This chapter presents the meaning of concordance and examines the underpinning evidence base for effective prescribing consultations. Concordance is compared with the traditional approach of compliance in medicine taking, concluding that the evidence base for the latter has been shown to be inadequate in a number of respects. The chapter gives an overview of the evidence base for the concept of concordance and draws out the implications from research for the new generation of prescribers, outlining the reasons why practitioners who are independent (IPs) and/or supplementary prescribers (SPs) need to incorporate these principles into their practice. An overview of the skills and competencies that prescribing professionals need in order to adopt concordance in practice is then presented. This is followed by a review of research on healthcare professionals’ use of concordance in practice. The evidence to date suggest that healthcare professionals are not yet enacting this approach to medicines discussion in practice. Further research is required to both understand professional practice and develop interventions to move practice towards a partnership model of communication

This chapter describes the development of non-medical prescribing across the different healthcare professional groups. Prescribing by community nurses is described and its expansion to include independent prescribing by other first-level registered nurses and later pharmacists and allied health professionals. Supplementary prescribing and how it is used is also outlined along with the educational preparation for the independent/supplementary prescribing role.

The authority to prescribe raises a range of important ethical concerns. This chapter provides an account of the ethical issues in independent and supplementary prescribing with an overview of ethical frameworks, medical and non-medical prescribers. The core of ethical considerations of prescribing is the imbalance of power between the prescriber and patient where there is the potential for abuse and the power to control. As such, links to governing bodies are included with specific relationships between ethics and codes to remind practitioners that objective external standards are necessary to ensure they have a frame of reference against which to judge their actions

Many health professionals have extended patient care roles and prescribe as supplementary prescribers in partnership with independent prescribers or independently in their own right. However, all prescribers can be vulnerable to the same systemic causes of prescribing error. Prescribing errors, unless detected by another person involved in medicine use, lead to incorrect medicines being taken or given, with the risk of harm. All prescribers need to be vigilant and aware of potential causes of errors in decision making or miscommunication during the prescription writing process such as incomplete knowledge of the patient’s medical condition and treatment, look-alike and sound-alike drug names, illegible handwriting, use of abbreviations, unusual dose frequencies and drug selection errors in electronic prescribing systems. Prescribers also need to consider actions that should be taken to minimise the risk of prescribing error, e.g. knowledge of electronic the prescribing system, prescription writing standards (including for controlled drugs), prescribing of biological medicines by brand name and awareness of high-risk drugs linked to problematic polypharmacy in older adults

The competence framework for prescribers states that they should be able to accurately complete and routinely check calculations relevant to prescribing and practical dosing. Prescribers should know about common types of medication error and how to prevent them. The incorrect application of dosing equations is considered a major contributor to preventable adverse events associated with the prescribing of medicines. Anyone required to check calculations performed by others must be competent to perform such calculations independently. A complex calculation is any process requiring more than one step in the preparation and/or administration of a medicine to a patient. Throughout the chapter there are useful tips on how to reduce the risks associated with complex calculations. This chapter includes information on units of measurement, units of amount and various methods used to calculate drug concentration, dose and rate of drug administration. Also included are simple pharmacokinetic concepts and calculations specific to palliative care. At the end of each section there are sample calculations (with answers) allowing readers to test their calculation abilities

This chapter explores the biopsychosocial factors that influence prescribing behaviour. It begins by introducing theories of behaviour to explore how health systems, pharmaceutical companies, individual professions, roles and identities, colleagues, patients, the time of day, personal beliefs, habits, emotions and the environmental setting can all influence prescribers and their prescribing behaviour. It also discusses the influences of wider society and culture and how that has also shaped healthcare, prescribing practice and patients’ understandings of illness and their expectations around healthcare and treatment. Having taken a look at all these influences on prescribing behaviour, it gives an overview of interventions that help prescribers optimise their prescribing decision making and prescribing behaviours as well as optimise patient satisfaction with and adherence to treatment. These include person-centred and shared decision making, using motivational interviewing to enhance communication during consultations and evidence-based training programmes that have used these approaches to optimise non-medical prescribing.

