Choosing the most appropriate option
Separate legal requirements govern the prescribing, supply and administration of medicines.
Decisions to adopt one process or a mix of the permitted arrangements will be influenced by different clinical situations, and different professional groups.
Clinical Governance framework
All the legal mechanisms used for prescribing, supplying and administering medicines to individuals must be included in the employing organisation’s overall clinical governance framework. This is to ensure that all healthcare professionals practise safely and competently within organisational requirements.
Administration of Medicines
Independent prescribing is prescribing by a practitioner, who is responsible and accountable for the assessment of individuals with undiagnosed or diagnosed conditions and for decisions about the clinical management required, including prescribing.
This mechanism may be appropriate where the independent prescriber is competent to assess, diagnose and make treatment decisions with an individual on a one to one basis.
There are three distinct forms of independent prescriber.
Doctor or dentist
Doctors and dentists are able to prescribe on registration.
A non-medical prescriber who is a trained and registered practitioner as defined in the Human Medicines Regulations and can prescribe medicines within their clinical competence. Professions who can be non-medical prescribers are:
- Chiropodists / podiatrists
- Nurses including midwives
- Therapeutic radiographers
- Optometrists – can only prescribe for ocular conditions affecting the eye and surrounding tissue only. They cannot prescribe parenteral medicines.
Community practitioner nurse prescriber
A community practitioner nurse prescriber (CPNP) is a district nurse, community nurse, community public health nurse (health visitor) or school nurse, who has successfully completed the appropriate training. They can independently prescribe from a limited formulary called the Nurse Prescribers’ Formulary for Community Practitioners (Part XVIIB(i) of the Drug Tariff), which can be found in the British National Formulary (BNF).
Controlled drugs and independent prescribers
Not all controlled drugs can be prescribed by all independent prescribers, it varies by profession. More details can be found on the PSNC website.
Unlicensed medicines and independent prescribers
Not all independent prescribers can prescribe unlicensed medicines, it varies by profession. More details can be found on the PSNC website.
Supplementary prescribers are non-medical prescribers who are trained and registered practitioners as defined in the Human Medicine Regulations 2012. They can prescribe medicines within their clinical competence according to a clinical management plan (CMP), written and agreed with a prescriber and often with the individual. Many non-medical prescribers train as both independent and supplementary prescribers.
This may be appropriate in the following circumstances:
- individuals with stable long-term conditions, where a supplementary prescriber is competent to manage the treatment between reviews by the doctor (or dentist)
- where there is a close working partnership between the independent prescriber (doctor or dentist) and the supplementary prescriber, and where the supplementary prescriber has access to the same common clinical record
- for some situations involving controlled drugs and unlicensed medicines where independent prescribing is restricted for some professional groups
Supplementary prescribing is not suited to unplanned urgent or acute prescribing situations, because before prescribing can begin, the prescribers must agree a Clinical Management Plan (and the individual needs to agree to be treated under one).
The following staff groups can act as supplementary prescribers once qualified to do so:
- Chiropodists / podiatrists
- Nurses including midwives
- Therapeutic and diagnostic radiographers
Controlled Drugs and supplementary prescribers
Not all controlled drugs can be prescribed by supplementary prescribers. More details can be found on the PSNC website. The controlled drugs must be specifically named in the CMP.
Unlicensed medicines and supplementary prescribers
Supplementary prescribers can prescribe unlicensed medicines if they are specifically named in the CMP.
Patient Specific Directions
A Patient Specific Direction (PSD) is the traditional written instruction or electronic authorisation from a prescriber to supply or administer a medicine. PSDs must be signed (either by hand or electronically) by a doctor, dentist, or non-medical prescriber (independent or supplementary) for medicines to be supplied and/or administered to a named individual after the prescriber has assessed the individual on a one-to-one basis.
Exemptions in the Human Medicines Regulations
A number of health professions have specific exemptions in medicines legislation to supply or administer specific licensed medicines in the course of their professional practice. These are sometimes known as Schedule 17 exemptions.
Use of exemptions for supply and administration of a medicine is most appropriate where the healthcare professional is delivering specific care within their area of expertise, and the range of medicines specified in medicines legislation meets an individual’s needs.
Currently, exemptions are available for the following registered healthcare professionals:
- Nurses (for occupational health schemes)
- Midwives – can also administer and/or supply any P or GSL medicine as part of their professional practice under Regulation 223 of the Human Medicines Regulations 2012
- Optometrists – can train to use a wider range of medicines under a list of additional exemptions
- Chiropodists/podiatrists – can train to use a wider range of medicines under a list of additional exemptions.
More information about working under exemptions can be found via the professional bodies’ websites and Human Medicines Regulations 2012 Schedule 17
Controlled Drugs under exemptions
Some controlled drugs can be administered by certain health professionals under the exemptions in the medicine regulations. Currently this includes registered midwives and paramedics and more information can be found in Schedule 17
Exemptions for use in an emergency
There are further exemptions for certain parenteral medicines which can be administered by anyone in an emergency. These are known as Schedule 19 exemptions. It should be noted that not all medicines recommended for emergency situations are covered by these exemptions. In addition, only parenteral administration of the listed medicines is allowed.
It is considered good practice to have a local policy or procedure to support practitioners when working under an exemption to the Human Medicines Regulations, e.g. local anaphylaxis policy.
In the Human Medicines Regulations 2012 and subsequent amendments, there are other situations that are not covered in detail in this article series, for example:
- the administration of medicines in nuclear medicine
- using emergency adrenaline auto injectors in schools
- using emergency asthma inhalers in schools
- widening the availability of naloxone
- access to medicines in a pandemic
Patient Group Directions (PGDs)
Working under a PGD is not prescribing; it is the supply and/or administration of a medicine. A PGD is the written instruction for the supply and/or administration of medicines to groups of individuals who may or may not be individually identified before presentation for treatment.
Use of a PGD may be appropriate in the following circumstances:
- When there are ‘high volume’ groups of individuals who present for treatment, such as people needing vaccines or contraception.
- Where the registered healthcare professionals are listed in the legislation, are authorised to use a PGD and are deemed as competent to supply and/or administer the medicine.
A PGD is not suitable where an individual needs to receive a complex regime of medicines or for the treatment of long term or chronic conditions.
More resources on PGDs are available on our Patient Group Directions page.
P and GSL Medicines
Pharmacy only (P) medicines can be administered without a prescription.
General Sales List (GSL) medicines can be supplied and administered without a prescription.
For further information see When Patient Group Directions are not required
Sometimes P and GSL medicines are known as homely remedies.
Medical gases are not usually prescription only medicines, so may not need to be prescribed see When Patient Group Directions are not required
- Explanation of use of unlicensed medicines added
- Clarification of midwives exemptions