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Independent
and
Supplementary
Prescribing
at a Glance

Edited by
Barry Hill
Aby Mitchell

WlLEY Blackwell
Independent and
Supplementary
Prescribing
at a Glance
Independent and
Supplementary
Prescribing
at a Glance
Edited by
Barry Hill
MSc Advanced Practice (ANP), PGC Academic
Practice (PGCAP), BSc (Hons) Critical Care,
DipHE/OA Dip Counselling Skills, Senior Fellow
(SFHEA), Teaching English as a Foreign
Language (TEFL), NMC Registered Nurse (RN),
NMC Registered Teacher (TCH), NMC
Registered Independent Prescriber (V300)
Director of Education (Employability),
Programme Leader and Senior Lecturer,
Northumbria University, Newcastle, UK

Aby Mitchell
RGN, BA (Hons), MSc Advanced Practice
(Healthcare Education), PGCAP, FHEA
Professional Lead for Simulation and
Immersive Technologies, Senior Lecturer Adult
Nursing, University of West London, London, UK

Series Editor: Ian Peate

This edition first published 2023
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Contents

Contributors vii
Preface x

Part 1 Prescribing 1
1 Scope of Practice NMP 2
2 Professional, legal, and ethical issues 4
3 Independent and supplementary prescribing 6
4 Community practitioner nurse prescriber (V150/V100) 8
5 Critical thinking and clinical reasoning 10
6 Exploring interventions 12
7 Evidence-­based diagnosis 14
8 Referring to other members of the multidisciplinary team 16
9 Clinical management plans 18

Part 2 Consideration of non-­pharmacological and pharmacological interventions 21

10 Non-­pharmacological approaches 22
11 Pharmacological treatment options 24
12 Prescribing reference guides 26
13 Medication selection 28
14 How to prescribe 30
15 Risk benefit assessment 32
16 Pharmacodynamics 34
17 Pharmacokinetics 36
18 Holistic assessment 38
19 Quality of life 40
20 Evidence-­based practice 42
21 Medicines and public health 44
22 Infection prevention and control 46

Part 3 Advanced history taking and examination 49

23 Consultation models 50
24 Principles of history taking and physical examination skills 52
25 Preparation for objective structured clinical examination 54
26 History taking for patients who lack mental capacity 58
27 Prescribing and the mental capacity act 60
28 Skin history taking and physical examination 62
29 Neurological history taking and physical examination 64
30 Head, ears, eyes, nose, and throat 66
31 Lymph node assessment 68
32 Endocrine history taking and physical examination 70
33 Respiratory 72
 34 Cardiovascular history taking and physical examination 74
35 Abdominal history taking and physical examination for non-­medical prescribers 76
36 Genitourinary system history taking and physical examination 78
37 Musculoskeletal history taking and physical examination 80

Part 4 Shared Decision-making 83

38 Equality, diversity, and inclusion 84
39 Concordance 86
40 Building relationships 88
41 Inclusive prescribing and informed choices 90
42 Medicine’s optimisation 92
43 Social prescribing 94

Part 5 Prescribing Practice 97

44 Adverse drug reactions 98
45 Frameworks and guidelines 100
46 Prescribing generic products 102
47 Medication calculations 104
48 Non-­medical authorisation of blood components 106
49 Electronic prescribing 108

Part 6 Patient education and health promotion 111

50 Unlicensed medicines 112
51 Record-­keeping and data management 114
52 Adherence 116
53 Patients recognising deterioration 118
54 Patients’ responsibility and self-­management 120

