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Supplementary prescribing in mental health nursing

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Supplementary prescribing is a term that describes a voluntary partnership between an independent prescriber (doctor or dentist) and a supplementary prescriber (nurse or pharmacist) to implement an agreed individual clinical management plan (CMP) for a specific non-acute medical condition with the service user’s agreement. It has opened the door to a potentially monumental change to mental health nursing practice by transforming the prescribing relationship.



VOL: 99, ISSUE: 32, PAGE NO: 28

Jo Davis, MA, PGDipEd, RMN, CPN Cert, is service improvement lead, County Durham and Darlington Priority Services NHS Trust, Durham

Steve Hemingway, MA, BA, PGDipEd, RMN, is lecturer in mental health nursing, University of Sheffield


Supplementary prescribing is a term that describes a voluntary partnership between an independent prescriber (doctor or dentist) and a supplementary prescriber (nurse or pharmacist) to implement an agreed individual clinical management plan (CMP) for a specific non-acute medical condition with the service user’s agreement. It has opened the door to a potentially monumental change to mental health nursing practice by transforming the prescribing relationship.



Supplementary prescribing has been met with responses ranging from welcoming it with open arms through to fearful apprehension and even absolute refusal to participate. Nurse training began early this year, and the first intake of nurses are now acting as supplementary prescribers. Box 1 summarises the Department of Health’s rationale for introducing supplementary prescribing and outlines how it will be implemented.



Mental health service users
How can supplementary prescribing make a difference to service users?



Supplementary prescribing could improve the level of responsiveness to the needs of service users and their access to the service and treatment they require. Studies have shown that service users, once acclimatised to the idea of nurses prescribing, do value the service they receive, especially the extra time to discuss their medical and related problems (Harrison, 2003; Brooks et al, 2001; Luker et al, 1998). Although these studies did not all focus on mental health and were undertaken with patients who had been prescribed medication from the limited prescribing formulary, they demonstrate the potential benefits to mental health service users. It is still too early to ascertain whether service users will welcome mental health nurses prescribing potentially more powerful psychotropic medication than before.



Some commentators have suggested that prescribing for mental health nurses has received a lukewarm response (Cutliffe and Campbell, 2002), whereas others have suggested that recipients of the service will not mind who prescribes the medication as long as it is appropriate for them (Hartley, 2002). Service users do, however, want nurses to be knowledgeable and expert on psychopharmacological issues (Jordan et al, 2002).



Undoubtedly, there will be situations when supplementary prescribing could be of real benefit to particular service users. The Community Care Act (Department of Health, 1990) acknowledged that people with chronic illnesses were being neglected at the expense of those who were acutely ill. Because people with severe and enduring mental illness have a high risk of cardiovascular and other physical complications, prescribing by mental health nurses could specifically target those service users in a ‘care gap’, thereby providing more holistic care (White, 2000).



Mental health services
Will supplementary prescribing save money?



Supplementary prescribing could be seen to be about cutting costs and supplementing the existing medical workforce (McArtney et al, 1999). However, it should be about improving patient care and modernising the services delivered by making more effective use of available resources. Nevertheless, any associated unseen costs must be taken into consideration, such as the releasing of both student supplementary prescribers to undergo training and independent prescribers (psychiatrists) to undertake mentorship and supervision. In addition, the forthcoming new NHS pay system may have implications for nurses who are supplementary prescribers. Therefore, careful monitoring of cost as well as clinical effectiveness should be incorporated into any evaluation (Gournay and Gray, 2001).



Will supplementary prescribing be more cost-effective?
Supplementary prescribing should be a component of good medication management, which ensures a comprehensive and integrated approach to pharmaceutical treatment. Therefore, it could contribute to seamless services and disciplines and allow health care professionals to be in the right place at the right time to respond to service users’ needs. This should be achieved by more effectively utilising the skills and expertise of other members of the mental health care team.



