This study enabled an in-depth investigation of issues affecting pharmacist and physiotherapist non-medical prescribers. Participants’ lived experiences supported further exploration of the findings from a Delphi study . Five themes, describing the experiences of the participants were identified.
The theme of “Staff” reflected the previous Delphi findings whereby the clinical team (medical, nursing and peer support) accounted for approximately 40% of factors affecting NMP achieving consensus , and further confirming the role of medical professionals and colleagues in supporting NMP, identified in the preceding review . This is unsurprising as all participants described working collaboratively to share the patient caseload, within a multidisciplinary team usually led by a medical professional. Traditionally senior medical staff were accountable for the patient’s care, and team members had closely defined roles. More latterly the move has been towards advanced practice in the non-medical professions, to develop a flexible workforce that is able to adopt innovative ways of working. This was described in the 2017 draft workforce strategy, which highlighted the increasing demand on the NHS, and the limited number of clinicians to provide care , and which built on earlier work such as developing primary care services [9, 37]. In addition, NMP courses require the trainee to complete a period of practice-based training supervised by an experienced prescriber. Until recently all regulatory bodies required this trainer to be a member of the medical profession, fostering closer links between trainer and trainee, which many participants commented on.
The “Self” theme, accounting for approximately a quarter of all references, focused on the “Prescribing role”, the role that prescribing had within the participant’s job and whether prescribing was integral to that role. All prescribers are required to prescribe within their scope of practice and the prescriber’s role implicitly defines that scope, together with guidance from regulatory and professional bodies [38,39,40]. Some pharmacist prescribers described challenges when prescribing had been added into their existing role, implying that for this group, the potential impact of prescribing had not been fully considered.
The“Practical aspects” and Governance” themes together highlighted the importance of ensuring adequate facilities for the prescriber, and a strong governance framework to support their prescribing practice. Covid-19 was found to affect some prescribers, either by altering how they practice, or by temporary changes to their role, as found by the “Covid-19″ theme. However, changes brought about by the Covid-19 pandemic also appeared in the “CPD” theme, with many participants describing online conferences and meetings becoming routine practice; enabling participation by a wider audience.
The relatively limited number of references to patient care may be considered surprising when compared with the Delphi study, where the top ranked statement concerned the effectiveness and benefits of prescribing for patients . However, this finding partially reflects the different research methods, with Delphi seeking consensus whereas focus groups enable deeper exploration of lived experiences of the participants. It also reflects the topics chosen for discussion, which were those where there were areas of potential disagreement between the two prescribing professions, and hence patient care was a subsidiary aspect of the discussion.
The previous review exploring barriers and facilitators to non-medical prescribing identified that many of the factors involved were inter-dependent . The experiences of the participants in this study supported this finding, with the important secondary co-dependencies depicted in Fig. 2. The “Quality and safety” theme was interdependent with all aspects of the “Governance” theme, resulting in improved care for patients. For example, participant FG2-P5 described constructive discussions with senior medical staff, informed by policies and guidance, resulting in team-wide changes in prescribing practice and improved patient care. For pharmacy managers, there was an implicit conflict between service delivery and governance, inferred by the “Second check” theme. Pharmacists are experts in medicines ; clinically screening prescriptions, the so called ‘second check’, to ensure appropriateness for the patient. Pharmacy managers are required to maintain the governance structure surrounding medicines supply, within a limited staffing establishment, and this can result not only in limiting time for pharmacist prescribing, but also difficulty in providing the second check. Evidence indicates that pharmacist prescribers make fewer errors than medical staff , but pharmacist participants perceived that they had been left without an important safety net. Further co-dependencies described by participants included the impact on senior medical staff of policies regarding patient accountability, with concern by some senior medical staff that they were accountable for the non-medical prescriber’s actions. This lack of clarity regarding accountability was identified in the previous review . The prescribing competency framework for all prescribers states that the prescriber is accountable for their prescribing decisions , however if a policy regarding patient accountability states that the consultant is responsible for the actions of their entire team, then this could result in confusion.
