Extending independent prescribing – the regulatory gift that keeps giving?

As of 31 December 2023, certain registered healthcare practitioners with independent prescribing qualifications became able to prescribe stipulated controlled drugs in a prescribed manner.

This follows the implementation of the Misuse of Drugs (England and Wales and Scotland) (Amendment) (No.2) Regulations 2023 (“regulations”) which amends the Misuse of Drugs Act 1971 (“Act”), the Misuse of Drugs Regulations 2001, and the Misuse of Drugs (Amendment) (No.2) (England, Wales and Scotland) Regulations 2015 (“2015 regulations”).

Controlled drugs are statutorily defined within the Act; it is unlawful to produce, supply or offer to supply a controlled drug to another unless exempt, e.g., a specified registered healthcare practitioner.

Whilst doctors and dentists have always held prescribing abilities, other registered healthcare practitioners have only, relatively recently, been legally permitted to independently prescribe or supplementary prescribe. Independently prescribe means to prescribe on their own initiative for a patient, while supplementary prescribing means to work with an independent prescriber – e.g., a doctor within an agreed Clinical Management Plan.

Who does this impact and how?

The regulations will mainly impact podiatrists, physiotherapists, paramedics, chiropodists and therapeutic radiographers who already hold independent prescribing qualifications and have the relevant prescribing annotation written against their name on the Health and Care Professions Council (“HCPC”) register.

In brief, these specified HCPC registered practitioners have, since 31 December 2023, been able to issue an NHS prescription for the following controlled drugs, in the specified manner, for the treatment of an organic disease or injury:

• Paramedic independent prescriber
  • Morphine Sulphate by oral administration or injection
  • Diazepam by oral administration or injection
  • Midazolam by oromucosal – e.g. mouth and cheek – administration or by injection
  • Lorazepam by injection
  • Codeine phosphate by oral administration.
• Therapeutic radiographer independent prescriber
  • Tramadol
  • Lorazepam
  • Diazepam
  • Morphine
  • Oxycodone
  • Codeine.

These will all by oral administration except for morphine which may also be by injection.

In addition, a podiatrist or chiropodist (“podiatrist”) independent prescriber (“IP”) has also been able to supply or offer to supply Co-codamol 8/500, 15/500 and 30/500, Co-dydramol 10/500 and Codeine phosphate to patients as since 31 December 2023.

In accordance with the 2015 Regulations, podiatrist IP’s can already prescribe diazepam, dihydrocodeine tartrate, lorazepam and temazepam for oral administration whilst physiotherapist IP’s can prescribe oral or injectable morphine, transdermal fentanyl and oral diazepam, dihydrocodeine tartrate, lorazepam, oxycodone hydrochloride and/or temazepam.

Other implications

In addition to the above, the regulations also legally establish the following:

• An NHS prescription for controlled drugs can now be issued by a podiatrist, paramedic, therapeutic radiographer or physiotherapist IP
• The definition of an NHS prescription has been extended to refer to an IP for the medical treatment of a single individual
• A paramedic IP and therapeutic radiographer IP can specifically instruct any person to administer the stipulated controlled drugs to a patient providing ‘it is administered for a purpose for which it may be prescribed under that regulation and by the method by which it was prescribed to be administered’.

Benefits

As all employers will be aware, whether a care home, pharmacy or NHS trust, a registered healthcare practitioner with additional qualifications will always be a valuable asset – including an IP.

In hiring or contracting with such a practitioner, prescriptions for specified controlled drugs, alongside other non-controlled drugs, can be issued without consultation with a doctor or dentist.

This therefore reduces the need for a GP referral and the associated long waiting times in addition to meeting patient demand and increasing patient satisfaction. For the practitioner, an IP qualification not only makes them more marketable but also enhances their own knowledge, skill and experience within their practice area. An IP qualification can open up career opportunities which may not have previously been available.

As we head towards a more community-based, multi-disciplinary way of working, it would appear that a greater skill set will become highly desirable and lucrative.

Regulatory burden

As expected however, additional qualifications come with additional responsibilities. In the case of IP’s, this being the responsibility of making independent prescribing decisions for patients based on their skill, knowledge and experience and known drug allergies and contraindications.

IP’s must ensure before prescribing that they have the required knowledge of the patient’s medical history, current medications being taken and knowledge of the relevant interactors listed within the British National Formulary along with any recent updates.

An IP will also need to demonstrate greater communication and team working skills to ensure the best outcome for their patient given they may be working alongside other practitioners and/or with patients who are taking existing medications.
As means of example, a physiotherapist IP attending a care home to visit a resident will need to effectively communicate with the resident, where they have capacity, as well as with their carers, care home manager and any onsite GP. This is in addition to reading the relevant parts of their care plan.

In doing so, the physiotherapist IP will need to understand the resident’s current state of health, any known allergies and co-morbidities before being able to safely prescribe a controlled drug, where required, and make the corresponding record in the patient’s notes.

For the individual themselves, IP’s will need to personally ensure they have sufficient insurance or indemnity coverage in place. They will also need to meet any additional CPD requirements associated with the prescribing qualification, remain current with all topical controlled drug updates and work within their own level of professional competence and expertise as per the HCPC’s Standards for Prescribers.

As all practitioners will be aware, failure to adhere to such standards, working beyond their scope of practice or competence, or incorrectly prescribing a drug which causes harm to a patient may result in an HCPC referral.

In turn, and for those employing IP’s, they are reminded that they remain vicariously liable for their employees prescribing acts and omissions and should be aware that their insurance premiums are likely to increase owing to the potential risks associated with employees prescribing stipulated controlled drugs in a prescribed manner.

Why now?

As already discussed above, the benefits of independent prescribing enable patients to swiftly receive medication and reduces the burdens on the already stretched NHS.

The government’s implementation of the regulations also feeds into the NHS Long Term Workforce Plan which includes:

• Increasing the number of advanced practitioners, IP’s and allied health professions acting as senior decision-makers in appropriate settings
• As of 2026, all newly qualified pharmacists becoming IP’s when they register with the General Pharmaceutical Council enabling NHS England to commission clinical services from community pharmacies
• Supporting 3,000 pharmacy graduates who have not completed an IP course to gain the required skills, knowledge and qualification to prescribe as independent clinicians.
• Making Physician Associates GMC registered will “enable expansion of their scope of practice, with the potential for them to be given prescribing responsibilities in the future, subject to the necessary approvals.”
• Making Anaesthesia Associates GMC registered with the “potential for them to be given prescribing responsibilities in the future, subject to the necessary approvals”.

Conclusion

The expansion of independent prescribing is just one step towards increasing the number and scope of healthcare practitioners who can prescribe independently which will, in turn, reduce waiting times, ease the burden on the NHS and ensure patient satisfaction.

However, there is another side to the prescribing coin which should not be overlooked and this includes the associated regulatory burdens and responsibilities of:

• Ensuring sufficient insurance is in place to cover the increased potential risk (for the employer and healthcare practitioner)
• Meeting the increased CPD requirements ensuring the IP is sufficiently knowledgeable, competent and current with controlled drugs and any relevant updates
• Making evidence based prescribing decisions following review of the patient records in conjunction with a conversation(s) with the patient or relevant care giver
• Making a record of the controlled drug prescribed within the patient notes so those subsequently prescribing are aware of all relevant information
• The potential increase in receiving a patient complaint or referral to the regulator.

Whilst the regulatory burden for IP’s appears to be great, it should not be forgotten that prescribing controlled drugs carries risk and patient safety remains paramount.