
the effort. Remote relationships hard and need
access to electronic records. SP may not work
for patients with multiple carer/disease

Qualitative semi-structured interviews with

15 stakeholders doctors, nurses,
pharmacists, managers, directors in one
NHS trust in the secondary care, hospital
setting
Postal questionnaire of chief pharmacists in
primary and secondary care settings about
nurse and pharmacist SP

Department of Health [43] research

conducted by National
Prescribing Centre

opment but raised concerns that SP might limit their

professional autonomy.
Research involving nurse SP revealed similarly
positive perceptions of SP amongst nurse samples.
Courtenay et al. [29] using a postal questionnaire
method sent to a convenience sample of predominantly
primary care IESP trained nurses, reported that most
were confident in their prescribing but only a minority
actually practiced SP.
4.1.2. Views of other healthcare professionals
In contrast to nurses and pharmacists positive
responses to SP, the views of other healthcare professionals and doctors in particular revealed a more
qualified assent. An over-riding theme and concern in
many studies was that doctors appeared to be generally unaware of SP and although broadly positive
about SP, had a number of reservations relating to, for
example, the erosion of doctors traditional roles, professional hierarchies and safety. Commenting on nurse
prescribing generally, Avery et al. [26] reported that
medical mentors were generally positive about nurse
prescribing and supervision but already had a positive working relationship with nurses prior to training.
Doctors experience of CMPs varied and limited time
for mentoring and a lack of remuneration were identified as problems. Pharmacists medical mentors in
the study by Lloyd and Hughes [18] raised concerns
about medical deskilling and boundary encroachment
but argued that SP would allow them to retain ultimate
control as doctors. Other stakeholders were more pos-

Scoping study with undisclosed numbers of

pharmacists, nurses and doctors given
hypothetical cases to develop CMPs

itive, however, and Hobson and Sewell [42] noted that

primary care trust (PCT) pharmacists and hospital chief
pharmacists, for example, were positive overall about
pharmacist SP, despite some concerns about adequate
training, professional competency and responsibility.
Gray et al. [32] undertook a national postal questionnaire of all English directors of nursing to explore their
opinions on the early implementation of mental health
nurse SP and found that directors perceived psychiatrists to be positive overall about SP, despite a perceived
lack awareness of SP and concerns about psychiatrists
ability to mentor. Two studies in the grey literature
elicited the views of hospital nurses [19] and junior
and senior house officer doctors [20] and reported that
nurses and doctors had reservations about pharmacists
being the most appropriate healthcare professionals to
prescribe in the hospital setting. Nurses were more
accepting of pharmacist prescribing than doctors but, as
in other studies, doctors were often unaware of pharmacist prescribing. Hay et al. [33] explored attitudes
to nurse SP amongst various clinical team members
and reported that although there was overall support
for nurse SP, there was a perception that SP simply
formalised existing practices, that it might have a negative impact on the workload of other team members
and there appeared to be confusion about the role of SP
nurses in a clinical team.
4.1.3. Patients and publics perspectives
What was striking in this review was that very little research appeared to have been undertaken that

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explored the experiences and opinions of the actual

patient, despite SP being a tripartite arrangement
involving a doctor, either a nurse or pharmacist and
the patient. Weiss et al. [24] uniquely used a patient
advisory group to inform the overall research but also
undertook 15 patient observations and 10 patients interviews in specific case studies. The study reported that
patients struggled to identify benefits in pharmacist
SP but believed GPs workloads might be reduced
and many reported longer consultations and more
medicine information with the SP pharmacist. Significantly, patients were largely unaware of the CMP and
adequate consent to SP was often not obtained by their
doctor or pharmacist. In a small, single-centred retrospective study by Smalley [22], patients who had
attended a pharmacist SP hypertension clinic were
found to be positive about the service, reported being
more involved in their treatment, having a better understanding of their condition and receiving better care
from the pharmacist.
The views of the public were identified in one
nurse SP study involving a small convenience sample of the general public who had not experienced
SP [28]. It was reported that the majority of participants would have confidence in a nurse prescribing for
them and general rather than nurse-specific concerns
were cited such as whether the correct medicine and
dose had been prescribed and what side effects and
interactions may occur. The grey literature revealed a
qualitative study only partly reported by Jones et al.
[39] from the mental health setting that involved service
users together with nurses and psychiatrists involved in
their care. The authors argued that the results of their
study indicated that nurse SP was beneficial because
nurses offered a greater focus on collaboration and
treatment options, listened to concerns and provided
information.
4.1.4. Professional relationships
Linked to the emergent theme of research that
elicited the views of various healthcare professionals were a small number of studies that explicitly
explored the actual relationship between professionals
in the SP model. Several pharmacy studies indicated
that existing medical control and pharmacists subordination to doctors might be significant concerns
for non-medical prescribing. Hughes and McCann
[15], interviewing GPs and pharmacists, found that