References 122
Index 129

vi
 Contributors
Clare Allabyrne Chapter 26
Associate Professor and Programme Lead in Advanced
Clinical Practice (Mental Health)
London South Bank University, London, UK
Emma L. Bennett Chapters 41, 47
Advanced Critical Care Practitioner (FICM Member)
University Hospital of Wales, Cardiff, UK
Jill Bentley Chapters 14, 21, 49
Lecturer in Advanced Clinical Practice, Non-Medical
Prescribing and Adult Nursing, and Advanced Critical Care
Practitioner (FICM member), Salford Royal Foundation
Trust, Mancester, UK
Sebastian Birch Chapter 27
CAMHS Clinical Nurse Specialist and Senior Lecturer
in Mental Health Nursing University of Roehampton,
London, UK
Roberta Borg Chapter 24
Advanced Critical Care Practitioner (FICM Member)
Hampshire Hospitals NHS Foundation Trust, Hampshire, UK
Joanne Brown Chapter 32
Endocrine Clinical Nurse Specialist
Stockport NHS Foundation Trust, Society for Endocrinology
Early Career Steering Committee and Nurse Committee
Member, England, UK
Ashton Burden-Selvaraj Chapters 34, 35
Trainee Advanced Critical Care Practitioner and Collaborator
Equality, Diversity and Inclusion Working Group
Intensive Care Society, London, UK
Edward Chaplin Chapter 26
Director
Head of the Scientific Committee
European Association for Mental Health in Intellectual
Disability,
London South Bank University, London, UK
Clare Cooper Chapters 6, 15
Advanced Clinical Practitioner and Senior Lecturer
Advanced Practice
University of Northampton, Northampton, UK
ISTUDY fbetw.indd 7
Sian Cooper Chapter 25
Advanced Clinical Practitioner (ACP) in Psychiatry
NHS foundation trust
Manchester, England, UK
Elizabeth Cray Chapter 19
Neurosurgical Advanced Clinical Practitioner
University Hospital Plymouth, Plymouth, UK
Anne Davidson Chapter 48
Education Lead
Patient Blood Management Practitioner Team
NHS Blood and Transplant, Newcastle, UK
Jo Delrée Chapter 26
Associate Professor and Head of Division
Mental Health and Learning Disability Nursing
Institute of Health and Social Care
London South Bank University, London, UK
Simon Ross Deveau Chapter 44
Advanced Clinical Practitioner and Nurse
Visiting Specialist University of Plymouth
Torbay Hospital, Torquay, UK
Sadie Diamond-Fox Chapters 5, 7, 23, 24, 25, 48
Assistant Professor in Advanced Clinical Practice (ACP) &
ACP Lead (Fellow HEA)
Advanced Critical Care Practitioner (FICM Member)
Regional Advancing Practice Supervision and
Assessment Lead
Northumbria University Newcastle, UK
Newcastle upon Tyne Hospitals, UK
Health Education England, UK
Peter Dryden Chapter 46
Assistant Professor
Department of Nursing, Midwifery and Health
Northumbria University, Newcastle, UK
Laura Elliott Chapters 28, 53
Advanced Clinical Practitioner and Senior Lecturer
Advanced Practice
University of Northampton, Northampton, UK
vii
06-02-2023 07:38:22
 Karen Elton Chapter 46
Assistant Professor and Programme Leader,
Senior Fellow (HEA)
Northumbria University, Newcastle, UK
Annette Hand Chapters 3, 9, 12
Assistant Professor of Nursing (Clinical Academic)
Northumbria University and Newcastle upon Tyne
Hospitals NHS Foundation Trust, Newcastle, UK
Hayley Hassett Chapter 42
Senior Lecturer in Non-Medical Prescribing
University of Hertfordshire (Fellow - HEA),
Hertfordshire, UK
Colette Henderson Chapter 18
Programme Lead in MSc Advanced Practice and Deputy
Programme Lead for Non-Medical Prescribing
University of Dundee, Dundee, UK
Barry Hill Chapters 1, 16, 17, 29, 30
Director of Education (Employability), Programme Leader
and Assistant Professor
Northumbria University, Newcastle, UK
Lynne Hughes Chapter 22
Senior Lecturer in Adult Nursing
University of Northampton, Northampton, UK
Tim Kuhn Chapter 34
Advanced Critical Care Practitioner (FICM Member) and
Senior Lead Nurse
Critical Care and Critical Care Outreach Team, Croydon
University Hospital, London, UK
Dorothy Kupara Chapters 45, 51, 54
Senior Lecturer and Course Leader for Learning Disabilities
Nursing, HEA Fellow University of West London,
London, UK
Hazel McPhillips Chapters 8, 38, 40
Lecturer
School of Health and Social Care
Edinburgh Napier University, Edinburgh, UK
Aby Mitchell Chapters 2, 39, 43, 52
Professional Lead for Simulation and Immersive
Technologies and Senior Lecturer in Adult Nursing
University of West London, London, UK
Tichaona Mubaira Chapter 11
Clinical Nurse Specialist in CRHTT West
Berkshire Healthcare Foundation Trust;
Associate Lecturer
University of West London, London, UK
viii
ISTUDY fbetw.indd 8
Kevin Murphy Chapter 4
Programme Lead for the Higher Apprenticeship in
Specialist Practice District Nursing (HASPDN) and
Assistant Professor in Adult Nursing (Fellow - HEA)
Northumbria University
Reuben Pearce Chapter 11
Nurse Consultant in Crisis Resolution and Home Treatment
Services
Berkshire Healthcare NHS Foundation Trust;
Associate Lecturer
University of West London, London, UK
Sam Pearson Chapters 10, 19
Non-Medical Prescribing Programme Lead and Senior
Lecturer in Pharmacy Practice
Edge Hill University, Ormskirk, UK
Ollie Phipps Chapter 50
Senior Lecturer and Course Director for Non-Medical
Prescribing
Canterbury Christ Church University;
Advanced Clinical Practitioner
Maidstone and Tunbridge Wells NHS Trust, Wells, UK
Jaclyn Proctor Chapter 20
Senior Clinical Practice
Edge Hill University Medical School;
Respiratory or Acute Medicine Advanced Clinical
Practitioner and Non-Medical Prescriber Lancashire, UK
Claire Pryor Chapters 3, 9, 12
Subject Lead for Non-Medical Prescribing, Programme
Lead and Assistant Professor
Northumbria University, Newcastle, UK
Christina Rawlinson Chapter 25
Advanced Clinical Practitioner (ACP) in Psychiatry,
NHS foundation trust, Mancester, England, UK
Anosha Sirpath Chapter 36
Senior Lecturer
Course Leader or Module Leader for Independent and
Supplementary Prescribing, Fellow - HEA
University of West London, London UK
Sonya Stone Chapter 35
Assistant Professor of Advanced Clinical Practice
(Advanced Clinical Practitioner)
Faculty of Intensive Care Medicine (FICM)
Clinical Lead for eICM,
School of Health Sciences,
University of Nottingham,
Nottingham, UK
21-02-2023 12:39:52
Maureen Wallymahmed Chapter 20 Lisa Williams Chapter 13
Programme Lead for Non-Medical Prescribing Advanced Clinical Practitioner
and Senior Clinical Practice Rotherham Foundation Trust (TRFT)
Edge Hill University, Ormskirk, UK Hospital at Night, England, UK

