While there have been previous published reviews of non-medical prescribing, none have considered the evidence from one setting, in this case primary care, or have focused on outcomes.
In this review, 19 papers of 17 empirical studies (two studies published two articles each) were identified which provided evidence of patient outcome of NMP in primary care settings. The majority were undertaken in the UK with only one each from the USA, Canada, Botswana and Zimbabwe. Seven papers report on UK studies of nurse prescribing from a limited nurses' formulary. Seven papers reported on qualitative designs and four of these had fewer than ten participants. Two reported on surveys of opinion and experience. Eight papers reported on record reviews of prescriptions or clinical consultation by NMPs. Those studies that provide objective measures are mainly descriptive. Only one provided some comparative evidence of another type of prescriber, GPs, by which to judge the impact on patient outcomes or outcomes on the efficiency for the health system [52
]. While there may be a publication bias in reporting positive outcomes present in those identified, many of the studies included in the review had design weaknesses and limitations, both as indicated by the authors and evident through critical appraisal of the papers. The strength of evidence they provide on the whole is limited.
The review findings from stakeholders' perspectives suggest that NMP in primary care effectively improves patients' understanding of treatment, condition and self-care and provides a better level of care. As the literature suggests that concordance is a major issue in the effective use of medicines in primary care settings [62
] the impact of additional information and advice may be significant in considering which type of prescriber is effective for which particular patient groups. This proposition requires further testing and investigation.
We found very limited evidence in relation to other indicators of effectiveness of NMP outcomes such as of patient safety and clinical outcomes. The overall number of research-based studies to evaluate impact and outcome of NMP was low given that NMP was introduced in many countries over 30 years ago. In part this reflected the number of papers excluded as it was not possible to separate primary care related data from secondary care related data but it may also be that NMP is seen as producing positive outcomes in situations where there are no alternative prescribers. This may explain the absence of empirical outcome evidence from low income countries in particular, although this may also reflect the review search strategy, which did not search country specific journals not indexed on the major electronic databases. Given that it is a minority of countries that have given prescribing authority to professionals other than doctors and dentists, it may be that it is this type of evidence that would be of value to policy makers and requires further investigation and publication.
In relation to efficiency of NMP in primary care, the review suggests that patients received services that were timely, seamless and of high quality from nurse and pharmacist prescribers. One study reported opinions that NMP was cost effective in primary care. We were unable to find any papers from a health economics perspective or that modelled the efficiency impact from either patient or the health services perspective. We suggest that this is an aspect that warrants further investigation.
All the studies investigating acceptability of NMP indicated that NMP was well accepted and favoured by patients, nurses, pharmacists and other health care professionals. The gradual growth over time of legislative authority to NMP and also of the numbers of non-medical prescribers, particularly nurses, in countries such as the USA and the UK, suggests that the acceptability is based not just on immediate levels of satisfaction with the clinical encounter but perceived value to the health care system as a whole.
The review findings also report that patients considered it was easier, quicker and convenient to get an appointment with NMP and their access to medicine and health care professionals was improved. For all countries the issue of timely access to appropriate medicines has health service and public health ramifications. For countries with well developed primary care services such as the UK, the ability of primary care professionals other than doctors to provide consultations that include prescribing may improve waiting times to consult and help manage demand and potential dissatisfaction. The issue of equitable access to safe and affordable medicine is critical for lower-income countries where the access to medicines is compromised by insufficient health facilities and staff, low investment in health and the high cost of medicines [63
]. In these settings if legislative authority to prescribe is not extended to groups other than doctors and dentists, using mechanisms such as patient group directions or standing orders for community health workers for a specified essential drug list and immunisation list may have significant and critical public health impact. The contribution of these types of mechanisms with a broader group of community health staff is not within the scope of this review but warrants further investigation.
This review has limitations in that it included only English language studies and those accessed through electronic sources and therefore may have excluded evidence from many Scandinavian, African, South East Asian and South American countries. However, our review of countries that have legislated for prescribing authority for professionals other than doctors and dentists would suggest that researchers from many of these countries are likely to publish evidence in English language journals, although not necessarily ones that are indexed through the databases we searched.
Our focus on patient and health service outcomes has been both a strength and a weakness: while outcomes are important, the small number of studies finally included demonstrate how limited the evidence is. We argue that it is these aspects that most urgently need investigation. Our focus on solely primary care has also meant that we have had to exclude some more recent studies providing evidence from mixed primary and secondary care settings, aspects such as clinical appropriateness of NMP, e.g. Drennan et al, 2009, Latter et al, 2010, and Bissell et al, 2008 [3
]. In many of these studies there were substantial numbers of NMP in primary care settings. We suggest that secondary data analysis of some of these studies by health care setting may be invaluable to providing evidence for service planners, commissioners and managers.