This article highlights changes in the current scope of physiotherapy practice in the UK with regards to prescribing rights.
The History of Injection Therapy and Physiotherapy
December 1995
Injection therapy came within the scope of physiotherapy practice.
February 1996
Association of Chartered Physiotherapists in Orthopaedic Medicine (ACPOM) received £3000 in funding from the Department of Health to help develop evidence based guidelines for the use of injection therapy within physiotherapy practice and to insure that it would be done safely.
1997
Review of the 1968 Medicines Act in which it wanted to develop a framework whereby determining in what situations health professionals could undertake new roles in prescribing medicines.
The Chartered Society of Physiotherapists (CSP) responded to this review and argued that physiotherapists should be allowed to prescribe and administer drugs giving reasons that patient care can sometimes be time sensitive and that if physiotherapists could administer drugs without need for referrals then patient care could be more efficient. They also commented that it would maximise effective use of resources. The CSP also insisted that if these changes were to occur then there must be strict and appropriate post qualification training put in place.
1999
Crown Report. This report recommended that specialist physiotherapists be extended prescribing rights. It also legitimised current administration practice via patient specific directions(PSDs) and patient group direction (PGDs). There was clarification on the two types of prescriber, the independant prescribers who were responsible for assessment of patients and their clinical management, and supplementary prescribers who were responsible for care after being assessed by an independant prescriber. The report also requested that a new body be formed to oversee the introduction of new prescribing rights. This body was to be called The New Prescribers Advisory Commitee.
In response to the Crown Report the CSP wanted physiotherapists to be recognised as either independant or supplementary prescribers based on their training and qualifications, that medicines prescribes not be restricted by legislation but rather by the qualifications and training of the prescriber, and the rules of professional conduct are maintained and that the CSP should be the ones to validate any courses and set the training standards.
2000
Implementation of Crown Report. This report suggested legislation allowing physiotherapists to be supplementary prescribers and to increase their role to independant prescribers after sufficient development at the supplementary level. Also the report wanted to clarify the law in where other health professionals such as physiotherapists could now give medicines in PGD settings.
2001
NHS guidelines state that PGDs must be signed off by a doctor, dentist or pharmacist.
Health and Social Care Act. Clause 60 of this act ammends clause 58 of the 1968 Medicines Act and allows physiotherapy, as a registered profession, to move forward and arrange for prescribing rights.
2002
Prescribing Steering Group met for the first time. This group was set up by the CSP to try to push forward the prescribing rights legislation and meet with government officials to this end.
2005
Physiotherapists given supplementary prescribing rights.
2008
Allied Health Professions Prescribing and Medicines Supply Mechanisms Scoping Project set up. This project was undertaken to determine whether there was a need and an ability for allied health professionals such as physiotherapists to extend their prescribing rights further. The outcome of this project for physiotherapists was that independant prescribing should be the next progression [1].
Injection Therapy
Injection therapy is carried out mainly on peripheral joints and is administered either intra-articularly or prei-articularly. It is used most commonly to reduce pain and inflammation, but also as a side effect of reducing these symptoms it then allows for greater range of movement and so increases functional capacity. Physiotherapists can use injection therapy to relieve pain and also to get a better understanding of any disease processes involved by being able to carry out a more thorough assessment.
Indications for the use of injection therapy according to the CSP are arthritis, tendonitis, capsulitis, tenosynovitis, bursitis, impingement syndromes, myofascial pain syndromes, entrapment neuropathy, ganglia and ligamentous injury.
Injection therapy consits of two main types of drugs, a corticosteroid and a local anaesthetic.
Corticosteroids are used as they have an effect on the inflammatory process and can when used for low grade soft tissue reinjuries break the inflammatory response cycle. They also suppress inflammation in joints and connective tissue and inflammatory flares in joints with degenerative diseases.
Examples of coticosteroids used are Hydrocortisone acetate, Triamcinolone acetonide, Methylprednisolone acetate, and Triamcinolone hexacetonide. With the exception of Hydrocortisone acetate which is effective for only 36 hours, the other drugs can be effective for weeks and even months.