Joe Wood Chapter 33

Nicola Weston Chapter 31
Advanced Critical Care Practitioner, Physiotherapist, and
Advanced Critical Care Practitioner
Point of Care Ultrasound Educator
(FICM Member)
Medway NHS Foundation Trust, Gillingham, UK
Department of Critical Care
University Hospitals Sussex NHS Foundation Trust
Nick Worth Chapter 37
Brighton, UK
North West Faculty for Advancing Practice HEE and
Lecturer Non-Medical Prescribing
John Wilkinson Chapter 23 University of Salford;
Anaesthetics Registrar Fellow of the Society of Musculoskeletal Medicine
Northern Deanery, UK England, UK
 Preface
R
egistered nurses, registered midwives, physician associates,
and healthcare professionals who want to become an inde-
pendent prescriber within the United Kingdom (UK) must
successfully complete a Nursing and Midwifery Council (NMC)
or Health and Care Professions Council (HCPC) approved post-­
registration prescribing programme in order to meet the standards
of proficiency necessary for an annotation to be made against an
entry onto their professional register. Independent prescribers are
practitioners responsible and accountable for the assessment of
patients with previously undiagnosed or diagnosed conditions and
for decisions about the clinical management required, including
prescribing. They are recommended to prescribe generically,
except where this would not be clinically appropriate or where
there is no approved non-­proprietary name.
Written by healthcare academics, this book provides an essen-
tial practical and theoretical resource for healthcare students
related to independent and supplementary prescribing. Each part
of this book is mapped against a recognised prescribing frame-
work published by the Royal Pharmaceutical Society (RPS) for all
registered healthcare professionals. This will be the newest and
most up-­to-­date book of its kind in the UK aimed at those study-
ing independent prescribing practice. This is the only book to
address independent prescribing for all permitted healthcare pro-
fessionals based on the RPS Prescribing Framework using litera-
ture from 2021 and addressing NMC and HCPC regulatory body
requirements. This book is at a glance and it makes for the practis-
ing clinician; being only 150 pages, it is the perfect size for busy
healthcare professionals. The snapshot figures and key points
make this book accessible, appealing to a variety of learning styles,
x
and focused for busy healthcare professionals. Literature
informing the book comes from the RPS and Royal College of
Nursing (RCN) Guidance on Prescribing, Dispensing, Supplying
and Administration of Medicines (2020), and RCN and RPS
Professional Guidance on the Administration of Medicines in
Healthcare Settings (2019), and has adopted the RPS Prescribing
Competency Framework as well as the NMC’s standards of com-
petency for prescribing practice. Each chapter is written in a for-
mat that will enable the reader to review the chapter as a complete
unit, and therefore the reader can choose in which order they wish
to read the book.
A multitude of professional bodies have updated guidance on
undergraduate and postgraduate education programmes prepar-
ing students to become prescriber-­ready. The NMC updated future
nurse pre-­registration programme standards, standards for nurses,
standards for midwives, standards for nursing associates, and
standards for post-­registration programmes. Additionally, the
HCPC now advocates the guidance for the same framework mean-
ing that all registered healthcare professionals can use a UK stand-
ard of practice and this book facilitates the key points at a glance.
This book follows the current at-­a-­glance series and provides
information in a concise and comprehensive manner, which will
engage readers by including full-­colour images and graphics, as
well as accurate and useful information, and a user-­friendly over-
view of key prescribing topics utilising prescribing competency
frameworks. The book is also available in a range of formats,
including e-­book, to increase accessibility.
Barry Hill and Aby Mitchell
Prescribing Part 1

Chapters
1 Scope of Practice NMP 2
2 Professional, legal, and ethical issues 4
3 Independent and supplementary prescribing 6
4 Community practitioner nurse prescriber
(V150/V100) 8
5 Critical thinking and clinical reasoning 10
6 Exploring interventions 12
7 Evidence-­based diagnosis 14
8 Referring to other members of the
multidisciplinary team 16
9 Clinical management plans 18
 Scope of Practice NMP
2