Differences were highlighted between professions, many of which could be anticipated from the way in which each profession traditionally works. For physiotherapists, prescribing forms another treatment option when caring for patients, fitting in to existing roles such as in musculoskeletal clinics , whilst also supporting the development of new roles based on existing skills . For the secondary care pharmacist participants, prescribing in many instances was in addition to their existing role, without due consideration to restructuring job plans to allow sufficient time. Consequently, physiotherapist participants felt well-supported for administration time, whereas for the pharmacist participants, unless expressly included in their job plan, administration time was a source of stress. Similarly, pharmacist participants, used to working in a team, described a team approach to decision making, compared with physiotherapists, used to planning treatment courses for patients, who were more inclined to make their own decisions.
For the physiotherapist participants, the choice of medicines that they can prescribe is limited by their professional scope of practice and legislation [38, 44], compared with pharmacists who can prescribe any medication, except certain drugs for the treatment of addiction [45, 46]. For the physiotherapists, probable changes in controlled drug legislation have the potential to influence how advanced practice roles develop, particularly if physiotherapists continue to have restricted access to controlled drugs . One physiotherapist participant described the constraints imposed by controlled drug legislation in chronic pain management, but commented that current guidance was moving away from drug treatment and hence expanding the choice of controlled drugs physiotherapists could prescribe may have limited impact in their case [47, 48].
Physiotherapist participants were more likely to describe lack of awareness of physiotherapist prescribing by the clinical team, than pharmacist participants. This reflects both the relatively short time span in which physiotherapists have had prescribing rights (independent prescribing rights since 2013) and the small numbers registered as prescribers (1017 independent prescribers in 2019) [17, 19]. In comparison, pharmacists gained independent prescribing rights in 2006, with 8077 independent prescribers on the register in 2019 [49, 50].
Planned changes in pharmacist pre-registration training, including at undergraduate level, will result in newly registered pharmacists registering as independent prescribers . Pharmacist participants expressed concerns about this development, including detraction from training aspects and potential exacerbation of prescribing errors, as previously identified with junior medical staff . The participants placed their views in the context of their own prescribing training, highlighting the struggle that less experienced pharmacists had with the course, and commenting that routine pharmacy work still needed addressing. However, the development is in line with the Carter report and draft workforce strategy, which both envisaged a clinical pharmacy workforce, with pharmacy technicians adopting some of the traditional pharmacist roles [36, 53]. The concerns expressed by pharmacist participants regarding time pressures to complete their tasks suggest that advanced pharmacy technician roles, which would release pharmacist time for prescribing, have still to be adopted.
Trustworthiness of the data is supported by the approach to analysis. Full, in-depth discussion of the findings by all authors, with challenge of the derived themes to ensure that they reflected the participants experiences was undertaken. The differences in background and experiences of the research team composition ensured that EGC’s longstanding prescribing experience in critical care, and possible preconceptions, were counterbalanced by the other team members, who were non-prescribers but clinicians in both physiotherapy and pharmaceutical fields. Data saturation was achieved, with the themes and main subthemes identified by each focus group and profession. This is supported by the answers to the final question regarding advice to new prescribers, added as a positive end note to each session. No new ideas were articulated but participants emphasised the need for a prescribing role, ensuring facilities were in place beforehand, asking for advice and not being pressurised to prescribe medication that they deemed outside their personal competence.
Strengths and limitations
The study allowed in-depth discussion of issues affecting pharmacist and physiotherapist prescribers, with ideas developed by the participants throughout the discussion. Participants drew on their experiences to describe issues affecting them, allowing a greater understanding of the background and contributory factors. As the themes were derived directly from these lived experiences, they acquired content and face validity.
The virtual platform, with choice of dates and times, allowed participants to join who may otherwise have been unable to because of constraints such as work commitments.
The Covid-19 pandemic limited recruitment: in particular fewer physiotherapist participants were recruited than planned. However, findings appeared unaffected with no new themes emerging from the second focus group. This supports the assertion that data saturation was achieved for the major themes identified.
It is acknowledged that recruitment may have been enhanced by widening the geographical catchment area. However, it was possible that some of the variation seen in the previous Delphi results  may have arisen from the wide range of practice and geographic areas in which participants were employed. Therefore a deliberate decision was made to limit recruitment to pharmacist and physiotherapist prescribers working in the NHS West Midlands area (either primary or secondary care), to reduce the risk of introducing variability into the findings.