Local anaestheics are also used alongside coticosteroids. These are used as they instantly relieve pain and so can help with diagnosing a cause of the pain, they increase the effect of the corticosteroid by increasing the volume of the injection, and they dilute the corticosteroid and so help to reduce any risk of tissue atrophy.
Examples of local anaesthetics are Lidocaine which is short acting and Bupivacaine which is longer acting. Due to the fact that Bupivicaine is longer acting, only the short acting Lidocaine is recommended by the CSP in their clinical guidelines for use in conjunction with corticosteroids.
Injection therapy is not without its adverse effects however and includes post injection pain, soft tissue infections, tendon ruptures, joint sepsis, subcutaneous atrophy, steroid arthropathy, facial flushing and alteration in glycaemic control. These adverse effects can however be reduced by avoiding any contraindications which include joint infections, sepsis, bleeding disorders, recent trauma, hypersnsitivity to steroids ao anaesthetic, prosthetic joints, anticoagulant therapy, concurrent oral steroids, haemarthrosis and poorly controlled diabetes[2].
Current Prescribing Rights
Physiotherapists at present can only supplementary prescribe, although it is an exciting time as there is currently a public consultation open until the 8th of December 2011 [3] . This consultation is looking to move towards giving Physiotherapists the right to independently supply, administer and prescribe medicines. In order for this to be included as an extended scope of practice the Medicine Act 1968 and Misuse of Drugs Regulations 2001 would have to be amended to ensure there were no legal implications for independently prescribing Physiotherapists, thus the reason for the public consultation.
Supplementary Prescribing
Supplentary Prescribing is a “voluntary prescribing partnership between an independent prescriber (doctor) and supplementary prescriber (pharmacist, nurse, physiotherapist, etc) to implement an agreed patient-specific Clinical Management Plan with the patient’s agreement” [4]
Physiotherapists with relevant experience and training to a recognised standard by the health professional council have been allowed to supplementary prescribe (SP) since 2003. The big difference between SP and independent prescribing (IP) is there are no legal restrictions to the clinical conditions that Physiotherapists can be involved in. However, it is expected that supplementary prescribing would be used for chronic medical conditions and other health needs [4].
Currently physiotherapist SPs can prescribe any medicine, under the terms of the patient-specific Clinical Management Plan (CMP) which has been agreed with a doctor. These include controlled drugs and unlicensed medicines that are listed in the agreed CMP for any medical condition [5]. The only form of treatment that patients cannot currently receive exclusively from Physiotherapists is the prescription of drugs, and remains the single aspect of patient care which patients must access from an independent prescriber [6]. This is due to the fact that SP is managed and clinically governed by an IP who must be a Doctor, and care to the patient is given as a team management approach with a clear patient specific plan of care that the SP would work within. There are some stipulations to what the patient’s clinical management plan of care must include:
- Patients name
- The illness or condition of the patient that can be treated by the SP
- The date the treatment plan is to commence
- Which prescribed medicine can be given by the SP
- What restriction/limitations there are to the administered dose
- Situations identified that the SP must consult with the IP
Amendment to national regulations have occured in order to allow SP by allied health professional inclusive of physiotherapists.
Medicine Act 1968
The legislation outlined in the Medicine Act 1968 governs health professionals in clinical practivce regarding the administrion, supply and prescription of medcines. The Medicine Act states that a prescription from an appropriate practitioner is required for the supply of medicinal products, a substance or combintation of substances used for the treatment or prevention of dieases in human beings or animals. Originally, an appropriate practitioner is defined by the Act as a doctor or dentist, but has since been extended to include certain members of the nursing and pharmaceutical professionals[7].
- Medicinal product is defined in an European Economic Community Dierctive as substances or combintation of substances that are provided to treat or prevent diseases in humans or animals. Substances that are used for medical diagnosises, restoring, correcting or modifying physiological functions in humans or animals[7].
- Origninally an “appropriate practitioner” has been defined as a doctor or dentist. This has currently been revised to include certain members of nursing and pharmaceutical professions[7].
