The introduction of nurse prescribing has been a long and slow process and the Government’s hopes that there would be 10,000 new nurse prescribers by 2004 have not materialised (see History Box, page 17).
The lack of progress has been put down to:
- Limitations to which medicines nurses are allowed to prescribe
- An absence of funding to pay GPs to act as clinical mentors
- Nursing shortages
- Lack of money for staff cover
- A failure by trusts to realise the true potential of nurse prescribing.
The Government, however, remains committed to extending nurse prescribing. This is because it wants to improve patients’ access to medicines and make better use of the skills of nurses and pharmacists. Nurse prescribing could also reduce doctors’ workloads, allowing them to concentrate on more complicated cases.
The Government has made some policy changes recently that could give nurse prescribing the boost it needs. These include:
- The new GP contract
- Extending the formulary
- Extending supplementary prescribing/more cash for training courses.
This article will explain the different types of prescribing, look at the implications of the Government’s proposals and help you decide if you want to become a nurse prescriber.
There are two main types of nurse prescriber: independent and supplementary (see Box, below).
Independent nurse prescribers
This means that the nurse prescriber takes responsibility for clinical assessment, establishing a diagnosis and the clinical management required, as well as responsibility for prescribing. There are two types of independent nurse prescriber:
- Health visitor and district nurse prescribers. This group can dispense a limited range of drugs and a small number of prescription-only medicines. There are 25,000 district nurses and health visitors who can prescribe in this way
- Extended formulary nurse prescribers. These nurses are trained to prescribe from the Nurse Prescribers’ Extended Formulary (NPEF). Over 2300 nurses are qualified to prescribe from the NPEF for around 80 medical conditions and 180 prescription-only medicines, together with all Pharmacy and General Sales list medicines for these conditions. Conditions covered by extended formulary nurse prescribers include minor ailments, minor injury, health promotion and palliative care.
Supplementary prescribing is a partnership between a medical practitioner (independent prescriber) who establishes the diagnosis and initiates treatment, a nurse or pharmacist (supplementary prescriber) who monitors the patient and prescribes further supplies of medication and the patient who agrees to the supplementary prescribing arrangement.
Each patient has an individual clinical management plan that contains details of the patient, the condition, treatment with medicines and when the patient should be referred back to the independent prescriber.
Unlike independent nurse prescribing, there are no legal restrictions on the clinical conditions which supplementary prescribers may treat.
Also, there is no specific formulary or list of medicines for supplementary prescribing. The only exception is controlled drugs.
Supplementary prescribing is more suitable for patients with:
- Long-term medical conditions such as asthma, diabetes or coronary heart disease
- Long-term health needs, such as anti-coagulation therapy
- More complex conditions such as mental illness.
Over 1700 nurses have already qualified and registered as nurse supplementary prescribers and 100 pharmacists have done so.
Patient group directions (PGDs) were launched in 2000. They enable nurses to supply and administer prescription-only medicines to patients under the generalised directions of a doctor but without a prescription from a doctor.
This means medicines can be given to groups of patients without individual prescriptions having to be written for each patient.
Physiotherapists, paramedics and pharmacists can also use patient group directions and from May, dietitians, occupational therapists, prosthetists, orthotists and speech and language therapists were added to the list.
There is no specific training that health professionals must undertake before supplying medicines in this way but the National Prescribing Centre (NPC) has produced a competency framework to help professionals who use PGDs (available at: www.npc.co.uk).
USING A PGD
Nurses may use PGDs when providing:
- Immunisation programmes that use centrally supplied vaccines
- Out-of-hours care where supply is likely to be quicker to the patient than prescribing
- Management of a specific treatment episode by nurses working in first contact services and urgent/emergency care, for example emergency contraception.
USING A PSD
Patient-specific directions (PSDs) are written instructions from a doctor, dentist or nurse prescriber for a medicine or appliance to be supplied or administered to a named patient. This could be a simple instruction in the patient’s notes or on a patient’s ward drug chart. If there is a PSD, there is no need for a PGD or clinical management plan.
