Fiona Peniston-Bird, consultant on the development and implementation of non-medical prescribing.
What is supplementary prescribing?
The Department of Health (DH) defines supplementary prescribing as ‘a voluntary partnership between the responsible independent prescriber (a doctor or dentist) and a supplementary prescriber, to implement an agreed patient-specific clinical management plan (CMP) with the patient’s agreement’.
Key features that underpin supplementary prescribing are:
- Good communication between the prescribing partners;
- Access to shared patient records;
- The patient is a partner in their care and is involved at all stages of decision-making.
Currently registered nurses, pharmacists, physiotherapists, radiographers, podiatrists and optometrists can undertake supplementary prescribing training. There are no legal restrictions on the clinical conditions that may be treated, although supplementary prescribing would normally be used for the management of chronic conditions.
The CMP is patient-specific and is drawn up in conjunction with and agreed by the independent and supplementary prescribers, and the arrangement are endorsed by the patient. The CMP enables the supplementary prescriber to manage the treatment of an individual patient (including prescribing) within identified parameters.
The patient needs to be reviewed by the independent prescriber at an agreed interval stated in the CMP.
Items which may be prescribed by a supplementary prescriber are:
- All General Sales List (GSL) medicines, pharmacy medicines, appliances and devices that can be prescribed by GPs;
- Foods and other borderline substances approved by the Advisory Committee on Borderline Substances (ACBS);
- All prescription-only medicines (POMs);
- Medicines for use outside of their licensed indications for example, ‘off label’ prescribing (using a drug outside of it’s licence), ‘black triangle’ drugs (drugs that are subject to intense monitoring), and drugs marked ‘less suitable for prescribing’ in the British National Formulary (BNF);
- Unlicensed drugs provided they are part of a clinical trial that has a clinical trial certificate or exemption, and are prescribed in accordance with Nursing and Midwifery Council prescribing standards (NMC 2006);
- Controlled drugs under a supplementary prescribing arrangement following parliamentary approval to changes to the Home Office’s Misuse of Drugs Regulations and to related amendments to NHS regulations.
How do I become a nurse independent prescriber?
You must be a registered nurse and must fulfil the NMC entry criteria in order to undertake the training. This includes:
- Three years post-registration experience;
- Being able to study at degree level three;
- Competency in numeracy skills;
- Competent to take a history, undertake a clinical assessment and diagnose in your area of practice.
You will need to arrange for a designated medical practitioner to provide a minimum of 12 days supervised clinical practice. Following the training you must register as a nurse independent prescriber with the NMC before you start prescribing. There is a small fee for this.
You need to know which budget will pay for your prescriptions and the budget holder must agree to this. You must have the infrastructure to support your prescribing practice including the BNF, local formulary, policy documents and access to continued professional development. Your job description will need to reflect your prescribing status.
Can a nurse with a V100 prescribing qualification prescribe ‘off-label’ drugs such as nystatin oral suspension for a neonate?
Medicines prescribed for babies and children are often unlicensed for use with children which means that they are used outside of their licence or ‘off label’. The NMC Standards of Proficiency for nurse and midwife prescribers allow nurse independent prescribers to prescribe ‘off-label’ medicines providing they meet certain criteria outlined in Practice Standard 18. However according to the DH non-medical prescribing policy team, nurses who hold the V100 qualification and so are restricted to prescribing from the Community Practitioner Formulary (CPF), must adhere to that formulary and prescribe within its restrictions so ‘off-label’ prescribing of nystatin oral suspension for neonates is not permitted.
[Please note this answer is now out of date. See Fiona Peniston-Bird’s blog for an update.]
I am a qualified nurse independent prescriber but have not yet written a prescription. How can I get started?
Prescribing Competencies for Nurses by the National Prescribing Centre (NPC, 2001) will help you reflect on your competencies and establish what areas you may need to focus on in order to begin prescribing. The NPC also provides therapeutic workshops for non-medical prescribers.
Peer support from non-medical prescribers is crucial. Ensure that you can network with other nurses who are prescribing within your organisation. Try to attend any meetings or forums that are held, and if necessary ask to spend some time working alongside a nurse who holds a similar post and is using their qualification. This might give you the confidence to get your prescribing off the ground.
The NMC is currently working on guidance for continuous professional development for qualified nurse prescribers.
