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Current nurse prescribing practices in dermatology

Karina Jackson
RGN BA(Hons) MSc
Clinical Nurse Specialist
St John's Institute of Dermatology
Guy's and St Thomas' NHS Foundation Trust
London

Nurse prescribing has developed rapidly in the last 10 years. The Medicinal Products: Prescription by Nurses Act in 1992 laid down the legislation for nurse prescribing to commence. The Second Crown Report (1999) proposed that prescribing authority should be extended to new groups of healthcare professionals.(1) The report recommended a distinction between two categories of prescribers, independent and supplementary. