Independent prescribing allows nurses, pharmacists and other healthcare professionals (as outlined below) who have successfully completed an accredited prescribing course and are registered as IPs to prescribe any medicine including unlicensed medicines (DH [66]) for any medical condition. This includes CDs (Human Medicines Regulations [133]) but only within the healthcare professional's own level of experience and competence, and in accordance with the relevant professional codes. For nurses this is the Nursing and Midwifery Council's (NMC) Code (NMC [257], Public Health England [291]), while other professions have equivalent ethical codes and requirements. Prescribing must also be considered to be part of that nurse's role.

The full list of healthcare professionals who can become IPs is as follows:

IPs, except optometrist IPs, can prescribe medicines for any medical condition within their competence. Optometrist IPs are restricted to prescribing for ocular conditions affecting the eye and surrounding tissue only. Nurse and pharmacist IPs can prescribe any controlled drugs (CDs) except cocaine, dipipanone or diamorphine for the control of addiction. They can prescribe these drugs for other conditions. Physiotherapist and podiatrist IPs can prescribe a restricted list of CDs (see Table 15.1) while optometrist IPs are not permitted to prescribe CDs. There are proposed changes to the legislation that would permit therapeutic radiographer and paramedic IPs to prescribe a range of CDs.

All IPs with the exception of optometrist IPs can authorize an emergency supply of medicines but not for Schedule 1, 2 or 3 CDs, with the exception of phenobarbital for the treatment of epilepsy. Nurse and pharmacist IPs can prescribe unlicensed medicines, subject to accepted good clinical practice, while physiotherapists, podiatrists, optometrists and therapeutic radiographers are limited to ‘off‐label’ medicines (i.e. licensed medicines used outside their marketing authorization, again subject to accepted good clinical practice). Presently, paramedic IPs cannot prescribe any unlicensed medicines or prescribe off label.

Supplementary prescribing has been defined as ‘a voluntary prescribing partnership between an IP and an SP to implement an agreed patient specific clinical management plan with the patient's agreement’ (DH [60]). Amendments to the Prescription Only Medicines (Human Use) Order ([290]) and the NHS regulations allowed supplementary prescribing by suitably trained nurses from April 2003. SPs prescribe in partnership with a doctor or dentist (the IP) and are able to prescribe any medicine, including CDs and unlicensed medicines, that are listed in an agreed clinical management plan. The plan is drawn up with the patient's agreement, following diagnosis of the patient by an IP and following consultation and agreement between the independent and SPs (DH [60], pp.6–7). A range of other professions can be SPs, including some that currently are not permitted to be IPs (Human Medicines Regulations [133]). Practitioners who are SPs have to successfully complete a course of accredited training and be annotated on their professional register as such.

The following professions can be SPs:

All prescribing carried out by an SP must be subject to the practitioner's clinical competence and within an agreed clinical management plan with the patient and IP partner. SPs can prescribe CDs (with the exception of cocaine, dipipanone and diamorphine for the treatment of addiction) and unlicensed medicines, subject to accepted good clinical practice, if they are included in the clinical management plan. Community nurse prescribers can prescribe a range of dressings, appliances and licensed medicines that are listed in the Nurse Prescribers’ Formulary (BNF [25]).

The key principles that underpin supplementary prescribing are:

Independent and supplementary non‐medical prescribers must demonstrate the competencies outlined in the Royal Pharmaceutical Society's Prescribing Competency Framework. This framework is supported by all prescribing professions and accredited by the National Institute for Health and Care Excellence (NICE) (RPS [318]). The competency framework was developed to set out what good prescribing looks like. It has 10 competencies divided into two domains: ‘The Consultation’ and ‘Prescribing Governance’. Within each competency there are a number of statements that describe the activities or outcomes the prescriber should be able to demonstrate. The domains and competencies, along with some example statements, are outlined in Table 15.2.

Patient group directions (PGDs) allow healthcare professionals to supply and administer specified medicines to predefined groups of patients without a prescription (NICE [251]). PGDs were defined in Health Service Circular 2000/026 as ‘written instructions for the supply or administration of medicines to groups of patients who may not be individually identified before presentation for treatment’ (DH [59]). Both the NICE guidance and original legislation identify that the preferred method of providing clinical care involving supplying and/or administering medicines should be on an individual, patient‐specific basis, usually involving a prescriber. However, it is recognized that there may be situations where PGDs offer an advantage for patient care, without compromising patient safety, and there are clear arrangements for governance and accountability in place. A tool is available (SPS [339]) to help organizations and potential authors and signatories of PGDs to think about and follow necessary procedures before and during the stages of developing and authorizing PGDs, including determining whether the use of a PGD is appropriate.

PGDs must be used only by named and authorized registered health professionals who can legally supply and/or administer medicines using a PGD in line with the Human Medicines Regulations ([133]). Healthcare professionals who may supply or administer medicines using a PGD are:

PGDs must only include medicines with a UK marketing authorization (i.e. licensed medicines), although off‐label use of a licensed medicine can be included in a PGD when it is clearly justified by best clinical practice. It is a requirement that the PGD states that the medicine is being used outside the terms of the marketing authorization. ‘Black triangle medicines’ (i.e. those subject to close adverse drug reaction monitoring and reporting) can also be included when clearly justified by best clinical practice and when the black triangle status is stated on the PGD. If antimicrobials are included on a PGD, care should be taken not to jeopardize local and national strategies to combat antimicrobial resistance and healthcare‐associated infections, and a local specialist in microbiology must agree that a PGD is needed.

Schedule 4 and 5 CDs can be included in a PGD, while nurses and pharmacists can supply and/or administer diamorphine or morphine for the immediate necessary treatment of sick or injured persons.

The contents of a PGD are laid out in the legislation (Human Medicines Regulations [133], NICE [251]) A PGD should be developed by a multidisciplinary PGD working group with a named lead author. The group must include a doctor (or dentist), a pharmacist and a representative of any other professional group using the PGD. Institutions should have a multidisciplinary PGD approval group, and the group may be an existing local medicines decision‐making group, such as a drug and therapeutics committee or medicines management committee.

Similar guidance is available for Scotland (NES [225]).