Radiography (2006) 12, 3e5

GUEST EDITORIAL

Radiographer prescribing: Enhancing seamlesscare in oncology

Background

The last decade has seen therapy radiographersembrace radical changes in technology and pat-terns of service delivery unparalleled since theintroduction of the linear accelerator and treat-ment simulator in the 1960s. The backdrop to thesechanges has been the repercussions from thepublication in 1995 of the Calman Hine Report.1

The importance of this document to the develop-ment of cancer treatment delivery and care cannotbe over-emphasised, one key feature being that itfirst brought the importance of seamless care tothe attention of many practitioners. The NHSCancer Plan,2 the government strategy devisedlargely to implement the findings of the report,clearly identifies the importance of therapy radiog-raphers in the delivery of planned improvements inservice. This recognised the need to optimise theskills and competencies of the workforce withoutconstraining their professional boundaries.

Radiographers are well placed to enhance thedelivery of seamless care in the support of patientsundergoing radiotherapy as demonstrated byradiographer-led treatment review: but the servicethey offer in care and advice has been constrainedby the radiographer’s inability to prescribe drugsfor the management of treatment toxicity. Thisyear, however, legislation will be passed enablinga variety of health professionals (HPs) to become‘new’ drug prescribers.

Historical context and legislativeframework

Over time, provision has increasingly failed tomeet the demands of health care services. Pa-tients have had greater expectations of control

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and flexibility of service and the multidisciplinaryteam approach to care emerged to dominatea range of specialisms. Furthermore, the scopeand complexity of medicine has led to situationswhere the practitioner with most knowledge andexperience of drugs in a particular care settingmight not be a doctor.

Baroness Julia Cumberlege saw the potentialthat district nurses and health visitors had toredefine their roles. In her report ‘NeighbourhoodNursing’3 she noted that patient care was oftencomplicated by the inability of the nurse to pre-scribe the evidence-based treatment she or hewould suggest to be prescribed by the GP followingfull assessment. Another three years passed beforea working party headed by Dr June Crown pro-duced their report4 outlining who should pre-scribe, what they should prescribe and how itshould be funded. Those nurses with a districtnurse or health visitor qualification and workingin primary care were defined, to prescribe froma limited formulary designed around commonareas of practice, and it should be funded fromexisting prescribing budgets i.e. it should be sub-stitute prescribing not additional.

As at that point only doctors, dentists andveterinary surgeons could legally prescribe accord-ing to the Medicines Act 1968, legislation waspassed in 1992 to permit nurses to prescribe.Several pilot studies later, from 1999 nurse pre-scribing was rolled out nationally across Englandand Wales. To date there are over 28,000 nursesprescribing independently from the Nurse Prescrib-ers’ Formulary.

At the time when the national roll out of thetraining of nurse prescribing began, Dr JuneCrown’s working party produced their second re-port.5 This looked at who else should be able touse prescribing responsibilities. The expectation

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4 Guest Editorial

was that extending prescribing would optimise theuse of resources, enhance professional relation-ships and improve patient access to care and toseamless care.

They defined extended independent and de-pendent (supplementary) prescribing, recommen-ded that other groups of professionals should beable to legally prescribe and outlined a process bywhich the professional bodies might make a casefor their members. They also made recommenda-tions about the use of Group Protocols (patientgroup directions). These allow for the provision ofsupply and/or administration of medicines byprofessionals other than doctors and dentists andare not, strictly speaking, prescribing.6

Extended independent prescribing involves thehealth professional making the diagnosis andprescribing from a restricted formulary for thecondition without the involvement of a doctor. Onlynurses can prescribe this way at present, but shouldbe joined by pharmacists by the end of 2005. Theformulary is revised and expanded on a yearly basisand a Department of Health consultation to greatlyenlarge it is currently being considered.

Supplementary prescribing is an ideal tool forthose working with patients with enduring condi-tions for which there is already a diagnosis. Itinvolves the creation of a clinical managementplan e a treatment plan drawn up by the in-dependent prescriber (doctor or dentist), thesupplementary prescriber and the patient. Thisenables the supplementary prescriber to varydosages and prescribe alternative products asnecessary. The majority of the British NationalFormulary (BNF) is available here; but as shouldbe the case with all prescribers, medical or not,its usage should be restricted to those items withinthe prescriber’s competency areas. Nurses startedto prescribe this way from 2003, closely followedby pharmacists. From 8 April, 2005 the secondwave of legislation came into effect, enablingsupplementary prescribing for Radiographers,Physiotherapists, and Podiatrists (subject to Parlia-mentary approval). In order to appreciate some ofthe issues surrounding this opportunity, it may beuseful to review the experience of radiographersin the administration of drugs in oncology.

The new prescriber and the oncologycontext

Since 1998 radiographers have been trained atpost-graduate level to administer drugs (selectedfrom a limited range) under patient group direc-tions (PGDs) for the management of treatment side

effects including pain, rectal symptoms, constipa-tion, diarrhoea, skin reactions, wound care, oralcare, nausea, and vomiting. For example, a radiog-rapher could assess, advise and supply pre-packs ofImodium to patients exhibiting diarrhoea as a sideeffect of pelvic radiotherapy, avoiding the addi-tional wait for consultation with the clinicaloncologist. Under the new provision, the supple-mentary prescriber will be licensed to prescribeany substance within the British National Formu-lary (excluding controlled drugs) agreed within theclinical management plan, and within competency,allowing for greater scope of interventions in thecare of patients experiencing side effects.

