As life expectancy increases, and the world’s population continues to grow (1–3), many countries are shifting the focus of their health system from acute to chronic diseases, alongside managing increasing service demands (4). Global level predictions indicate > 2 billion people will be aged > 65 years by 2050, with the number > 80 years expected to double in the next decade, reaching 400 million by 2050 (1, 5). The implications for ensuring access to medicines are profound: 75% of the aging population in developed countries live with one or more chronic conditions (6), with many requiring multiple medications (5, 7). Recent data from the United Kingdom (UK), United States (US) and across Europe confirms 25% of adults take three or more medicines each day (2, 8) and that by 2020 the world’s population will receive 4.5 trillion doses of medicine each year (8–10).
There is however, a worldwide deficit of 18 million health workers (11), with a predicted 350,000 shortfall in the UK, and a third of the current workforce due to retire by 2030 (12).
With a 16% increase in workload since 2010, UK workforce deficits are magnified in primary care (13), where 90% of all health encounters occur (14), and there is shortage of 2,500 general practitioners. Given the unprecedented level of future demand it is crucial that sustainable solutions that alleviate shortfalls in the global health workforce are identified (11, 12). The nature of primary care has shifted, and an increasing number of appointments in UK general practice are provided by non-medical staff (12, 15). The recent NHS Long Term Plan proposes for example, a further 20,000 non-doctor roles for primary care (16). Inadequacies with traditional doctor-led care systems mean that in order to maintain patient access to prescription medicines, new approaches are urgently required (12, 17). Allied Health Professions i.e. therapeutic radiographers, paramedics, podiatrists and physiotherapists (AHP) have in particular been identified as having an integral role to the required transformational change (18).
Extending prescribing rights to nurses, pharmacists and allied health professions (19, 20) has been the focus of a UK policy drive to improve services and access to medicines by making better use of existing skills and support service innovation (18, 21–23). Of the 907,000 UK healthcare professionals entitled to undertake prescribing training (24), over 90,000 of the eligible workforce are now qualified as prescribers (24), placing the UK as a pioneer in the development of non-doctor prescribing worldwide.
In the UK Independent Prescribing (IP) and Supplementary Prescribing (SP) are two different forms of non-doctor prescribing. Training typically involves 27 classroom days and 12 days in practice under medical supervision (25, 26), a dual qualification in IP and SP being awarded to nurses, pharmacists, radiographers and paramedics, podiatrists and physiotherapists. Independent prescribers can make prescribing decisions without the need for a doctor, while supplementary prescribing is defined as dependent prescribing, as it is based on an initial diagnosis by a doctor and an agreed clinical management plan (CMP) detailing medicines that can be prescribed by the SP (27). SP prescribing rights were extended to some allied health professions in 2005, with further changes to legislation in 2013 permitting physiotherapists and podiatrists to prescribe medicines independently (28–30).
Although several other countries, including Australia, Ireland, and Netherlands, have seen similar developments in non-medical prescribing, approaches to training, accreditation and models of prescribing practice are varied (31–34). Physiotherapists have for example, authorisation to provide advice about and/or to administer or supply medicines in some states in Australia, New Zealand and Canada, but only those in the US military can prescribe (35, 36). Podiatrists have similar authority in Australia and some European countries but are only entitled to prescribe in some Canadian states (35, 37).
When used by nurses and pharmacists, SP and IP are reported as acceptable and beneficial to patients, with some evidence of enhanced clinical outcomes compared to those achieved by doctors (32, 38–40). More recently a systematic review of non-doctor prescribing, also known as non-medical prescribing (NMP), reported that NMP has no adverse impact upon patient outcomes, patient satisfaction or resource utilisation (41). Reviews on the impact of extended physiotherapist roles reveal research hampered by small numbers of practitioners, role variation and poor role definition (42, 43), literature dominated by service descriptions and audit with positive reporting bias (35, 42, 43), and a lack of evidence regarding podiatric practice (35). Whilst PP-SP helps streamline service delivery (44, 45), IP is expected to bring additional benefits in line with nurse and pharmacist prescribing (46, 47). Exploration of clinical and cost effectiveness in this area is however limited and has to date lead to inconclusive findings (48–53). As most evidence relates to nurses and pharmacists, it is important to evaluate the impact of prescribing by allied health professionals (AHPs) in order to inform commissioning and implementation of NMP services where they are beneficial.
Six years after the introduction of current legislation enabling physiotherapists and podiatrists to prescribe independently, there has been nearly a fourfold increase in the number of physiotherapists and podiatrists with prescribing rights in England (54, 55). As of November 2019 there were 1,017 physiotherapists and 376 podiatrists with an annotation as independent prescriber, with a further 118 physiotherapists and 71 podiatrists with just supplementary prescribing (56). There is a lack of evidence of reporting on PP-IP practice, or the medicines they prescribe. Evidence from a national survey collected during preparation for the IP role indicated that PPs planned to prescribe on a regular basis, with an overall volume of prescribing suggestive of 1–2 items per day. Reflecting clinical specialities key areas of intended prescribing for physiotherapists were musculoskeletal (MSK) services, orthopaedics, respiratory and pain management, and for podiatrists’ skin, infections and MSK conditions (57).
There are additionally no studies available which quantify the impact of podiatrist and physiotherapist independent prescribing on patient satisfaction, access to services, quality of life or report cost-implications of care delivery. This is important given the increasing emphasis in the UK and around the world on extending prescribing rights to nurses, pharmacists and AHPS as a key strategy in addressing workforce deficits and ensuring patients have ongoing access to medicines (11, 12, 17, 58).