1
Part 1 Prescribing

Table 1.1 Who can become an NMP in the United Kingdom. Source: Based on HEE.1

Independent and Supplementary Community practitioner

supplementary prescribers prescribers only prescribers

• Nurses/midwives • Diagnostic Nurses (health visitors

• Pharmacists radiographers and district nurses)
• Physiotherapists • Dieticians
• Podiatrists
• Paramedics
• Optometrists
• Therapeutic radiographers

Table 1.2 A summary of what NMPs can prescribe. Source: RCN / Royal College of Nursing.5

Independent prescriber Supplementary prescriber

CDs Yes – Schedule 2–5 CDs, except Yes – Schedule 2–5 CDs,
diamorphine, dipipanone,or cocaine for except diamorphine,
treatment of addiction dipipanone, or cocaine for
treatment of addiction

Unlicensed Yes – provided they are competent and Yes – covered by the Clinical
medicines take responsibility for doing so.May vary Management Plan (CMP)
for nurse prescribers in Scotland

Off-­label/off-­licence Yes – should only be prescribed where it is Yes – covered by the CMP
prescribing best practice to do so andmust take full
clinical and professional responsibility for
their prescribing

Private prescribing Yes – for any medicine within their Yes – for any medicine
competence covered by the CMP

Non-­Medical Prescribing (NMP) Royal Pharmaceutical Society (RPS)

Doctors are by far the largest group of prescribers, who, along with
dentists, can prescribe on registration. They have been joined by inde-
pendent and supplementary prescribers from a range of other non-­
medical healthcare professions, who are able to prescribe within their
scope of practice once they have completed an approved education
programme. This extension of prescribing responsibilities to other
professional groups is likely to continue where it is safe to do so and
where there is a clear patient benefit. NMP is the term used to describe
any prescribing completed by a healthcare professional other than a
doctor or dentist.1 Non-­medical prescribers (NMPs) include nurses,
midwives, and pharmacists, as well as other allied healthcare profes-
sionals who have completed an accredited prescribing course and reg-
istered their qualification with their regulatory body (Table 1.1). This
enables them to prescribe medications as either community practi-
tioner nurse prescribers (with a v150 or v100 course) or independent
prescribers (with a v200 or v300 course) (Table 1.2).
In January 2019, the RPS and the Royal College of Nursing
(RCN) co-­created Professional Guidance on the Administration
of Medicines in Healthcare Settings.2 The guidance was devel-
oped in response to the announcement of the withdrawal of the
Standards for medicines management by the Nursing and
Midwifery Council (NMC) and will be hosted on the RPS and
RCN websites. Application of this guidance is a multidiscipli-
nary responsibility. All staff groups involved in the administra-
tion of medicines should be involved in developing organisational
policies and procedures. In addition to corporate and clinical
governance responsibilities, registered healthcare professionals
are personally responsible for putting patients first and for a
commitment to ethics, values, principles, and improvement.
They are also responsible for practising within their own scope
and competence, using their acquired knowledge, skills, and
judgement.