Other requirements of supplementary prescrib-ing match well the existing professional contextof radiographers, oncologists and their patients.Supplementary prescribing will be most useful forchronic conditions, for example, the cancer dis-ease trajectory which involves significant extendedperiods of care following initial diagnosis. Theclinical management plan may be facilitatedthrough the usual interaction processes leadingto informed consent.

An outline curriculum for training programmesto prepare AHPs to assume the role of supplemen-tary prescribers has been devised by a DH steeringgroup based on those existing curricula for nursesand pharmacists and is currently under discussion.Multidisciplinary post-registration level 3 courseswill provide a core component and specific path-ways covering three areas of competence: theconsultation, the prescription, and the context ofcare. The taught course will consider prescribingbehaviour not the clinical specialism, the studentis expected to have the relevant knowledge ofspecific medicines and interventions, and will workwith a medical mentor to further develop this inline with the programme. The register of theHealth Professions Council will identify radiogra-phers who are supplementary prescribers, with theusual requirement for self-declaration of themaintenance of competence.

Implications for practice

Supplementary prescribing for therapy radiogra-phers will be both exciting and demanding: theevaluation of educating radiographers for deliveryof care through PGDs has identified several issuesto be addressed. Changes to prescribing must be inresponse to local needs and with the optimisationof human resources in mind. It may be argued thatwhere oncology nurses adequately support radio-therapy patient care, it may be inappropriate to

Guest Editorial 5

remove scarce radiographers from treatment plan-ning and delivery. Indeed, in some cases anoncology nurse may already be a non-medicalprescriber in a unit. However, facilitating ad-vanced practice in areas of patient care in themidst of an ever more technical environment mayalso have a benefit in that it may encourageexperienced staff to remain in the profession.Working patterns with PGDs indicate that therewill be few radiographers employed solely to fulfillthis role and there is most likely to be integrationwith radiographer-led treatment review. Trueseamless care, however, would be provided whenthere is sufficient trained staff to offer supple-mentary prescribing on each treatment unit; themost disruptive mode of working could occur whenthe sole radiographer prescriber sees patientsfrom many units purely to prescribe for the sideeffects of their treatment. Tensions could arise notjust between the radiotherapy team members butfor the individual practitioner.

Support for those in trainingwill be critical:manyradiographers fail to complete courses for drugadministration through PGDs mainly because ofa failure of access to adequate patient experience.For example, when radiographers are moved fromthe treatment floor to the simulator, in the face ofservice requirements the agreement between themanager and the learner in the workplace can befragile. Personal experience suggests that clinicaloncologists have considerable regard for theirradiography colleagues and in many technologicalareas (most notably portal image viewing)support radiographer role development as beingmutually beneficial. They would need to considerthis development in prescribing to be helpful tothemselves and their junior staff in providing animproved and safe service for patients if they are towhole-heartedly provide the level of mentoring andsupport required by the novice prescriber. It shouldbe noted here that it has never been intended thatcancer-related symptoms would be managed byanyone other than the clinical oncologist.

Professional development for therapy radiogra-phers has been achieved in the face of increasingservice pressures and an ever stretched workforce;a practice that takes the radiographer away fromthe treatment unit may be seen as an expensiveluxury better fulfilled by others. However, a reviewcommissioned by Cancer Research of the educa-tion and training curricula for medicine, nursing,physiotherapy, and therapeutic radiography high-lighted that ‘.[therapy radiographers].have the

best grounding not just in cancer but particularlyin cancer care.encouraged to see patients as peo-ple with cancer.’.7 With this endorsement addingto an already persuasive debate, radiographersshould be encouraged to embrace this opportunityfor the enhancement of patient experience andfurther improvement in professional practice.

References

1. Department of Health. Policy framework for commissioningof cancer services. London: HMSO; 1995.

2. Department of Health. The NHS cancer plan. London: HMSO;2000.

3. Department of Health and Social Security. Neighbourhoodnursing: a focus for care (Cumberlege report). London:HMSO; 1986.

4. Department of Health. Report of the advisory group on nurseprescribing. London: HMSO; 1989 [Crown].

5. Department of Health. Review of prescribing, supply and ad-ministration of medicines: final report. London: DH; 1999.

6. Department of Health. Health service circular: patient groupdirections (England only). DH; 2000 [HSC 2000/026].

7. Coles CR, Fleming WG, Golding LG. Curricula for cancer:a practice-focused approach. London: Cancer Research UK;2003.

Further reading

1. A useful source of information on non-medical prescribinghas recently been published by the NHS ModernisationAgency: Medicines matters: a guide to current mechanismsfor the prescribing, supply and administration of medicines.Department of Health, <www.dh.gov.uk>; 2005.

2. Patient group directions: a practical guide and framework ofcompetencies for all professionals using patient group direc-tions. National Prescribing Centre, <www.npc.co.uk>; 2004.

3. Please also see ‘supplementary prescribing’ on the Depart-ment of Health website, <www.dh.gov.uk>.

Geraldine Francis*

School of Radiography, Faculty of Healthand Social Care Sciences, Kingston University,Penrhyn Road Campus, Kingston upon Thames,

Surrey KT1 2EE, United Kingdom*Corresponding author. Tel.: þ44 208 547 8164.

E-mail address: gfrancis@hscs.sghms.ac.uk

Dianne HoggBurnley, Pendle & Rorsendale Primary Care Trust,

Burnley, Lancashire, United Kingdom

Available online 1 December 2005