many doctors considered community pharmacists to

be shopkeepers and believed pharmacist prescribing would threaten existing professional hierarchies.
These issues, together with doctors lack of awareness of SP and concerns about access to pharmacies,
were argued by the authors to be significant barriers
to closer and more effective inter-professional working relationships. Buckley et al. [41] interviewed NHS
trust stakeholders to consider the inter- and intraprofessionals issues surrounding nurse and pharmacist
prescribing generally. The authors argued that although
all the stakeholders doctors, nurses and pharmacists
viewed non-medical prescribing as a positive development, some doctors responses were professionally
defensive and suggestive of an inability to relinquish
medical control. Prescribing under protocol was preferred by many doctors and patient safety was often
cited as a reason not to allow non-medical prescribing but the authors questioned whether this differed
from junior doctors lack of pharmacological knowledge. Jones [38] identified a number of issues relating
to the relationship between nurses and psychiatrists and
argued that nurse SP was paradoxical in that whilst it
could be used to police the activities of junior doctors,
it enabled consultant psychiatrists to still have ultimate
control over delegated prescribing; the formation of a
new relationship, founded on the mutual respect of the
nurse and doctor and clear task delegation was argued
to be necessary.
4.1.5. Education and training
A theme that emerged from the empirical studies
identified concerned the adequacy of non-medical prescribing education, particularly in terms of the content
of the courses undertaken by nurses and pharmacists.
Several studies reported a perception amongst stakeholders that the skills of nurses and pharmacists were
different and that additional and profession-specific
training was needed, despite several universities offering courses that admitted students from different
professions and taught them together. Buckley et al.
[41], for example, observed that stakeholders perceived
nurses as having a lack of necessary pharmacological
knowledge and pharmacists, a lack of closeness and
knowledge of the patient. Dawoud et al. [11] noted
that an early cohort of pharmacists undertaking SP
training felt they were competent in pharmacology and
pharmacokinetics and hence wanted less of this in a

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course but more training involving the physical examination of patients and counselling. Hobson and Sewell
[42] reported several PCT and chief pharmacists views
that the lack of clinical assessment of nurse prescribing trainees was a concern, but not for pharmacists.
Although much of the nurse prescribing education literature identified was not specific to SP, two studies
referred specifically to this prescribing model. Bradley
et al. [27] focused upon the implementation of SP
on existing nurse prescribing courses at four institutions and interviewed lecturers, identifying themes
surrounding recruitment concerns, time limitations,
the CMP and a lack of pharmacological knowledge
amongst student nurses. Skingsley et al. [40] focused
on neuropharmacology training requirements for mental health nurse prescribers generally and reported that
nurses found it rewarding but challenging, especially
in relation to aspects of theory and scientific terminology. The authors noted, however, that the addition of
SP training might lead to increased nurse cohorts from
more varied clinical settings and questioned whether
the courses could cope with this increased demand and
variety.
4.2. Anecdotal literature
This review also identified a significant number of
anecdotal papers that reported on the authors experiences of SPmore often in nursing. Echoing other
studies in the review, authors appeared to be positive
and confident about their SP roles but identified several practical barriers. Allsop et al. [45] concluded that
nurse SP in the mental health hospital setting required
robust policies, effective relationships and the support
of other healthcare professionals to identify where SP
could benefit their work. Baird [46] identified problems
in community based SP with some GPs and pharmacists lack of understanding of SP, confusion over initial
patients diagnoses and co-morbidities leading to partprescribing, a concern also identified in other studies
[24]. Anecdotal pharmacist SP experiences and opinions were also positive in tone: Tomlin [47] noted that
hospital SP had been rewarding and successful but had
tended to formalise existing practices such as doctors
signing prescriptions pharmacists had already written;
Clayson and Evans [48] were similarly positive about
SP in their primary care pharmacy work and Elfellah
et al. [49] described the benefits of SP in adapting it