- Medicine has been divided into three categories in accodange to their legality based on the hazards and risks they posses[7]:
- POM: Prescription only medicine – may be sold or supplied under the supervision of a pharmacist form a registered premise with a presciption from an appropriate practitioner (i.e. doctor, dentist, and certain nurses)
- P: Pharmacy medicine – may sold or supplied under the supervision of a pharmacist from registered premise
- GSL: General sales list – may be sold or supplied from any lockable business premise
Classes Offered
In 2005, prescribing rights were extended to physiotherapists by the Department of Health (DoH) and the Medicines and Healthcare Products Regulatory Agency (MHRA), in addition to the implementation of training courses for Allied Health Professionals. Supplementary prescribing classes involve at least 26 days in the classroom, and 12 days in practice with a designated medical practitioner [4].
The CSP state that any weekend and/or one day courses are only suitable for members who are allready qualified and partaking in on-going learning. Establishing competency initially requires a longer diploma course.[8]
[9] supports post graduate education courses for supplementary prescribing Physiotherapists. This ACPOMIT taugh course and the diploma offered by The Society of Orthopaedic Medicine (SOM) are approved by the CSP as suitably accredited courses. This diploma along with similar university led diplomas in Cardiff, Coventry, Plymouth, Hertfordshire, Southampton, and Essex all provide credited diplomas for Injection therapy
Entry requirement levels vary depending on where the course is taught, but tend to include previous completion of specialist musculoskeletal training, post graduate clinical experience in a musculoskeletal setting and the support of an employer to use injection therapy.[10]
Delivery of the course is given by tutor lead online/classroom teaching with an assessment component that is weighted over three components 1) written assignment 2) practical application of the technique to at least 10 case patients under supervision and 3) developed portfolio/ logbook reflecting and reporting on learning experience.
In March 2010 CSP posted an article to warn all private practitioners who may be considering taking a course in injection therapy. The article advised all practitioners to contact the CSP prior to application to check if they will be legally covered by the patient direction mechanism to administer and supply the medicines. [11] Many practitioners prior to this warning had registered complaints that they had not been warned that their newly acquired qualification in injection therapy was not applicable for private ‘high street practice’ purposes.
Limitations of Current Prescribing Rights
“You have a responsibility to deliver care based on current evidence, best practice and, where applicable, validated research when it is available.” [12]
It is clear that there must be close professional interactions between the independent prescriber (IP) and supplementary prescriber (SP) in addition to the requirement that the “patient is considered an equal partner in order to ensure informed consent and concordance” [4].
Concordance has been defined as: “a new approach to prescribing and taking medicines, based on partnership. The patient and the healthcare professional participate as partners to reach an agreement on the illness and treatment. Their agreement draws on the experiences, beliefs and wishes of the patient to decide when, how and why to use medicines…” [13]
The Prescribing Problem
Worldwide there is an issue of ‘non-compliance’, where patient’s do not always take medications as prescribed, for several reasons. These can be due to:
- Receiving prescriptions, but medication is unavailable at pharmacies (primary non-compliance)
- Taking incorrect dosages
- Taking medication at wrong times
- Forgetting one or more doses of medication
- Stopping the treatment too soon, ceasing to take the medication sooner than the prescriber recommended, or failing to obtain a repeat prescription (secondary non-compliance) [4]
The reasons for ‘non-compliance’ are complex. Best clinical practice utilises available evidence and subsequent clinical decisions are based on these findings. Although evidence-base for practice in this area is incomplete, there are suggestions that interventions to address this should be both complex and multi-factoral. Additionally, a concordance approach by the prescriber is likely to be more effective, and therefore will influence and promote effective taking of medications [4].
Do current Prescribing Rights’ allow for a Patient-Centred Approach to Physiotherapy Practice?
Although current prescribing mechanisms available to physiotherapists serve in providing some patients with increased access to medications, it is clear they are limited in their capacity to optimize patient-centred practice. The extent of which current measures fail to meet the needs of patients was illustrated by a recent scoping project undertaken by the Department of Health into the provision of medicines by allied health professionals (AHPs) [6].
