VOL: 98, ISSUE: 49, PAGE NO: 26
ROSEMARY COOK, MSC, PN CERT, RGN, IS NURSING OFFICER, DEPARTMENT OF HEALTH, LEEDS
The term ‘supplementary prescribing’ (SP) has been adopted to describe a new form of prescribing that can be undertaken by non-medical health professionals after a doctor has made a diagnosis and drawn up a clinical management plan (CMP) for the patient.
SP is an entirely new way of prescribing. Section 63 of the Health and Social Care Act (2001) allows ministers, by order, to designate new categories of prescriber, and to set conditions for their prescribing. Orders and changes to NHS regulations will be set out this month to allow SP, which is defined in Box 1, to be undertaken by nurses and pharmacists.
Drawing on the results of a consultation by the DoH and Medicines Control Agency (MCA/DoH, 2002), recommendations to ministers by the Committee on Safety of Medicines and the Medicines Commission (DoH, 2002) were announced by health minister Lord Philip Hunt last month.
The consultation paper proposed key principles that should underpin SP. These emphasise the importance of communication between the prescribing partners and the need for access to shared patient records. It is essential that patients are treated as partners in their own care and are involved at all stages of decision-making, including whether SP will be part of their care.
Secondary legislation will set out the criteria for lawful SP. This will mean that:
- The independent prescriber (IP) must be a doctor or dentist;
- The supplementary prescriber must be a registered nurse, registered midwife or a registered pharmacist;
- The IP and supplementary prescriber must share access to, consult and use the same common patient record;
- There must be a written CMP (see Box 2) relating to a named patient and to that patient’s specific conditions, and agreement to the plan must be recorded by both the IP and supplementary prescriber before SP begins.
Unlike independent nurse prescribing there will be no legal restriction placed on the clinical conditions that supplementary prescribers may treat. SP is likely to be most useful in dealing with long-term medical conditions, such as asthma, diabetes and hypertension, or with long-term health needs, such as anticoagulation as it requires a prescribing partnership and a CMP for the patient before it can begin. However, IPs, working with supplementary prescribers, will be able to decide whether SP is appropriate when drawing up the patient’s CMP.
Unlike independent nurse prescribing, there will be no specific formulary or list of medicines for SP. Following responses to the consultation, supplementary prescribers will be able to prescribe a wide range of medicines and products providing that they can be prescribed by IPs at NHS expense, and that they are referred to in the patient’s CMP and agreed with the independent prescriber. The following groups of medicines and products can be prescribed by supplementary prescribers:
- All general sales list (GSL) medicines, pharmacy (P) medicines, appliances and devices, foods and other borderline substances;
- All prescription only medicines (POMs);
- Medicines for use outside of their licensed indications (‘off-label’ prescribing), ‘black triangle’ drugs, and drugs marked ‘less suitable for prescribing’ in the British National Formulary;
- Unlicensed drugs (in specific circumstances only);
- Controlled drugs (once necessary changes have been made to misuse of drugs legislation).
Preparation for SP
For nurses, preparation for SP will be based on that for independent nurse prescribing from the Nurse Prescribers’ Extended Formulary (25 days of university contact time, plus 12 days learning in practice with a medical prescriber and self-directed study).
Supplementary prescribers, and probably their IP partners, will need brief additional training related to the nature, context and limits of SP. Independent extended formulary nurse and midwife prescribers, who have already completed the extended nurse prescribing preparation, will only need to top up with a short additional SP module.
In parallel with policy development work, the DoH commissioned the National Prescribing Centre to undertake a study to find out how SP might work in practice. The centre brought together a range of nurses, pharmacists and the doctors they work with, from a variety of specialisms across primary and secondary care, to ‘try out’ supplementary prescribing. They invented some typical patients, and worked up CMPs for them, identifying the information that would need to be included, and the best ways to reduce duplication of effort while ensuring patient safety. In doing so, it became clear that:
- Clinical management plans must be relatively simple and quick to complete, or SP will simply not be worth the effort. The plans should not duplicate a lot of information that is already recorded in the shared record. Templates for CMPs, which could then be individualised to meet patients’ needs, could be useful in minimising duplication of effort. Plans may also make reference to appropriate reputable guidelines or agreed protocols (such as chemotherapy protocols) for treatment of a specific condition, rather than reproducing lists of medicines, providing the guidelines or protocols are readily available for consultation by the supplementary prescriber;
- The SP partnership might have to work differently when the supplementary prescribers and IPs are in close contact (for example, nurse practitioner and GP), compared with when they are more remote (such as peripatetic diabetes specialist nurse and consultant diabetologist). Remote prescribing partnerships may only be feasible where shared electronic patient records are used and SP might need to include team as well as one-to-one prescribing partnerships in such cases;
- For patients with multiple health needs, or multiple professional carers, SP may not be suitable at all: the IP can decide if SP is appropriate for a particular patient;
- For nurse-led services, where nurses assess, diagnose, plan care and treat patients, independent nurse prescribing will be more appropriate than SP.
An example of a prescribing partnership is given below.
Nurse specialist and consultant partnerships
Mr A was diagnosed with Parkinson’s disease a year ago, and the PD nurse specialist sees him regularly to monitor his condition, give him information and support, and assess the effectiveness of his treatment in controlling his symptoms. The nurse and consultant now agree to share prescribing of the consultant’s usual protocol of drugs to treat the disease; these medicines are preprinted on a template CMP. Mr A’s personal details, including drug sensitivities, are inserted into the plan, and the consultant adds some additional medicines for Mr A’s chronic obstructive pulmonary disease.
A date for a joint review is agreed for six months’ time, and both practitioners record their agreement in the CMP. As the nurse and consultant are both hospital-based, and both have access to Mr A’s hospital record, the CMP does not need to reproduce all the information. The nurse reviews Mr A regularly over the next six months, prescribing medicines and altering dosages and preparations to achieve optimum therapeutic dose and minimise or treat side-effects, within the limits of the CMP. All prescribing is recorded in the hospital record. After six months, the nurse and consultant review Mr A’s condition, and discuss and amend the CMP.
What happens next?
The programme of preparation for nurses will be in place from January 2003, following approval of courses by the NMC. This will include arrangements for nurses who have already qualified to prescribe from the current extended formulary to access separately the additional SP element.
The preparation and training for pharmacists will be in place by Spring 2003. The necessary changes to the POM Order and NHS regulations will be laid in December to enable supplementary prescribers to begin prescribing after completing training. The DoH will provide guidance on implementation of SP early in 2003.
SP provides a new and robust legal framework for those situations where expert nurses already do, or could, advise their medical colleagues on appropriate choices of medicines, or where they currently obtain signatures on prescriptions for patients whom they have examined and assessed, but the doctor has not seen. It frees nurses to combine the professionalism of expert practice with the responsibility of prescribing for patients with complex or long-terms needs. The outcome should benefit patients by reducing the number of appointments they require and providing a more seamless service, and should benefit professionals by enabling them to work together to make the best use of their skills and time.
Department of Health: www.doh.gov.uk/nurseprescribing (for independent nurse prescribing); www.doh.gov.uk/supplementaryprescribing (for supplementary prescribing)
Medicines Control Agency: www.mca.gov.uk
National Prescribing Centre: www.npc.co.uk