285

by using a generic CMP for cardiac patients discharge

from hospital.
4.3. Clinical applications
Perhaps reflecting the greater scale and speed with
which nurse SP was being undertaken compared to
pharmacist SP, the nursing literature contained more
examples of specific clinical areas where SP had been
implemented. In both empirical research and anecdotal papers, it appeared that SP by nurses was being
introduced in many areas of practice, both in primary
and secondary care. The most commonly identified
area of research involved mental health [37,38,45] but
literature relating to other clinical areas was identified, including renal services [50], rheumatology [51],
dermatology [52], epilepsy [53] and substance misuse
[54]. James [36] describing her methodologically limited study of diabetic inpatients, reported that patients
experienced less medication delays, less variation in
attending staff and increased liaison between SP nurse
and ward staff and no prescription errors. Burton [55]
described pharmacist SP in an asthma and allergy clinic
and Young et al. [56] reported on several clinical areas
in one hospital trust but noted that SP for patients has
often been opportunistic and had yet to have an impact
on the redeployment of medical resources. One pharmacy study significantly the only study identified in
this review that measured a specific clinical outcome
reported that hospital SP pharmacists were more likely
than doctors to adhere to haemofiltration drug dose
guidelines [21].
4.4. Facilitators and barriers
Two common and linked themes identified in both
the empirical and anecdotal literature involved opinions
about, and experiences of, the barriers and facilitators
to implementing SP. Facilitators identified included a
good pharmacistdoctor relationship linked to mutual
trust, according to pharmacists and doctors in the study
by Lloyd and Hughes [18], and communication along
with effective support from peers, doctors and organisations were important for mental health nurses [34].
Jones [37] noted that both nurses and psychiatrists
recognised the need for a re-assessment and strengthening of inter-professional relationships for effective
mental health SP.

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Barriers and facilitators were often antonymic and

Hay et al. [33], for example, cited clinical team members beliefs that existing communication issues could
be a barrier. Although concerned with pharmacist
prescribing generally, studies by Child and Cantrill
[9] involving doctors and Child et al. [8] involving doctors, nurses and pharmacists found that all
professionals reported possible barriers to pharmacists prescribing and listed training, communication,
accountability and resource issues. Other significant
barriers to the implementation of SP identified included
time and financial limitations, no primary care strategy or funding for SP [6,12], difficulty in accessing
patients medical records [13,17,23,46,57], unsuitability for patients with co-morbidities [24], problems
accessing continuing professional development materials for nurses [30] and perhaps the most frequently
cited barriera lack of awareness of SP amongst not
only other healthcare professionals but also patients
and the public.
Furthermore, a number of very specific problems
were identified in this review, perhaps due to the relatively large number of anecdotal papers identified.
These SP barriers arose in the minutiae of practice
for nurses and pharmacists and included issues such as
problems in obtaining prescription pads after qualification [13,31], a lack of access to IT to print prescriptions
[31,46], lack of administrative support to run SP clinics and long delays between training and prescribing
in practicea concern which Weiss et al. [24] argued
may lead to the need for re-training. The CMP was frequently criticised for its encumbering, time-consuming
and restrictive nature [13,23,24,46].
4.5. Independent prescribing
Although IP was not included as part of the review,
a number of papers were identified that made comparisons between SP and IP, either descriptively [59] or
in empirical findings. For the latter, opinions about the
models were mixed and sometimes conflicting. Lloyd
and Hughes [18], for example, reported that although
many pharmacists thought IP to be a natural extension of SP, some questioned whether they had sufficient
skills and doctors viewed IP negatively. Warchal et al.
[23] similarly identified a perception amongst SP pharmacists that IP was a logical step but although the
majority of sampled pharmacists intended to become