Understanding how these prescribing methods would fit together in your practice area can be difficult. Figure 1 (see previous page) gives an example, using a patient with asthma.
What are the implications of Government policy on nurse prescribing?
The GP Contract
Nurses have increasingly been getting involved in the extension of walk-in-centres, providing primary care out-of-hours services and helping to reduce unnecessary burdens on emergency services.
The new GP Contract, which started in April, could give nurses even more opportunity to extend their role because after October 2004 GPs can, with the agreement of their primary care trust (PCT), opt out of certain services, including out-of-hours care.
Nurses who are trained to prescribe will be invaluable to PCTs because they will be able to ensure patients receive the medication they need at the same time and in the same place as their out-of-hours consultation (see Box left).
To help these nurses, the Government has produced a set of proposals to expand the range of medicines nurses can prescribe in emergency, first-contact and out-of-hours care.
On 14 April 2004, the Department of Health (DH) and the Medicines and Healthcare products Regulatory Agency (MHRA) began a public consultation on further potential medical conditions and medicines which nurses could prescribe in emergency and first contact care.
They are proposing to add over 60 medicines to treat 30 new medical conditions including respiratory, circulatory, eye and gastrointestinal conditions, infections, poisoning and substance dependence (see Box above). Nurses could prescribe medicines used to treat life-threatening conditions such as blood clots, deep vein thrombosis and meningitis.
This consultation was also circulated in Wales, Scotland and Northern Ireland and the proposed changes would apply throughout the UK.
However, the pace at which extended formulary nurse prescribing develops is a local decision.
The consultation closed in July and the responses are being collated. There is also an evaluation of extended formulary nurse prescribing being undertaken by the University of Southampton, which is expected to report in the late autumn.
The Home Office has completed public consultation on proposals for supplementary prescribing of controlled drugs, including opioids, by nurses and pharmacists. The Home Office aims to make the necessary changes to its regulations shortly. Subject to Parliamentary approval to these changes and to related amendments to NHS regulations, nurses and pharmacists will be able to prescribe controlled drugs under a supplementary prescribing arrangement later in 2004.
On 10 May 2004, the DH and the MHRA also began a three-month public consultation on extending supplementary prescribing responsibilities to physiotherapists, radiographers, podiatrists, chiropodists and optometrists.
This would enable them to help treat and manage conditions such as glaucoma, chronic back pain and multiple sclerosis. They would also be able to give pain relief following radiography sessions.
The DH is now developing a higher education course for allied health professionals who want to learn the process of supplementary prescribing. The courses for physiotherapists are planned to start this month, and will run for 25 days, with 12 supervised practice days over an academic year.
The Government aims to train several hundred pharmacists and several thousand nurse prescribers by the end of 2004. It is providing some 7 million for prescribing training in 2004/05 and a further 10 million in 2005/06.
The decisions on who is offered training and how the funds are used will be determined locally through strategic health authority (SHA) directorates of workforce.
Nurses employed outside the NHS in private health care may also join a prescribing training course. Nurses employed by charitable organisations and who provide the majority of their services to NHS patients will be able to have their training paid for from centrally provided funds. Other non-NHS nurses will need to identify an alternative source of funding.
To be legally eligible to prescribe you should:
- Be a first-level registered nurse or registered midwife
- Have valid registration on the Nursing and Midwifery Council professional register
- Have successfully completed the nurse prescribing preparation, and have a mark against your name in the professional register indicating that you hold this qualification.
A single training course now enables you to qualify as both an independent nurse prescriber and a supplementary nurse prescriber. The additional training for supplementary prescribing takes between one and two days and therefore the length of a combined course should be at least 26 days, plus 12 days learning in practice with a supervising medical practitioner. Most of the teaching is face to face but open learning, distance learning and e-learning formats are now offered.
