Award Title: Innovation in the Allied Health Professions:  Evaluation of supplementary prescribing by dieticians and independent prescribing by therapeutic radiographers
Funder: Department of Health and Social Care

Abstract: .  Background        Evidence suggests non-medical prescribing (NMP), initially performed by nurses and pharmacists, offers improved service efficiency, access to medicines, cost savings, quality of care and better use of knowledge and skills. NMP was extended to advanced practice allied health professionals, e.g. podiatrists, dietitians (D) and therapeutic radiographers (TR). However, there is little evidence regarding D-TR prescribing effects or its implementation.  Dietitian supplementary-prescribing (D-SP) and therapeutic radiographer independent-prescribing (TR-IP) are widely supported with improvements to service delivery and standards of care keenly anticipated.   Aim: to identify effective prescribing practice and innovative service models through evaluation of D-SP and TR-IP implementation.   Objectives: The objectives are to:  Review evidence to inform D-TR prescribing Describe and classify D-SP and TR-IP services and identify innovative service models across England Examine D-SP and TR-IP prescribing activity and trends and factors that support or inhibit uptake or implementation Explore patient/carer views and experiences of D-SP and TR-IP Identify impact of D-SP and TR-IP on patient choice, experience, access to medicines and outcomes Assess quality, safety and clinical appropriateness of D-SP and TR-IP practice Explore cost-consequences of D-SP and TR-IP service models Evaluate quality, effectiveness and cost of D-TR prescribing educational programmes Develop non-medical prescribing (NMP) implementation toolkit for D-TRs    Plan of investigation A four-phase study informed by principles of case-study design, using mixed methods Phase 1 (months 1-6) involves a rapid review.                                  Phase 2 (months 1-30): surveys of a) NHS trusts across England to assess current situation of D-TR practice and identify innovative models and b) D-SP-TR-IPs to explore prescribing activity and trends,   Phase 3 (months 10-36): embedded case-study using mixed methods to compare cost-consequences and outcomes of D-SP-TR-IP. A three stage longitudinal in-depth analysis of six diverse D-TRs in their practice settings pre-post prescribing training over 27 months.   Stage 1: Pre-NMP training (months 10-12): will explore current organisational management, delivery and experience of care, identifying contextual information and factors facilitating success.  Data collected as follows at each site: i)              Interviews: D-TRs, manager, colleagues, patients/carers (n-5) ii)             Documentary evidence iii)            Observation of D-TRs over one working week (maximum 5 days), using electronic diaries and to collect information on medicines management, work activity and related costs (n-40-60 consultations) iv)           Patient questionnaires (n-24-42) v)            Case-record review (n-10)   Stage 2: During NMP training (months 13-24): D-TR two-monthly interviews to monitor NHS and private resources involved in delivery of training.    Stage 3: Post NMP training (months 25-36): all stage 1 procedures repeated at least 3 months post-qualification to allow embedding in practice.   Analysis (months 10-38) will comprise interim analysis of phase 2 and 3 data, followed by consideration of complete data sets, including convergent evidence across case-sites. Economic analysis will compare pre-post findings within case-sties and consider NHS and private costs in a costs-consequences framework, and assess value of the training programme.     Phase 4 (months 12-42) will synthesise phase 1-3 in a participatory co-design to discuss emerging findings (months 16 & 37), develop a D-TR NMP model of implementation and an online tool-kit (months 16-37).   Months 37-42: write up and dissemination   Research Team: combines expert knowledge of NMP, workforce development, dietetics and therapeutic radiography professional expertise, pharmacy/medicines optimisation, statistics, and health economics. Our long-time patient advisor and patient involvement group will guide the study throughout.     Impact: comprehensive D-SP-TR-IP evaluation will evidence cost, effectiveness and patient benefits to inform policy developers, service commissioners; guide professional bodies, and managers and support wider implementation. It will allow informed decision-making about extension of prescribing rights to other healthcare professionals and inform NMP development in other countries who look to follow our experience.

Lay Abstract: A recent change in the law allows Dietitians (Ds) and Therapeutic Radiographers (TRs), working at an advanced level, to prescribe medicine for patients that they treat.   Dietitians, who manage diet and feeding for many health problems, can prescribe medicines from a treatment plan agreed with a doctor. This is known as  supplementary prescribing . Therapeutic Radiographers, who deliver radiotherapy and manage the side effects of this for people with cancer, can assess patients and prescribe medicine without the need of a doctor. This is known as known as  independent prescribing . Research on prescribing by other professionals, such as nurses and pharmacists, shows benefits to patients and to the NHS. From talking to patients, we know that faster access to medicines is important and this change may be welcomed if patient safety is assured.   We aim to study the effect of Ds & TRs prescribing on patients, staff and services. We will study how prescribing is used and identify where it works well, in order to help managers to plan services. The study will be conducted by an experienced research team, including a patient advisor, and will be guided by clinicians, managers and a patient group to advise when best to approach patients and help design tools and written information.    After reviewing literature on Ds & TRs roles, we will carry out surveys to explore where Ds & TRs are employed and how they are practicing. Repeat surveys will identify changes over time. We will also select 6 sites where Ds & TRs are about to take the prescribing qualification and compare practice, costs and patient experience before and after. We will do this by observing practice, timing consultations, assessing prescriptions, asking patients to complete a questionnaire, and studying routine data including safety reports. Patients/carers, Ds & TRs and their managers/teams will be interviewed to explore views and experiences. A toolkit will be developed to guide health service managers.   The study lasts 3.5 years. A patient newsletter will report on study progress and final summary provided to participants. Findings will be presented at conferences, in scientific journals and feedback events.

Research Activity Codes: 8.1 ORGANISATION AND DELIVERY OF SERVICES
Health Categories: GENERIC HEALTH RELEVANCE