independent prescribers, concerns were raised as to the

acceptability of this prescribing model to the medical profession and whether a tactful approach which
retained the doctors initial diagnostic role could be
introduced. The link between SP and IP was also identified by George et al. [13] who noted that IP might
be more likely to be undertaken by pharmacists who
were already practicing SP, due to an increase in confidence [12], and that this might also have implications
for training. These authors also noted that IP might
have a further advantage in not requiring a CMP and
problems related to its time-consuming and inflexible
nature. In the palliative care setting, Kinley et al. [58]
argued that as the prescribing formulary for extended
independent nurses opened up, SP may be a retrograde
step compared to IP because it retained links to medical
paternalism and precluded nurse responsibility.
4.6. Grey literature
A number of papers were identified in the grey literature and these could be divided into three broad types.
Firstly, there were publications from official bodies
such as the Department of Health, the National Prescribing Centre or the governing bodies of the nursing
(NMC) and pharmacy professions (RPSGB) that provided formal and often detailed information about how
SP would be implemented and controlled. Examples
included formal documents relating to the implementation of SP [2], non-medical prescribing summaries
[59], educational requirements, competency frameworks and resources for assessing SP practice [60].
RPSGB publications included briefing papers, commissioned research [24] and a conference report on the
early progress of pharmacist SP, which identified many
of the issues described in this review [61]. Identifying
issues that have already been described in this review,
the National Prescribing Centre undertook a practical
scoping study, wherein nurses, pharmacists and doctors
simulated SP for a number of hypothetical patients [62].
The study reported that the CMP needed to be simple
and quick to use, IT access was important and concluded that if patients have multiple health needs, or
multiple carers, SP might not work at all. The National
Prescribing Centre also undertook a questionnaire survey of non-medical prescribers and reported numerous
support and training needs [62]. One further report was
identified involving the implementation of pharmacist

R.J. Cooper et al. / Health Policy 85 (2008) 277292

SP in one area [63]: successes were reported in providing support for SP pharmacists, initiating local projects
and developing relationships with stakeholders but barriers identified in the use and design of the CMP, lack
of doctors and even some community pharmacists
awareness/understanding of SP, personnel changes and
implementation.
Secondly, there were several reports of SP in the
nurse and pharmacy press such as the Nursing Times
and the Pharmaceutical Journal and these were often
either positive in tone (see Pharmaceutical Journal
2003:270;1927 passim) or simply offered journalistic
reportage on SP developments. Thirdly, and in contrast, a number of articles were identified in the medical
and general press that were more critical of SP. The
medical practitioner publication Pulse, for example,
although reserving most criticism for IP, referred to SP
as a controversial plan that ignored doctors concerns
about increased workload, safety and funding [64].
Several opinion pieces were also identified that offered
medical opinion on non-medical prescribing generally
and these were often conservative and critical in tone.
Avery and Pringle [65], for example, noted that nonmedical prescribing and especially the proposals for
IP could be valuable initiatives but only if safeguards
such as training and access to appropriate IT were in
place and quality research used to monitor developments (see also [66]). Horton [67] argued that nurse
prescribing could offer valuable benefits but political
expediency may see it introduced too rapidly, without
attention being given to the scope of prescribing and
safety. Arguing that nurses were being manipulated
to fill workforce shortages and echoing arguments
advanced by McCartney et al. [68] in relation to cost
and labour savings the pace of nurse prescribing
was, he argued, reckless and amounted to an dangerous uncontrolled experiment. Croskerry [69], writing
about Canadian pharmacists prescribing rights generally, argued that patient safety would be compromised
by pharmacist prescribing and that pharmacists may be
especially vulnerable to commercial influences from
the pharmaceutical industry.

5. Discussion
A descriptive analysis of the SP literature reveals a
trend that SP nurse and pharmacist practitioners were

287

positive and generally confident about SP and that it has

been successfully implemented in a range of clinical
setting in the UK. However, other healthcare professionals and especially doctors appeared more qualified
in their assent and also lacked awareness of SP and a
range of implementation barriers and challenges were
also identified. However, a critical analysis of the emergent literature and themes indicates additional concerns
relating to the methodological quality and focus of
the extant empirical research and the emergence of a
number of underlying tensions and differences. These
concerns are argued to have significant implications for
further research and policy, respectively.
In terms of methodology, this review frequently
identified small-scale studies with non-randomised
convenience samples from geographically specific
sites, which may make generalisations difficult and
which may limit the interpretation of results. Although
this review included the grey literature, and hence
included some studies that may have been subject to
less thorough peer review, the identification of methodologically limited quantitative studies is disappointing
since this was also identified in previous non-medical
prescribing literature reviews [2,3]. In addition, many
of the studies identified focused upon the experiences
and opinions of SP practitioners and stakeholders and
three key research areas appear to have been underevaluated. Firstly, very little research was identified that
explored either the opinions or experiences of patients
using SP services. It is both striking and strange that
research concerning a healthcare development such
as SP that not only involves the patient directly
but was also introduced, at least in part, to benet
the patient should have ignored this group. Secondly, this review reveals an almost complete absence
of research concerning the economic or NHS cost
implications of SPone study [24] did contain an
economic commentary but no actual economic modelling or data. Economic aspects of prescribing have
become increasingly important in healthcare systems
with finite resources and increasing medicine costs
and can offer important data in relation to the costs
of training and funding, together with prescribing
trends and costs. Although it was previously difficult to compare medical and non-medical prescribing
due to different formularies in the UK, SP nurses and
pharmacists can now prescribe most medicines and
prescribing analysis and cost (PACT) data in the UK