Independent and Supplementary Prescribing at a Glance, First Edition. Edited by Barry Hill and Aby Mitchell.
© 2023 John Wiley & Sons Ltd. Published 2023 by John Wiley & Sons Ltd.
Scope of practice
The Health and Care Professions Council (HCPC) (2020) identifies
3
scope of practice as the activities a healthcare professional carries
out within their professional role. The healthcare professional must
have the required training, knowledge, skills, and experience to
deliver these activities lawfully, safely, and effectively. They must also
have appropriate indemnity cover for their prescribing role. Scope of
practice may be informed by regulatory standards, the professional
body’s position, employer guidance, guidance from other relevant
organisations, and the individual’s professional judgement.
The benefits of NMP
NMP has demonstrated patient care and economic benefits.
Consequently, investing in NMP is seen as ‘an investment to save,’
and encouraging NMP capacity is seen as a vital upskilling priority
and features as a key enabler in the planning and delivery of new
care models and transforming care. NMP training can support
role and career development by enabling practitioners to take on
greater responsibilities for managing patient care. NMP enhances
patient care by supporting patients’ timely access to treatment with
medicines, enabling choice while helping to reduce waiting times
and hospital admissions and maximising the wider skills of the
healthcare team.
NMP healthcare professionals
The British National Formulary (BNF) and the National Institute
for Health and Care Excellence (NICE) (2021)4 identify that to
protect patient safety, the initial prescribing and supply of medi-
cines prescribed should normally remain separate functions per-
formed by separate healthcare professionals. However, there are
several situations whereby simultaneous prescribing and adminis-
tration or supply are required of the same practitioner, such as in
the context of emergency situations.
Registered nurses
Nurse independent prescribers (formerly known as extended for-
mulary nurse prescribers) can prescribe any medicine for any
medical condition. Unlicensed medicines are excluded from the
Nurse Prescribing Formulary in Scotland. Nurse independent pre-
scribers can prescribe, administer, and give directions for the
administration of Schedule 2, 3, 4, and 5 Controlled Drugs (CDs).
This extends to diamorphine hydrochloride, dipipanone, or
cocaine for treating organic disease or injury, but not for treating
addiction. Nurse independent prescribers must work within their
own level of professional competence and expertise.
Pharmacists
Pharmacist independent prescribers can prescribe any medicine
for any medical condition. This includes unlicensed medicines
subject to accepted clinical good practice. They can also prescribe,
administer, and give directions for the administration of Schedule
2, 3, 4, and 5 CDs. This extends to diamorphine hydrochloride,
dipipanone, or cocaine for treating organic disease or injury, but
not for treating addiction. Pharmacist independent prescribers
must work within their own level of professional competence and
expertise.
Physiotherapists
Physiotherapist independent prescribers can prescribe any medicine
for any medical condition. This includes ‘off-­label’ medicines subject
to accepted clinical good practice. They are also allowed to prescribe
the following CDs: oral or injectable morphine, transdermal fentanyl
and oral diazepam, dihydrocodeine tartrate, lorazepam, oxycodone
3
hydrochloride, or temazepam. Physiotherapist independent prescrib-
Chapter 1 Scope of Practice NMP
ers must work within their own level of professional competence and
expertise.
Therapeutic radiographers
Therapeutic radiographer independent prescribers can prescribe
any medicine for any medical condition. This includes ‘off-­label’
medicines subject to accepted clinical good practice. Prescribing
of CDs is subject to legislative changes. Therapeutic radiographer
independent prescribers must work within their own level of pro-
fessional competence and expertise.
Optometrists
Optometrist independent prescribers can prescribe any licensed
medicine for ocular conditions affecting the eye and the tissues
surrounding the eye, except CDs or medicines for parenteral
administration. They must work within their own level of profes-
sional competence and expertise.
Podiatrists
Podiatrist independent prescribers can prescribe any medicine for
any medical condition. This includes ‘off-­label’ medicines subject
to accepted clinical good practice. They are also allowed to
­prescribe the following CDs for oral administration: diazepam,
­dihydrocodeine tartrate, lorazepam, and temazepam. Podiatrist
independent prescribers must work within their own level of
­professional competence and expertise.
Paramedics
Paramedic independent prescribers can prescribe any medicine
for any medical condition. This includes ‘off-­label’ medicines
­subject to accepted clinical good practice. Prescribing of CDs is
subject to legislative changes. Paramedic independent prescribers
must work within their own level of professional competence and
expertise.
Prescribing supervisor
The prescribing supervisor is an independent supervisor who com-
pletes assessment and teaching in practice (previously known as a
designated medical practitioner). The practice supervisor (PS) is a
colleague in practice who must be able to provide guidance and
supervision for your practice-­based learning while you are on the
course. The PS must be someone with whom you normally work,
and they must meet specific criteria as outlined by the higher edu-
cation institution. Support for the PS role is provided by the univer-
sity NMP course leads and NMP leads in organisations.
Following completion of an NMP course
The newly qualified NMP must:
•• Register with the relevant regulator, i.e. GPhC, NMC, or HCPC.
•• Provide confirmation to their employers of their successful
annotation.
•• Complete any other local/employer requirements, e.g. scope of
practice/formulary.
•• Ensure they have appropriate indemnity arrangements.
•• Maintain competence and undertake annual continuing p ­ rofessional
development and revalidation as specified by their regulator.
•• Ensure they have appropriate support to undertake their
­prescribing role.
 Professional, legal, and ethical issues
4
2
Part 1 Prescribing
Table 2.1 Legal, professional, and regulatory frameworks. Source: Adapted from Nuttall, 2020.
Legislation
Prescription-­Only-­Medicines
(POMs) (Human Use) Orders
1997 and Subsequent
Statutory Instruments
Misuse of Drugs Act 1971
Misuse of Drugs
Regulations 2001
Human Medicines
Regulations 2012
Human Medicines
(Amendment)
Regulations 2018
Table 2.2 Prescribing governance
The patient
Circumstances and current
medication
Past medical history
Current and anticipated
health status
Table 2.3 The British Pharmacological Society’s 10 principles of good prescribing – 2021. Source: Adapted from The British Pharmacological
Society, 2021.
Be clear about the reasons for
prescribing
Consider the patient’s medication
history before prescribing
Consider factors that might alter the
benefits and risks of treatment
Consider the patient’s ideas,
concerns, and expectations
Select effective, safe, and cost-­
effective medicines
Adhere to national guidelines and
local formularies where appropriate
Ensure prescriptions are written on
the correct documentation
Monitor the beneficial and adverse
effects
Communicate and document