Physiotherapists utilise Supplementary Prescribing, Patient Specific Directions (PSDs) and Patient Group Directions (PGDs) in order to provide patients with the medicines they need [6] . It is at present a legal requirement that physiotherapists only administer drugs detailed within the patients clinical management plan (CMP) which are determined by an independent prescriber- such as a doctor – when using any of the above pathways [6]. However, such professionals are often unavailable for consultation in many clinical working environments, such as outpatient departments. Therefore, ensuing delays’ in communication within the multi-disciplinary team unfortunately result in the needs of many patients failing to be met. Interestingly, doctor availability has been previously identified as posing “the greatest challenge” for physiotherapists implementing such treatments [6]. Moreover, such arrangements make it increasingly difficult for clinicians to adhere to Standard 13 of the Core Standards of Physiotherapy Practice of The Chartered Society of Physiotherapists [14].
With specific reference to PGDs, physiotherapists are unable to modify the provision of medication – such as modifying a patient’s prescription in order to supply a more suitable drug [6]. Furthermore, many departments require different medications to be detailed on separate PGDs, with some clinical settings requiring numerous PGDs in order to manage a single pathology. It is clear that this pathway poses a significant barrier to patient-centred care for physiotherapy departments who do not possess the necessary PGDs to manage certain health condiions [6].
Physiotherapists are often unable to prescribe or administer drugs quickly enough in order to optimize the management of a patient’s health condition under existing legislation, such as when patients respond to a treatment provided [6]. Despite the fact that AHPs such as Physiotherapists are able to asses and identify deterioration or improvement of a patient’s condition, they are currently unable to appropriately alter or reduce dosage without consulting an independent prescriber. Not only does this result in avoidable delays in the provision of appropriate treatments, but clinicians often take unnecessary preventative measures in order to minimise risk when a patient’s condition deteriorates, such as advising patients to contact their GP, or in some cases calling an ambulance [6].
It is clear that current prescribing mechanisms for physiotherapists do not meet the needs of patients. Furthermore, it is clear how delays in the cessation or commencement of drug administration, as well as dose modification could negatively influence the effectiveness of physiotherapy treatment.
‘Do current mechanisms reflect the Autonomy of modern day Physiotherapists’?’
“The role of allied health professionals is not yet adequately reflected in medicines legislation” [6].
According to the ‘Standards of Proficiency’ of the Health Professions Council (HPC), under Standard 1a.6 Registrant Physiotherapists must:
- Be able to practise as an autonomous professional, exercising their own professional judgement
- Be ableto assess a situation, determine the nature and severity of the problem and call upon the required knowledge and exerpeince to deal with the problem
- Be able to initiate resolution of problems and be able to exercise personal initiative
Physiotherapists do not currently enjoy sufficient prescribing rights in order to practice with full professional autonomy and use their high levels of knowledge and expertise to act appropriately in the best interest of patients. Therefore, the extent of which current prescribing pathways allow for practitioners to adhere to professional standards is questionable.
The roles performed by physiotherapists have evolved substantially during recent years, with modern day practitioners performing initial assessments, treatments and subsequent referrals similar to the way in which doctors have traditionally done so. This is reflected by the increased number of patients who seek primary contact with physiotherapists instead of their GP through self-referral schemes, as well as the lead role performed by physiotherapists in outpatient review clinics [6].
Consultation
The recommendation by the Allied Health Professionals Prescribing and Medicines Supply Mechanisms Scoping project in 2009 that further measures should be put in place to extend independent prescribing rights to adequately qualified Physiotherapists was subsequently accepted by the Department of Health Non Medical Prescribing Board [6]. Since then, a twelve week engagement exercise was undertaken in September 2010 in relation to independent prescribing rights for Physiotherapists [3].
The exercise found that 91% of the 388 respondents who were either individuals (83%) or organisations (17%) supported independent prescribing by Physiotherapists [3]. These findings were used to support the conduction of a public consultation on the matter.