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is also available for these groups. Thirdly, no literature was identified that addressed issues relating to
patient safety, despite concerns having being raised
that non-medical prescribing must address this issue.
Indeed, concerns about the methodological limitations
of non-medical prescribing research together a lack
of research involving economic, safety or governance
measures has been central to many of the academic
critiques of SP [67,69,70]. These authors have used
the lack of available data to argue that at the level of
policy, SP should be undertaken more cautiously. Commenting on nurse prescribing research, Barrett [71]
argues that unless additional research is undertaken
and data obtained that can support the clinical effectiveness of nurse prescribing, it will remain acutely
susceptible to the criticism that it is simply a politically motivated exercise in cost and workforce savings
[67,70]. Hence, methodologically robust research that
focuses upon key concerns such as patient safety and
economic outcomes is urgently needed to inform the
implementation of SP in the light of such criticism.
One further and striking omission was the absence of
any theoretical insights, through which SP research
and practice could be informed. Although one book
(for non-medical prescribing students) was identified

which included the sociology and psychology of prescribing [44], no research was identified that drew upon
or developed theory. Subsequent research should consider and use relevant theory, given the benefits that
theory can offer to healthcare and associated research
[72] and the relevance of SP to concepts such as boundary encroachment, power, reprofessionalisation and the
division of labour in healthcare.
In addition to these methodological concerns and
research omissions, several underlying tensions and
differences emerged thematically (Table 4) and these
must be addressed if SP is to be a success as a healthcare
initiative and which have a range of policy implications.
Firstly, differences between nurses and pharmacists
emerged, especially in relation to their SP training
and this has implications for educational policy. In
particular, as more higher education institutions offer
inter-professional admission to SP and IP courses, the
question of how professions different training needs
can be addressed is a concern. Secondly, SP appears to
be less problematic in the hospital setting, where existing practices have been formalised by SP and closer
working relationships between professionals already
exist. The primary and community care settings represent more of a problem for implementing SP and may

Table 4
Tensions and differences amongst supplementary prescribing themes
Differences/tensions

Implications for policy

Pharmacists and nursesDiffering training needs and existing

competencies but little empirical research identified that sampled
and compared nurses and pharmacists

Educational reviews may be needed, especially due to

increasing numbers of inter-professional non-medical
prescribing courses. Research needed to compare
nurse/pharmacist prescribing
Barriers to application of SP in primary care setting must be
addressed. May be harder for those working in non-hospital
settings (midwives and community pharmacists) to use SP

Primary and secondary careSP easier to implement in secondary

care, hospital settings where it formalises existing practice whereas
primary care has issues of record access, developing independent
and dependent prescriber relationships
SP and IPWhilst SP was perceived to be safer than IP and permitted
controlled drugs, it was considered less flexible and an
introductory/transitional prescribing model
Government aims and actual practiceDespite anticipated
time-saving and safety features, aspects of SP such as the CMP
might be time-consuming, restrictive and inflexible. Implementation
barriers undermine attempts to roll-out SP successfully

Medical and non-medical professionalsNurses and pharmacists

positive accounts of SP contrasted with doctors less positive views
on SP and overall lack of awareness and understanding

Will SP be viewed as a transitional prescribing model and of

value only in appeasing the medical profession or providing
newly qualified non-medical prescribers with prescribing
confidence prior to IP?
Could SP and in particular the CMP be reviewed to make it less
cumbersome and time-consuming? At local policy level,
ensuring adequate funding and removing simple barriers such
as prescription pad delays and access to computers needed.
Nationally, plans for electronic patient record and role based
access must be implemented
At local and national policy levels, more needed to raise the
profile of SP amongst medical profession