prescribing decisions and rationale
Prescribe within the limitations of
your knowledge, skills, and
experience
Independent and Supplementary Prescribing at a Glance, First Edition. Edited by Barry Hill and Aby Mitchell.
© 2023 John Wiley & Sons Ltd. Published 2023 by John Wiley & Sons Ltd.
Professional Regulatory
NMC (http://www.nmc-­uk.org) Medicines and Healthcare products
Regulatory Agency (http://www.mhra.
gov.uk)
General Pharmaceutical Council (http://www.pharmacyregulation.org) Drugs and Therapeutics Committees
Health and Care Professions Council
(http:///www.hcpc-­uk.org)
General Optical Council’s Standards of Practice for Optometrists and
Dispensing Opticians 2016 (http://www.optical.org)
UK Law for Medicines (https://www.gov.uk/guidance/eu-­guidance-­
documents-­referred-­to-­in-­the-­human-­medicines-­regulations-­2012#:
~:text=The%202020%20Regulations%20have%20been,and%20
advertising%3B%20and%20for%20pharmacovigilance.)
Prescribing practice
A thorough knowledge of the medicine to be prescribed, its therapeutic action, side effects, and interaction
Current patient medication and any potential interactions with new medications
A thorough knowledge of alternatives to prescribing
Previous drugs the patient has taken and full medical history
Frequency of the use of drug and dosage, adherence to current medications, and patient’s perception of health
Prescribers should establish an accurate diagnosis whenever possible and be clear what the patient is
likely to gain from the prescribed medicines
Obtain a list of current and recent medications
Ask the patient/carer about any over-­the-­counter medications, adverse drug reactions, and drug allergies
Consider individual factors, e.g. physiological changes with age, pregnancy, or impaired kidney, liver, or
heart function
Values-­based prescribing is a collaborative approach to prescribing whereby the practitioner takes into
account the wishes, values and principles of the patient when prescribing medication
Consider if the effect of medicines outweighs the extent of potential harms
Review published evidence
Choose the best formulation, dose, frequency, route of administration, and duration of treatment
Select medicines with regard to cost and needs of other patients (healthcare resources are finite)
Access and use reliable and validated sources of information, e.g. The British National Formulary
Be aware of common factors that cause medication errors and how to mitigate risk factors
Identify how beneficial and adverse effects can be assessed
Understand how to alter prescriptions because of information
Knowledge of how to report adverse drug reactions (via the Yellow Card scheme)
Communicate effectively with patients, carers, and colleagues
Use the health record to document prescribing decisions accurately
Be prepared to seek advice and support
Make sure appropriate prescriptions are checked
T
he United Kingdom (UK) prescribing law is ever changing;
therefore, it is important that prescribers consistently update
their knowledge of legislation. There are several legal,
professional, and regulatory frameworks to support prescribing
practice (see Table 2.1). For prescribers, the virtues of openness,
transparency, and duty of candour are imperative and hence these
should be embedded into clinical practice.
All prescribers are required to work within their own professional
boundaries and standards of conduct to provide high-­quality health-
care. Nurse prescribers’ practice is grounded by the professional code
of practice that guides the prescribing with rules and standards. The
introduction of the Royal Pharmaceutical Society (RPS) Prescribing
Competency Framework 2016 has ensured that high standards are
maintained and that capabilities are synonymous between disciplines.
Prescribing accountability is coincident with the components of ‘gov-
ernance’ and prescribers are held accountable for assuring quality
standards are met on the delivery of care. The Nursing and Midwifery
Council (NMC) recognises clinical governance is essential to continu-
ously improve quality and maintain standards of care. Nurse prescrib-
ers practise autonomously within the code of the ethical principles of
non-­maleficence, deontology, and paternalism. Prescribing demands
a higher degree of professional responsibility and accountability
ensuring that the prescriber is responsible for someone or something
and willing to take the consequences of actions or inactions.
Prescribing governance
The RPS Prescribing Competency Framework is structured in two
key domains, i.e. prescribing governance and the consultation
with the patient at the centre. Prescribing governance refers to pre-
scribing safely and focuses on the need to reduce risk and maintain
patient safety. As part of the role, nurse prescribers are expected to
work at an advanced clinical level demonstrating competence in
professional prescribing with evidence of accountability for clini-
cal decisions within legal, professional, and professional bounda-
ries. Legal and professional accountability requires prescribers to
provide a rationale for prescribing for:
•• What is prescribed?
•• When are over-­the-­counter products recommended?
•• When are decisions made not to prescribe or recommend a
product?
In addition, prescribers are expected to have knowledge and 5
competence in patient assessment within certain contexts (see
Table 2.2).
Chapter 2 Professional, legal, and ethical issues
To appropriately prescribe, it is essential that prescribers have a
good knowledge and understanding of pharmacology in relation
to the drugs prescribed; this includes:
Pharmacokinetics and pharmacodynamics: Pharmacokinetics
involves the changes in the serum concentration of a drug in the
body over a set period of time. Absorption, distribution, metabo-
lism, and excretion of the drug bring this about. The last two pro-
cesses also account for the elimination of the drug from the body.
Pharmacodynamics is the term to describe what a drug does to the
body, including therapeutic and adverse effects.
Safety and efficacy remain the key objectives for prescribing.
All prescribes are required to work within the boundaries of their
own standards of conduct and scope of practice. In gaining a pre-
scribing qualification, a practitioner must be fully conversant with
their codes of practice. Prescribers must:
•• Only prescribe within their scope of practice and recognise own
limitations in knowledge and skill.
•• Have a good understanding about common types of medication
errors and how to prevent and avoid these.
•• Identify potential risks associated with remote prescribing,
e.g. over the telephone/by a third party, and minimise risk
factors.
•• Develop and adhere to the process that supports safe prescrib-
ing practice, e.g. transfer of information and repeat prescriptions.
•• Keep up to date with prescribing practice and be aware of
emerging safety concerns relevant to prescribing.
•• Report prescribing errors, near misses, and critical incidences,
and review to prevent recurrence.
In order to ensure safe prescribing and the effective use of med-
icines, all practice should be underpinned by the principles pro-
vided in Table 2.3.
The prescriber must inform the patient: what to expect when
taking the medicine and how to take it; the duration of time they
will be on the medication and what effects and improvements they
are likely to see; and the efficacy of the medication and any
­precautions or likely side effects.
 Independent and supplementary
6