The training programme includes an assessment of theory and practice that must be passed before the qualification for nurse prescribing is included on your registration.
District nurse and health visitor prescribers are also eligible to train to use the NPEF. Nurses who have already completed the extended formulary nurse prescribing training, will only need to ‘top up’ with an additional piece of learning to become supplementary prescribers.
The Nursing and Midwifery Council (NMC) is responsible for ensuring the standard of training courses. It has recently determined a new standard for independent prescribing (for the extended formulary) and supplementary prescribing, and will only validate new recordable courses against that standard.
IS IT FOR YOU?
To be accepted for entry onto a programme of preparation, you must:
- Be capable of study at level 3 (first degree level)
- Have at least three years’ post-registration clinical nursing experience (or part-time equivalent); most nominees are likely to be at E grade or above
- Know a medical prescriber willing to contribute to your 12-day learning in practice element of preparation, and a period of supervised prescribing post-qualification. The medical prescriber will also be required to participate in the assessment process
- Have the agreement of your employing organisation to allow attendance and completion of all elements of the prescribing course, the necessary period of supervised prescribing following qualification as a prescriber, and continuing professional development
- Have a commitment from your employer to enable access to a prescribing budget and make other necessary arrangements for prescribing practice on successful completion of the course. To qualify for central funding you must occupy a post in the employment of an NHS organisation or GP practice in which you are likely to be able to prescribe.
The areas where the Government thinks nurse prescribers would be most useful (and would be given priority for training) are:
- Where nurse prescribing would have maximum benefits for patients and save patients waiting for a prescription for items prescribable by nurses to be obtained from another prescriber
- Patients see a doctor as well as the nurse solely for the purpose of obtaining a prescription.
This would include you if:
- You run your own clinics or services, for example nurse-led units, outpatient clinics, PMS pilots, minor illness clinics
- You work in isolation from other prescribers, for example working with homeless people or travelling families, in intermediate care facilities or community hospitals
- You could complete episodes of care by prescribing, for example as an emergency nurse practitioner in A&E, a family planning clinic nurse, or a nurse in a GP practice
- Where you would get enough opportunities to prescribe to maintain competency and confidence, and so protect patient safety, and where many patients would benefit from your prescribing expertise.
This would include you if:
- You are likely to be able to prescribe for several of the medical conditions set out in the Drug Tariff during the course of your work
- You have additional qualifications and professional expertise for the specified medical conditions, for example specialist practitioners, clinical nurse specialists in relevant areas, nurse consultants and nurse practitioners.
Nurse prescribers, whether operating within or outside the NHS, are professionally responsible for their own actions, and should ensure that they have professional indemnity - for example through membership of a professional organisation or trade union.
Where any nurse is qualified as an independent prescriber, and prescribes as part of his or her nursing duties with the consent of the employer, the employer may also be held vicariously responsible for the nurse’s actions.
Nurse prescribers are expected to keep up-to-date with best practice in the management of the conditions for which they may prescribe and in the use of the medicines on the NPEF. The National Prescribing Centre has produced a document Maintaining Competency in Prescribing to help nurse prescribers.
The Government wants to bring nurses, pharmacists and other AHPs under one prescribing ‘umbrella’. It is likely that other health-care professionals will also become prescribers in the near future and the Government is also committed to developing pharmacist independent prescribing. But the NMC, the Royal College of Nursing and many nurse prescribers would like the Government to go further and allow nurses to prescribe from the entire BNF.
If you think the service provided to your patients could be improved by being able to prescribe, now could be the time to make the most of current training opportunities.Next month we examine information technology and nursing.
- Nurse prescribing has got off to a slow start due to a limited formulary and barriers to training
- The Government is keen to see more nurses and AHPs learning to prescribe
- The new GP Contract could be a catalyst for nurse prescribing.