R.J. Cooper et al. / Health Policy 85 (2008) 277292

also limit specific groups undertaking SP such as midwives and community pharmacists, who may not have
ready access to patient records and lack close links
to medical prescribers. Thirdly, governmental aims of
SP have not been matched by the actual practice. For
example, whilst the safeguards of the CMP and continued medical involvement were intended to make SP a
safe model, they appear to have had negative practical
consequences. SP emerged as being time-consuming
and the CMP an inflexible and cumbersome procedural step and hence, in relation to policy, a review of the
format of the CMP may be necessary, to make it more
flexible and quicker to set-up and use. Local funding
problems and failure to commission non-medical prescribing posts at a local level and especially in primary
care are a further practical failing which undermine the
original aims of SP. Fourthly, the relationship between
SP and IP may be problematic and with the introduction
of nurse and pharmacist IP in 2006, SP might come to
represent merely an introductory or transitional prescribing model, allowing nurses and pharmacists to
gain prescribing confidence, and that IP would be an
eventual goalmeaning less involvement from doctors and more clinical and professional autonomy for
nurses and pharmacists. This may have significant policy implications for the commissioning and funding of
non-medical prescribing services. Fifthly, differences
emerged in terms of how medical and non-medical
professionals viewed SP and there was less support
and awareness of SP amongst doctors. This leads to
policy questions as to how to raise the profile of SP
amongst the medical profession and at what level. This
may require not only more advertising of the model
and its potential benefits to the medical profession (in
terms of reducing workloads and emphasising safety
aspects such as retaining the initial medical diagnosis and ongoing medical control within the medically
negotiated limits of the CMP) but also, perhaps, to
financial incentives and more local initiatives to facilitate SP uptake [63].
There are also a number of international policy
implications from this review, despite SP being a
unique UK prescribing initiative, and this review may
be relevant to existing dependent or collaborative prescribing models but also healthcare systems planning
non-medical prescribing. Firstly, although the standardised nature of SP and the CMP nationally in the UK
offers consistency and procedural certainty, this review

289

indicates that this may come at the expense of flexibility

and ease of use. This may be contrasted with protocol
and collaborative prescribing models [1], for example,
which utilise local and hence more variable but flexible procedures and indicates that a balance must be
struck between flexibility and procedural consistency.
A more beneficial feature of SP is the requirement that
non-medical prescribers undertake additional accredited training and this offers additional safeguards in
terms of ensuring a certain level of competency, in
contrast to collaborative or protocol prescribing, for
example, which may only have institutional or state
levels of competency assessment or even require a doctor to make such an assessment. However, this review
indicates that were such a nationally accredited scheme
introduced, sufficient attention should be given to the
differing educational and pharmacological needs of different professions, a problem made only more acute by
the increasing range of allied health professionals who
may train for SP. Unfortunately, aspects of SP such as
the explicit inclusion of the patient in the SP arrangement have not been evaluated and so it is not possible
to comment on whether SP represents a more inclusive
prescribing arrangement that involves the patient.
This review offers insights for other healthcare systems considering non-medical prescribing and will
offer reassurance in that the service is valued by
nurses and pharmacists and can be applied to various clinical setting in both hospital and community,
but raises concern in the issues relating to implementation barriers and medical apathy. The relationship and
tension between SP and IP may also inform international healthcare policy by questioning why a SP model
should be introduced if IP is an aspiration of nonmedical prescribers and is also less time-consuming
and more flexible.
This review contains a number of limitations and,
in particular, it must be recognised that no systematic review of empirical studies was attempted and so
the inclusion criteria and methodological assessment
of empirical studies was not undertaken in accordance
with recognised review procedures. Furthermore, this
review focused upon the UK healthcare system, the
NHS, and this is a unique government and taxpayer
funded service with devolved local commissioning of
services, which is not representative of many healthcare systems internationally. Hence, emergent themes
such as SP funding barriers may be difficult to com-

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pare internationally, despite being a policy concern at

local level. Finally, this review was conducted at a time
of significant change in the UK and the full impact of
IP or the qualification of allied health professionals as
supplementary prescribers, for example, could not be
considered in this review.

6. Conclusions
This review of the SP literature has revealed that SP
is a model of non-medical prescribing that, although
welcomed by non-medical professionals, faces a number of challenges. Some relate to implementation
barriers that may be resolved at a local policy level but
others such as the development of IP and the apathy
of the medical profession, represent more significant
threats to the success of this prescribing initiative.
Further research is urgently needed in this area of
rapid change in healthcare, to address issues relating
to safety, costs and patients experiences and so help
underpin healthcare policy.

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