In the UK, the education and training landscape for healthcare students has changed considerably in the last few years. This is largely because of key governmental policies introduced in response to the wider workforce issue in the UK National Health Service. In this chapter, we discuss recent UK policies and standards relevant to non-medical prescribing and reflect on the potential implications they may have on the provision of future education and training for undergraduate and prescribing course providers and students. We also highlight opportunities for providers that will help future-proof programmes

Public health practice is focused on enhancing the health of the entire population. A key public health concern around prescribing concerns the rapid rise in antimicrobial resistance, including resistance to antimicrobials of last resort. The situation has even been described as an ‘apocalypse’. Non-medical prescribers have a key role to play in reducing or preventing antimicrobial resistance and there is ample evidence that they are having a positive impact with regard to antimicrobial stewardship programs in various healthcare and community settings. They also have important contributions to make to preventing ill health in the first place, especially through vaccination programs

Consultation and decision making form a central and critical part of non-medical prescribing practice. This chapter introduces the reader to key consultation and decision-making models which can be used to help practitioners guide their development in this area. The importance of communication and consideration of the patient’s health beliefs will be discussed. Some of the evidence related to consultation by different non-medical prescribing professions will be explored. Frameworks supporting good prescribing will be discussed as well as influences on prescribing.

This chapter discusses the political, professional and legal aspects of non-medical prescribing from its inception in the 1990s to the present day. It considers important legal cases that illustrate the key issues of autonomy, negligence and consent and illustrates how these scenarios can impact on prescribing practice on a daily basis. The role of professional regulators is highlighted and the notion that patients/clients are no longer subservient to benign medical paternalism but rather are seen as consumers of healthcare is considered. New educational aspirations are mentioned with a reliance on evidenced-based practice and a holistic humanised approach to care delivery

Non-medical prescribing is increasingly important in the NHS, as is a multidisciplinary approach to asthma management in both primary and secondary care. The chapter on asthma prescribing and monitoring focuses on a stepwise approach to management in line with national guidelines and the importance of regular review of symptom control. Factors to consider when choosing the appropriate inhaler, including the assessment of inhaler technique, are outlined. The asthma medications commonly prescribed in primary care are discussed in terms of their utility, position in the stepwise management of asthma and common side effects. Drugs initiated or prescribed by asthma specialist teams in secondary or tertiary care are also covered. The chapter concludes with a number of resources for future reference.

Antimicrobials have revolutionised clinical care, but their use and misuse has contributed to the current drug-resistance emergency. The prescription of antimicrobials demand that prescribers demonstrate technical skills such as knowledge about pharmacokinetic and pharmacodynamics, up-to-date awareness of emerging infections and understanding of local and national drug susceptibility. In addition to these skills, prescribers must also demonstrate optimal and effective communication with patients, particularly when antibiotics are not warranted. These ‘softer’ skills are essential to balance the influence of social or cultural factors on decisions by all stakeholders involved in antibiotic usage. To balance these demands, prescribers can engage in systematic decision making that reflects upon the need and benefits of using antimicrobials. This will ensure that optimal diagnostic and imaging tests inform such decisions; following recognised guidance and best practice, whilst acknowledging the local drug susceptibilities and available resources; and engage and support patients and families to share decisions about antibiotic use and follow-up care.

The prescribing of medicines by a range of health professions is pivotal to the success of the future NHS. Prescribing is a key enabler of specialist and advanced practice, and health professionals that can prescribe medicines are crucial members of healthcare delivery teams. Widening the prescribing of medicines to some professions in addition to the medical profession has changed the role boundaries of those prescribing professions, necessitating changes to relationships between those involved in the patient’s care. The teams in which prescribers work are across the full range of professions, extending beyond traditional boundaries, and include consideration of housing, education, employment as well as physical, mental and social health. This diversity has introduced a need for further integrated working and collaboration across the system. Excellent teamwork, clinical governance, communication and information sharing are crucial, as is the need for team members to have a clear understanding of one another’s roles and the ability to communicate with one another.

This chapter provides a concise overview of the key principles of pharmacology that prescribers should be familiar with in their day-to-day prescribing practice. It includes sections on pharmacokinetics, pharmacodynamics, drug interactions and adverse drug reactions. This third edition includes updated examples and reference to deprescribing in relation to applied pharmacology, as well as information on biosimilars and bioequivalence

As healthcare professionals we strive to provide the best treatments for all our patients. We should have the confidence that after we have made an accurate diagnosis and assessment of clinical need, then the treatment which we recommend should be the best available for each patient. Evidence-based prescribing can be defined as using the best available information to recommend the most effective treatment for the person you are treating. At present we appear to be under siege from an assault of ‘fake news’ stories or ‘alternative facts’. As clinicians we have a duty to do the best for our patients on the most accurate information. In order to do this we require an armamentarium which includes the ability to sift fact from fiction. This chapter will provide a practical outline of how to sift the evidence and give you the confidence to prescribe using the best evidence base. It will also cover the issues of pharmacovigilance, adverse drug reactions and consider the future of evidence-based prescribing.