One primary care trust where nurse prescribing is making a difference to the way GP services are now organised is in Peterborough. The Greater Peterborough Primary Care Partnership is taking over responsibility for providing health care out of hours. The new system started operating in July but will be fully up and running by October.
Hazel Smith, Director of Health and Social Care Delivery at Greater Peterborough Primary Care Partnership, says: ‘Nurse prescribing is absolutely vital to the success of the service. All our district nurses and health visitors are trained and we have 18 other nurses trained as extended prescribers. Our diabetes nurse specialists are training as supplementary prescribers as well as AHPs and pharmacists. We also use PGDs extensively.’
Many of our nurses have volunteered to learn to prescribe and we hope to have all of them trained in the next few years. I think the Knowledge and Skills Framework and Agenda for Change have helped nurses see the point.’
A BRIEF HISTORY OF NURSE PRESCRIBING
1994: Nurse prescribing was first piloted in eight GP fundholding practices for health visitors and district nurses
1999: Crown report on the expansion of nurse prescribing in England
MAY 2001: Ministers announced that independent nurse prescribing would be extended
AUTUMN 2001: The Health and Social Care Act 2001 extended prescribing responsibilities to other health staff, including pharmacists
APRIL 2002: Independent nurse prescribers allowed to prescribe all pharmacy and general sales list medicines prescribable by a GP
NOVEMBER 2002: The Government announces training for nurses and pharmacists to become supplementary prescribers from early 2003
APRIL 2002: Consultation held on the expansion of the NPEF
AUTUMN 2003: Pharmacists began training
FEBRUARY 2004: The first 100 pharmacist supplementary prescribers qualified. Over 30 additional medicines and 10 new medical conditions were added to the NPEF.
Fiona Peniston-Bird, Non-medical Prescribing Facilitator for Surrey and Sussex Strategic Health Authority
‘It is still early days for the new GP Contract but I think with its implementation there is the opportunity for the numbers of nurse prescribers to grow. It has been a slow start to fill nurse prescribing courses; there are a number of barriers to undertaking the training, such as replacement costs for the nurse while undertaking the course. However, an increase in the number of doctors agreeing to be medical supervisors would help improve applicant numbers, and perhaps in the future there will be the opportunity for the medical supervisor role to be taken on by nurse prescribers.’
Ultimately to allow nurse prescribers to access the whole of the BNF would be a radical step forward and should be given careful consideration for the future.’
It is important that, once qualified, the nurse has ongoing support from their organisation in order to use their qualification to ensure continued improvements in the patient experience and service redevelopment.’
Molly Courtenay, Reader, University of Reading and Royal College of Nursing Adviser for Prescribing
‘I would think the changes to the GP Contract and the proposals to extend the formulary should increase the number of nurses taking up prescribing. Extending the formulary in a fragmented way has led to some confusion over what can and can’t be prescribed. Frustrations have arisen where the formulary doesn’t cover certain conditions and products and supplementary prescribing is not appropriate. The RCN would like to see the whole of the BNF being made available to nurse prescribers.’
- All nurse prescribers receive a copy of the Nurse Prescribers’ Formulary, which is published biennially. Nurses are now able to access the Drug Tariff through the PPA website: www.ppa.nhs.uk- www.groupprotocols.org.uk/
This site contains examples of PGDs which have been approved for use in a specific locality by practitioners employed there. You critically evaluate these to help you produce or adapt your own PGDs
- www.prodigy.nhs.uk/PRODIGY is a computer-based resource that assists decision-making during patient consultations
-Other useful websites: www.druginfozone.nhs.uk/homewww.mhra.gov.uk.www.nurse-prescriber.co.ukwww.bnf.orgwww.dressings.orgwww.npc.co.ukwww.nmc-uk.orgwww.rpsgb.org.uk/www.out-of-hours.infowww.nagpc.org.ukwww.ppa.org.ukwww.show.scot.nhs.uk/send/nurseprescribing- Emap Healthcare offer an open learning online nurse prescribing programme. For details call 020-78740600.