3
Part 1 Prescribing

prescribing
Table 3.1 Prescribing rights and medicines entitlements by profession

Profession Governing body Supplementary Independent prescriber, Independent prescriber,

prescriber excluding controlled drugs including some controlled drugs

Nurse NMC √ √

Midwife NMC √ √

Chiropodist/podiatrist HCPC √ √

Dietitian HCPC √

Paramedic HCPC √ √

Physiotherapist HCPC √ √

Diagnostic radiographer HCPC √

Therapeutic radiographer HCPC √ √

Figure 3.1 The supplementary prescribing partnership Table 3.2 Comparison of supplementary prescribing
and independent prescribing roles and responsibilities

Prescriber type
Named
Independent Supplementary Independent
Prescriber
Accountable for x √
patient initial
assessment and
diagnosis

Assess the As part of the CMP √

patient

Make a diagnosis x √
Patient
Specific CMP Prescribe √ √

Types of Any medication or class of Any that are

medication that medications within the permitted by
can be prescribed agreed CMP and permitted professional
Named
Named by professional relevant relevant legislation
Supplementary
Patient legislation
Prescriber

Independent and Supplementary Prescribing at a Glance, First Edition. Edited by Barry Hill and Aby Mitchell.
© 2023 John Wiley & Sons Ltd. Published 2023 by John Wiley & Sons Ltd.
 Clinical management plans
18

9
Part 1 Prescribing

Figure 9.1 Part complete CMP example. NOT FOR Figure 9.2 Part complete CMP example. NOT FOR
DUPLICATION (full co-­terminus access to patient records) DUPLICATION (where the SP and IP do not have co-­terminus
Patient Name Medication allergies/sensitivities
access to the medical records)
Patient Name Medication allergies/sensitivities
Additional Patient Identification: Date of birth/hospital or NHS number
Patient ID: D.O.B Additional Patient Identification: Date of birth/hospital or NHS number
Independent Prescriber (IP) Supplementary Prescriber (SP) Patient ID: D.O.B
Independent Prescriber (IP) Supplementary Prescriber (SP)
Condition or conditions to treat Aim of treatment

Medication Currently taken Medical history

Details of medications that can be prescribed by the Supplementary Prescriber
Preparation Indication Dose schedule/parameters Indications for
(e.g.) (e.g.) (e.g.) referral back to IP
Condition or conditions to treat Aim of treatment
for review
(e.g.) xxxxxxxxxxxx xxxxxx
Details of medications that can be prescribed by the SP

Preparation Indication Dose schedule/parameters Indications for

referral back to IP
Xxxxx Xxxxxxxxx Xxxxxxxxxxxx for review
Xxxxxxx Xxxxxxxxx Xxxxxxxxxx Xxxxxx
xxxxxx xxxxxxxxx Xxxxxxxxxxx Xxxxxx
xxxxxxxxx xxxxxx
Specific Guidelines or protocols supporting the Clinical Management Plan

Specific guidelines or protocols supporting the CMP

Monitoring and review frequency
Supplementary Prescriber Independent Prescriber & Supplementary
(e.g.) Prescriber (e.g.)
Monitoring and review frequency
SP IP
Process for reporting Adverse Drug Reactions (e.g.)
XXXXXX XXXXX

Process for reporting Adverse Drug Reactions

Details of shared record systems to be used by IP and SP

Details of shared record systems to be used by IP and SP

Agreement
Independent Date Supplementary Date Patient/carer Date
Agreement
Prescriber Prescriber
Independent Date Supplementary Date Patient/carer Date
11/08/2021 11/08/2021 12/08/2021 Prescriber Prescriber