Robust evaluation identifying strengths and weaknesses, prescribing patterns, impact on drug budgets and mechanisms for sharing good practice will be essential to ensure that potential benefits to service users, clinical staff and services are explored by everyone. The impact of supplementary prescribing on the service, finance, prescribing and training budgets is yet to be seen.



Will supplementary prescribing work without the support of medical bodies?
As supplementary prescribing relies upon the support of individual independent prescribers, work is required to gain the support of medical bodies at both national and local levels. Guidance from the USA is mixed, but suggests that a ‘collaborative relationship’ between the prescribing nurse and the supervising psychiatrist can be achieved (Hales et al, 1998). However, one of the biggest constraints is the lack of support from doctors (Cornwell and Chiverton, 1997).



If mental health nurses are to prescribe, psychiatrists will be essential to facilitating this development. Although the Royal College of Psychiatrists (2001) has hinted at there being some clinical benefits from supplementary prescribing, the college’s view needs to be clarified and collaboration sought to implement fully the new service for the benefit of service users. Ultimately, the care coordination framework will support and determine the need for supplementary prescribing based on individual need.



Will it be just a few individual nurses, doctors and service users who will lead the implementation of supplementary prescribing?
At a local level, supplementary prescribing depends on the relationship between independent and supplementary prescribers and organisational clinical systems that support such a relationship (for example shared clinical records), as well as agreement with the service user. Support for the pioneers will be crucial, both locally and nationally.



Mental health nurses
Will supplementary prescribing steer mental health nursing away from its primary function?



Few would argue that the core focus of mental health nursing is to support and care for the person experiencing mental distress and to aid and promote that person’s recovery. In recent years, the methods of carrying this out have continually changed, not least the blurring of role boundaries and access to specialist ‘therapist’ educational programmes. Prescribing should not be detrimental to the caring role and mental health nurses must ensure that service users do not see it as a separate process from being ‘cared for’ (Cutliffe and Campbell, 2002).



Do mental health nurses already prescribe indirectly?
Many nurses say that the introduction of supplementary prescribing will formalise the de facto prescribing that has taken place for many years (Ramcharan et al, 2001). Surprisingly, the response to the consultation was limited and, arguably, not reflective of a nursing community that is eager to seize the opportunity.



There is a significant difference between de facto prescribing and being accountable for prescribing authority. Certainly, advising the prescriber on effective treatments and medication relies on knowledge, theory and experience. But, ultimately, the unofficial prescriber does not take responsibility for signing the prescription.



Despite having agreed the range of medicines and conditions within the CMP with the independent prescriber, the supplementary prescriber is accountable for his or her prescribing authority and the part he or she played in that CMP. This may present a major new challenge to mental health nurses.



What will supplementary prescribing authority mean to mental health nurses?
Mental health nurses must not be fooled into thinking that supplementary prescribing is just one stage on from de facto prescribing and that somehow this does not make them fully accountable. Of course, the independent prescriber is responsible for both the assessment and the diagnosis. However, there is no such thing as partial accountability and misconstruing supplementary prescribing in this way would be a mistake. The mental health nurse is ultimately accountable for all of the clinical decisions that he or she makes, even though the CMP must be drawn up with the independent prescriber.



Mental health practice is complex and unpredictable, and can place the practitioner in vulnerable positions in terms of professional liability, let alone risk and personal safety. Mental health nurses are accountable for their clinical decisions, and they regularly face dilemmas involving consent, mental health legislation and confidentiality. Consequently, they must ensure they are fully aware of the legal implications of supplementary prescribing and are appropriately protected from the risks associated with professional practice and litigation. Supplementary prescribing may change their relationship with pharmaceutical companies, and this will need further exploration.