The ‘Consultation of Proposals to Introduce Independent Prescribing by Physiotherapists’ is currently underway, taking place between the 15th September – 8th December 2011 [3]. The proposals detailed within the consultation not only include independent prescribing rights for physiotherapists, but also wither such professionals should be allowed to mix medicines as well as administer a selection of controlled drugs proposed by The Chartered Society of Physiotherapy [3].
Individuals completing the Consultation will have the opportunity to choose from five options relating to the introduction of independent prescribing by physiotherapists:
- Independent prescribing for any condition from a full formulary
- Independent prescribing for specified conditions from a specified formulary
- Independent Prescribing for any condition from a specified formulary
- Independent prescribing for specified conditions from a full formulary
- No change [3].
The consultation is available to complete at the Autonomous Practice
“Autonomy is a privilege and allows the professional to have greater influence over the everyday terms of his or her work than comparable freedoms available to other workers”[15] p.99.
There is still great debate over what physiotherapists should and should not be permitted to do with regards to patients. Medicine controlled the education system of health care providers from 1945-1960, during which time occupations of all health care providers where determined by medicine[15]. If an occupation went against this than they were placed under extreme pressure to stop seeing patients, therefore at this time physiotherapists sacrificed their autonomy to be recognised by medicine[15]. Physiotherapists have been trying to regain their full autonomy since. UK physiotherapists have been permitted to practice autonomously since 1977[16].
Physiotherapists are autonomous in that a referral is not required from another health care professional to treat a patient, a patient is able to self-refer for treatment. Just because a physiotherapist is legally permitted to do provide a service does not mean they are actually providing this service on a regular basis. CSP members have been premitted to authorise sick notes for patients since 1992[17]. It is believed that the NHS lacks clarity on the role of a physiotherapist and this is part of the reason why their autonomous practice is progressing so slowly[17]. Extended scope practitioners and physiotherapy consultants have been requesting x-rays for a number of years but radiation training needed to request x-rays has been used to inhibit autonomous requesting as much as possible[18].
If there is a downfall to increasing autonomous practice for physiotherapists it would be that with the reduction in junior doctor hours worked, physiotherapists are now seen as a duplicate role as junior doctors in orthopaedic, paediatric, neurosurgery, and rheumatology[16].
Independent prescribing is when “the prescriber takes responsibility for the clinical assessment of the patient, establishing a diagnosis and the clinical management required, as well as for prescribing where necessary and the appropriateness of any prescription” [19].
Currently, doctors, dentists and certain nurses in respect of a limited list of medicines are legally authorised prescribers who fulfil the requirements for independent prescribers[20]. [1]. Extended Scope Practitioners
A few chartered physiotherapists are involved in administering and supplying to a PGD: typically, these are undertaking extended scope practitioners roles. Extended scope practitioners are clinical physiotherapy specialists with an extended scope of practice, who see patients referred for assessment, clinical diagnosis and management’ (CSP 2000). Extended Scope Practitioners in Stepping Hill Hospital, Stockport states that the ESPs who undertake injection therapy are working under a PGD. Additional ESPs whose role is of a therapeutic, rather than a diagnostic nature; those taking responsibility for the on going medical management of rheumatology patients for example, are also involved in monitoring medication and altering dosages as necessary under Patient Group Directions and Patient Specific Directions[7]. [20]. In order for physiotherapists to acquire independent prescribing rights, some amendments must first be made to the Medicines Act 1968, which states that prescribing is restricted to appropriate practitioners- namely doctors and dentists. Currently a public consultation is being conducted by The Commission on Human Medicines prior to recommending legislative changes to allow extended scope of practice in this area [3].
Similar to Supplementary prescribing, Independent prescribing classes involve at least 26 days in the classroom, and about 12 days in practice with a designated medical practitioner [4] The outcome of this project for physiotherapists as that the next logical progression in extending scope of practice should be independent prescribing. However concerns that role blurring with other healthcare professions, including junior doctors, nurses and orthopaedic surgeons have been raised. Nonetheless independent prescribing would improve patient-centered care by providing required treatments in a timely fashion.
Independent Prescribing
Definition
Classes Offered