11/08/2021 11/08/2021 12/08/2021

Independent and Supplementary Prescribing at a Glance, First Edition. Edited by Barry Hill and Aby Mitchell.
© 2023 John Wiley & Sons Ltd. Published 2023 by John Wiley & Sons Ltd.
T
his chapter should be read in conjunction with Chapter 3:
Independent and supplementary prescribing and the
Department of Health (2005) guidance on supplementary
prescribing.1
Supplementary prescribers (SPs) prescribe in partnership with a
doctor or dentist (the independent prescriber [IP]). SPs are able to
prescribe any medicine, including controlled drugs and unlicensed
medicines that are listed in an agreed clinical management plan
(CMP). They may prescribe for a full range of medical conditions,
provided that they do so under the terms of a patient-­specific CMP
and that treating these conditions is within their scope of compe-
tence. The CMP forms the backbone of the supplementary pre-
scribing process as without it, supplementary prescribing cannot
take place. CMPs are not the same as patient group directions
(PGDs) as they are individualised to the IP/SP and patient, and rep-
resent prescribing activity. PGDs, on the other hand, are written
instructions that relate to the supply and administration of specific
drugs to a specified group of patients: the patients are not individu-
ally identified in the PGD and this is not prescribing activity.2
It is paramount that the registrant is aware of their professional
and regulatory provision for using supplementary prescribing and
CMPs; this is detailed in Chapter 3. Working outside of this provi-
sion invalidates the CMP and supplementary prescribing process.
Drawing up a CMP
The IP and SP should draw up a CMP and agree on it in advance of
the commencing of the supplementary prescribing process. The IP
is responsible for the diagnosis of any patient conditions and the
CMP will outline the condition(s) for which the SP can prescribe.
Although the IP is ultimately responsible for setting the parameters
of the CMP, the IP and the SP should work together to draw up the
CMP and agree which product(s) should be included in it, consid-
ering any limitations of scope of their prescribing practice for that
individual patient and/or the specific patient condition.
The plan should be clear and precise, but kept as simple as ­possible
to facilitate appropriate prescribing decisions. It must be aligned to
the individual SP’s scope of competence and confidence. While the
CMP drafting process may seem time consuming, it ultimately saves
time on patient reviews. Supplementary prescribing cannot be
undertaken without an individualised, agreed CMP in place.
The CMP form chosen to draft the plan upon should reflect the
presence of co-­terminus or non-­co-­terminus access to patient
record (e.g. shared or non-­shared systems); see Figures 9.1 and 9.2
for examples. CMPs that are not held on shared records include
information on current medication and medical history.
It is important that the plans remain contemporary and are
reviewed with the patient so that any changes can be highlighted and
discussed with the IP to ensure the suitability of the CMP remains.
Any changes may require a redraft and re-­agreement of the CMP.
Inclusions on the CMP
The CMP must include:
• The patient’s name and any patient-­specific identifiers (date of
birth (DOB)/National Health Service (NHS) number, etc.).
• Patient sensitivities or allergy status.
• The diagnosis made by the IP (as the specific illness or c­ ondition
to treat). CMPs may relate to more than one condition, but this
is in line with the SPs’ scope of practice and confidence.3
• The clinical indications driving prescribing activity. 19
• The parameters of the CMP in relation to class of medicines,
medicinal products, dose schedules or limitations, etc. that the
Chapter 9 Clinical management plans
SP may work within.
• Specific reasons or indications for referral back to the IP.
• Clear articulation of any guidance or policy (and part of guide
or policy) that underpins the CMP.
• The date the plan is to take effect from.
• A review date for a joint clinical review appropriate to the
­condition being treated (usually within 12 months, or as appro-
priate for the specific condition or medications included on the
CMP). Prescribing outside this date using the CMP is not
allowed.
• Formal identification of the mechanism for shared clinical
records.
• Specific arrangements for reporting adverse drug reactions (e.g.
patient records and the Yellow Card scheme).
• The agreement of the patient, IP, and SP to enter the supplemen-
tary prescribing process: this does not have to be a signature on
the CMP, but there must be an indication of this agreement on
the CMP with clear associated documentation in the patient
notes. Without this agreement, supplementary prescribing
­cannot take place and the CMP is not valid.
The CMP is used in tandem with the patients’ clinical notes.
Specific guidance given or clinical guidance should be held in the
patient notes rather than being detailed on the CMP itself unless it
is required for clarity and patient safety.1 Each plan must be indi-
vidually drafted and agreed by the named IP and the SP. The agree-
ment of the patient to the supplementary prescribing process is
essential.
Medications that can be included on CMPs
Medications or products that can be included on the CMP must
follow the specific medicines entitlements of the SP as per their
professional and regulatory body. This is governed by law
(Chapter 3 details the different entitlements). The SP must not
agree to the inclusion of medicines or products on the CMP that
are outside of their scope of competence.
Managing the patient using the CMP
The SP will monitor and assess the patient, and according to treat-
ment response may be required to alter medicines. This means
within the CMP, there should be enough flexibility to ensure the
SP has discretion in the choice of dosage, frequency, products, and
other variables in relation to medicines management to effectively
treat the patient over time. Any deviation from the CMP renders
the supplementary prescribing process void.
Terminating the CMP
CMPs should be reviewed and terminated at appropriate intervals
for the patient condition or presentation. In addition, CMPs are
terminated when either the IP or SP requests to exit the agree-
ment; when the specified joint review is undertaken (unless they
are extended); and if the IP is no longer available to take responsi-
bility (at this stage, the CMP must be reviewed and potentially re-­
agreed with a new IP and include the SP and patient in this
decision).
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