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Nurse prescribing: week 2 - local formularies

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VOL: 98, ISSUE: 42, PAGE NO: 41

PETER BURRILL, BPharm (Hons), MRPharmS, DipPresSci, AFPMM, is Specialist in Pharmaceutical Public Health for North Derbyshire Public Health Network, and a National Prescribing Centre Training Adviser

MOLLY COURTENAY, MSc, PhD, CertEd, RNT, RGN, is a lecturer at the School of Nursing and Midwifery, University of SouthamptonSponsored by PFIZER



Local medicines formularies have now become accepted as being the basis for effective prescribing in both primary and secondary care. The aim of such formularies is to guide prescribers towards using products with demonstrable clinical and cost-effectiveness. A consequence of using such formularies, however, is that prescribing choice is restricted. Nurse prescribers, whether working in general practice, acute trusts or in the community, need to understand the principles behind formulary development and be able to practise within the consequential constraints.



The rationale for having local formularies
Why do prescribers need local formularies when they already have a national formulary - the British National Formulary (BNF)? The reason is that the BNF is too comprehensive for everyday use - it lists every drug available in the UK. Furthermore, many drugs in the BNF have a limited evidence base. To gain a licence, a drug only has to have been shown to be efficacious compared to placebo. Licensing decisions, moreover, can be made on trials involving as few as 1,500 patients. Health professionals are interested in a drug’s effectiveness, and in a cash-limited organisation like the NHS, the cost-effectiveness of a drug is important. Prescribers, therefore, need a formulary of more manageable proportions than the BNF for their everyday practice to enable them to make rational choices of a drug to cover up to 95% of situations presenting in their practice.



Characteristics of a good formulary
While compiling a formulary, three main criteria are used for determining the selection of a drug:



- Efficacy - determined in clinical trials. ‘Can it work?’



- Effectiveness - demonstrated in practice. ‘Does it work?’



- Efficiency - deduced from an assessment of costs and benefits. ‘Is it worth it?’



There are three characteristics of a good formulary. It should:



- Lead to more consistent prescribing between partners, practices, primary and secondary care



- Lead to a better understanding of the side-effects and adverse drug reactions of drugs, allowing anticipation and early detection.



- Promote high quality, cost-effective prescribing.



Using local formularies
A formulary should be a working tool, not a decorative item for the desktop. It must be monitored, reinforced and revised continuously. Initial gains are quickly lost unless there is continuous feedback and intervention.



There is surprisingly little published evidence that formularies change prescribing behaviour, but personal experience has proved that they certainly can. For instance, in North Derbyshire a formulary and guideline on antibiotics has been in use for a number of years. This has changed antibiotic usage in the area so that North Derbyshire is now one of the lowest users of antibiotics in the country. A wound care formulary has now been introduced locally at the request of the nurses, to try and make sense of the many products listed in the Drug Tariff.



Developing a formulary
When developing a practice formulary, the starting point is to analyse current prescribing using PACT (Prescribing Analysis and CosT) data. After a pharmacist has worked through the BNF chapters one at a time, a meeting is held with the relevant practice staff to discuss the analysis and the published evidence on effectiveness, safety and cost. This exercise is advantageous in its own right. After a series of meetings, agreement is normally reached on which drugs and preparations to include. The aim is to develop a formulary that is more than a simple list of drugs, and includes recommended dosages and simple directions such as ‘first line’, ‘use only if intolerant to drug X’, but does not become a mini BNF.



Local formularies are useful if they are well constructed, and they can bring about change in practice. In the present NHS climate of monetary constraints they are probably essential. They certainly can help to improve medicines management and efficiency and, if used with guidelines, they can drive appropriate and consistent good clinical practice.




The number of independent nurse prescribers is forecast to reach more than 30,000 by 2004. What the various groups can prescribe - subject to certain training - looks set to expand following government announcements earlier this year. The importance of keeping abreast of the latest developments is vital. A free, online website, called Nurse Prescriber, which is the official website of the Association for Nurse Prescribing, has been developed to provide information and support to nurses involved in this area.



The new regulations
The Department of Health estimates that there are 23,000 district nurses and health visitors qualified to prescribe a limited number of medicines detailed in the Nurse Prescribers’ Formulary. During 2001, support was given by the government for the extension of nurse prescribing (DoH, 2001). Education and training for extended nurse prescribing commenced in 2002. By 2004, a further 10,000 nurses will be trained and able to prescribe from an extended formulary.



These independent prescribers will be able to prescribe all pharmacy products and general sales list items and a number of prescription-only medicines (over 130) for four broad categories: minor injuries; minor ailments; health promotion and palliative care.



In addition, in April this year, health minister Lord Hunt published a consultation paper on ‘supplementary’ prescribing for nurses and pharmacists (DoH, 2002). It proposes that some nurses and pharmacists, following further training, will be able to prescribe medicines for chronic conditions such as asthma, diabetes, high blood pressure and arthritis, but only after a patient has been diagnosed by a doctor.



It is envisaged that nurses and pharmacists will work closely with doctors and that the prescribing will be underpinned by a clinical management plan drawn up between the doctor (independent prescriber) and the nurse (dependent prescriber). The government is currently considering the responses to the consultation paper, and an announcement is expected at any time.



Training and keeping up-to-date
Keeping abreast of all the latest developments, and learning from other colleagues, is vital if these latest changes are to work. Training has already been highlighted as a crucial issue in many of the responses to the DoH’s earlier consultation paper (DoH, 2001). Although the findings of evaluation studies of pilot nurse prescribing schemes have been mostly positive (Luker et al., 1997), there is concern over ensuring the appropriate levels of education and training. It is evident that current programmes need strengthening in the areas of medical diagnosis (Luker et al., 1997), pharmacology, and choice of prescriptions (Blenkinsopp et al., 1998). One of the main reasons for developing Nurse Prescriber was to try and provide up-to-date information and support to those in the frontline of nurse prescribing.



Using the website
The site can be accessed easily via the internet either using a search engine or the website address:



To find specific information, users can choose between using the search facility on the site or a variety of options on the home page. A case study from the website is shown in Box 1.



Since the launch of Nurse Prescriber at the beginning of last year, the site now has more than 1,500 registered users and feedback has been extremely encouraging. Qualified prescribers and nurses undertaking prescribing programmes have clearly found the educational modules, case studies, news and journal sections a valuable learning resource.

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