Should I provide a repeat prescription for drugs that I am not familiar with?
This question highlights the importance of having a working knowledge of the NMC Standards of Proficiency for nurse and midwife prescribers. Practice standard 19 advises that ‘you may issue a repeat prescription, but you do so in the knowledge that you are responsible as the signatory of the prescription and are accountable for your practice’.
You need to ask:
- Am I competent to prescribe for this medical condition?
- Am I fully aware of the pharmacology involved?
The NMC recognises that repeat prescribing is likely to be a significant aspect of the role for all nurse/midwife prescribers. The NPC in England has published good practice guidelines Saving time, helping patients: a good practice guide to quality repeat prescribing.
I am working as a nurse prescriber. Do I need to take out additional professional indemnity?
You will need to ensure that your union provides you with professional indemnity cover for your prescribing practice. The RCN provides £3million cover. The Medical Defence Union can provide £10 million cover but for a higher annual subscription. It would be wise to check that your job description reflects your prescribing practice indicating that your employer supports your practice and accepts vicarious liability.
I am a self-employed nurse independent prescriber. Can I independently prescribe Botox for my patients?
You are able to independently prescribe botulinum toxin for your patients. Botulinum toxin if used for aesthetic purposes, is used ‘off-label’ and so is outside the product licence. You must ensure that your practice reflects your NMC Code of Professional Conduct, and Standards of Proficiency for Prescribers. You should have your own organisational infrastructure to support your practice, policy document and clinical governance, and you will need to consider safety issues regarding the prescribing and administering of this product.
What is a designated medical practitioner (DMP)?
In order to be accepted onto the independent nurse/supplementary prescribing course, you must have agreement from a DMP that she or he will oversee and agree 12 days (which equates to 12 x 7.5 hours, 6.5 hours excluding breaks or 78 hours in total) learning in the clinical area in which you will be prescribing once qualified.
The DMP does not have to deliver the entire 12 days, but must agree the content of the learning contract with the student and allow time to reflect on their clinical experience. Other health professionals may be involved in the 12 days, for example, it might be appropriate to spend time with the trust pharmacy team or local community pharmacist.
The DH has suggested that those undertaking the training should also identify a ‘buddy’ who is a qualified non-medical prescriber to support them through their course and this time might be included in the 12 days. Many universities hold information sessions for DMPs or they may visit them in practice.
The NPC guide Training Non-medical Prescribers in Practice.
Why is the Community Practitioners Formulary so limited and can I use it in the secondary care setting?
The Community Practitioner Formulary (CPF) was developed for district nurses and health visitors and included mostly dressings, appliances, over-the-counter and pharmacy-only medicines with a small number of prescription only medicines, which were deemed necessary for these nurses to prescribe.
The CPF is now available for all nurses undertaking the specialist practitioner qualification and includes practice nurses, school nurses, and community mental health nurses. The NMC is considering including community staff nurses who would also undertake training to allow them to prescribe from this formulary. It is unlikely that the formulary will increase significantly.
The general consensus is that should nurses require access to a larger formulary then they should consider undertaking the nurse independent/supplementary prescribing training. Nurses who hold the qualification to prescribing from the CPF can use it in the secondary care setting and in some instances this can be very beneficial for patients, for example, patients with wounds. To enable nurses to do this there must be policies and procedures to support their prescribing practice including guidelines covering documentation and how the prescriber will annotate their qualification on the prescription. This should all be contained within a trust’s non-medical prescribing policy. There must also be clarity about how the nurse will maintain his/her competency in prescribing through continued professional development to ensure patient safety.
Am I entitled to a six-monthly British National Formulary?
If you are a nurse independent prescriber or a supplementary prescriber prescribing for NHS patients, you should receive a BNF every six months from the non-medical prescribing lead within your organisation. The BNF is also available online free of charge. If you are actively prescribing but do not currently receive a BNF or access it online, you are prescribing without the necessary tools and may not be safe in your practice. You should contact your organisation’s non-medical prescribing lead and ensure you are on their list to receive an up-to-date BNF. If you prescribe for children, you should also have the annual BNF for children.
Nurses who are qualified to prescribe from the Community Practitioner Formulary should receive a Nurse Prescribers Formulary every two years and are not entitled to receive a BNF.
Useful link: www.bnf.org