What will supplementary prescribing mean to continuing professional development?
Potential supplementary prescribers will need to plan thoroughly and systematically for continuing professional development (CPD) and carefully consider the organisational contexts in which they practise. CPD will need to be comprehensively supported, and identifying the need for introducing supplementary prescribing should be conducted in a systematic way and incorporated into service development plans and monitoring processes. It will be up to individual nurses to decide whether they wish to expand their role. Those who do will be liable for the cost of registration after completing the programme. Explicit agreement and support must be negotiated with all relevant parties to ensure planned and consistent development and implementation.



How can it be ensured that the supplementary prescriber does not become overburdened?
Access to robust and quality supervision and caseload management will be crucial. Establishing tester sites should highlight any potential problems. It is crucial that support mechanisms are adequate and that quality support and supervision for nurse prescribers is ensured.



A prescription alone is an insufficient reason for the intervention of a mental health nurse, but supple-mentary prescribing may be sufficient as a part of a comprehensive treatment package.



Educational preparation
Do mental health nurses have the necessary knowledge to prescribe?



Psychopharmacology is an area in which mental health nurses are especially weak (Jordan et al, 2002). The reasons for this include the lack of continuing education after qualification and the subjugation of mental health nursing to the general nursing curriculum. There is also some evidence that current pre and postregistration programmes for mental health nurses are not preparing them adequately to deal with issues related to prescribed drugs (Hemingway and Freeman 2002; Jordan et al, 2002; Bennett et al, 1995; Brooker et al, 1994).



In terms of biology and pharmacology, preregistration programmes appear to be improving since the implementation of Fitness for Practice (UKCC, 1999) and Making A Difference (DoH, 1999a), with an emphasis now being given to achieving competence in core subjects rather than concentrating on generic content as in the Project 2000 curriculum (Hemingway and Freeman, 2002), but this needs to be continued.



How can education be improved to prepare mental health nurses to prescribe competently?
The new initiatives in medication management (Jordan et al, 2002; Gournay and Gray, 2001) could be adapted for pre and postregistration education on medication issues. Lessons should be learned from the USA, where education is tailored towards the knowledge needed (psychopharmacology) and the mechanics of prescribing (psychotherapeutics). A more thorough grounding is needed in the neuropsychiatric sequelae, pharmacokinetics and pharmacodynamics, and education about the most effective and less disabling drugs.



The National Service Framework for Mental Health (DoH, 1999b) emphasises that clients should receive the best available drug. More emphasis on adequate education could help meet this aim and strengthen the potential of the mental health nurse to obtain prescriptive authority. Mental health nurses may therefore benefit from a mental health and psychiatric focus within the supplementary prescribing training.



Will the extended prescribing programme plus the additional supplementary prescribing module meet mental health nurses’ needs?
Supplementary prescribing training began early this year, the course comprising 27 taught days and 12 days of supervision. It could be argued that the supplementary prescribing course includes a lot of content but that the training is generic, so repeating the mistake made with the Project 2000 curriculum. But if supplementary prescribing and extended nurse prescribing training were to become part of postregistration degree programmes for mental health nurses, a more holistic educational framework could be offered.



If mental health nurses are to maximise the opportunities presented by the monumental change in prescribing legislation and expand their role, there needs to be a response from education providers that puts more emphasis on psychopharmacology (Hemingway, 2003).



Both pre and postregistration training needs strengthening in this area. This will necessitate comprehensive planning among service providers, higher education institutions and workforce development confederations. The significant resource implications (Gournay and Gray, 2001) for supervision, release of clinical staff for training or mentorship, and programme delivery will also need to be considered and incorporated into business plans.



The success of supplementary prescribing will depend on systematic planning and commitment to the educational and CPD needs of nurse prescribers from both mental health services and education providers. If supplementary prescribing is to be effective, meet client expectations (Jordan et al, 2002) and the objectives of the National Service Framework for Mental Health, and expand and professionalise the role of mental health nurses, the professional, organisational and educational response must not be piecemeal.



Further information concerning supplementary prescribing is available on the Department of Health website:

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