This study has used NHS prescription administrative databases to examine trends in prescribing practices of 30,753 (2006) rising to 36,281 (2010) primary care nurses in England. To our knowledge this study presents data on the prescribing practices of the largest number of primary care nurses to date.
We found that NHS employers authorised greater numbers of primary care nurses to prescribe over the time period. The percentage actually prescribing as recorded by the prescription administrative system remained static over time (43%). We have objectively quantified the percentages of nurses that are using their independent nurse prescriber (INP) qualification and demonstrated a decline in use of community nurse prescribing (CNP) qualifications, not reported previously. We found higher percentages of nurses in primary care not using their prescribing qualifications than reported by generic surveys, including primary care, in the USA [32, 33] and the UK [12, 29] but lower than Australia  where prescribing rights have been more recently introduced. The finding of regional variation, with areas with no prescribing by practice employed nurses, has been noted before  but the evidence here suggests this feature has not changed over time.
These findings suggest that this innovation has yet to be fully adopted as usual or normal practice for primary care nurses with prescribing qualifications . Some UK studies have suggested nurses’ lack of employer support [30, 59] and there is a need for change champions in local health care systems , however these were nurses who had employer support as evidenced by the employer registering them as prescribers with the ePACT database. It raises questions as to why such numbers of nurses have gained the prescribing qualification for it then not to be used in practice. One hypothesis, derived from the literature [30, 59] and requiring testing, is that nurses who have access to a clinical mentor or supervisor are more likely to prescribe than those who no or little access. A second hypothesis that requires further investigation is that the ambivalence to this role is more wide spread amongst primary care nurses than previously reported and they are choosing not to prescribe and as such acting as ‘street-level bureaucrats’  i.e. as front line staff making policy through their implementation decisions. Primary care nurses acting as street-level bureaucrats in the face of policy implementation has been noted before in the UK  and other countries .
While the number of nurses and the volume of prescribing by nurses increased over the five year period, prescribing in primary care remains an activity mainly undertaken by doctors in England. This has been noted previously  and in other countries where nurses prescribe in primary care . We found that the largest volume of items prescribed by nurses in primary care (both INPs and CNPs) were those items used in common nursing care activities practice i.e. wound dressings, incontinence and stoma devices. Beyond these, the medicine categories where there had been the greatest increase in both volume and percentage of prescribing compared to GPs, were those that could be bracketed as health promotion e.g. contraception, smoking cessation . While practice nurses have become involved in the chronic disease management processes for primary care patients [66, 67] it is not evident from this study that as a group they undertake significant prescribing with these patients. Surveys of practice nurses in the UK over the last two decades show that health promotion and family planning activities are ranked as the most frequent [68, 69]. One hypothesis, that requires further investigation, is that nurse prescribing is most acceptable to both nurses and others when it improves their efficiency in delivering primarily nursing interventions, treatments or health promotion within their scope of practice. Such investigation could include the prescribing practices of nurses with specific responsibilities for patients with long term conditions such as community matrons in the English setting .
We found tentative evidence that there may be higher rates of nurse prescribing in areas with lower ratios of GPs to patient populations (Spearman’s rho = -0.16) and higher levels of deprivation (Spearman’s rho = 0.19). We suggest this requires further investigation over time and in the face of predicted shortages of GPs in deprived and rural areas, where the UK and other countries have difficulty in attracting and retaining family doctors [71, 72].
Our findings of the first five years following the introduction of independent nurse prescribing, involving all classes of medicines, suggests that while the English policy objectives were for increased flexibility professional roles [40, 41], this has only been at the margins of medical practice. However, it may have significantly improved access and efficiency in health care for some groups of patients and released medical time. Prescribing by nurses in primary care for specific patient groups has the potential to release general practitioner time. Economic modelling, from one UK study, for patients with infections and those with hypertension, suggested the involvement of independent nurse prescribers was less expensive compared to a GP only prescribing model . Further investigation is required over longer periods and specifically examining questions of efficiency, improved access and cost effectiveness for different patient populations.
The study has a number of limitations. As an analysis of a data set established for financial reimbursement, it cannot investigate at the patient or prescriber level. Hence, we were not able to address other aspects of nurse prescribing activities such as ceasing medications. Nor is it able to address questions such as clinical safety or health economics. The data are limited to five years of prescriptions in NHS England and other mechanisms which circumvent the ePACT database may be in place such as patient group directions  (known elsewhere by terms such as ‘standing orders’ ) with bulk purchase e.g. vaccines, masking a greater level of nurse activity in prescribing. However, despite these limitations this study provides empirical data and insights not available elsewhere as to the types of prescribing undertaken by primary care nurses, over time and from a national perspective. As such it offers some valuable information to nurses and policy makers both in the UK and elsewhere and in addition sets a research agenda for future study.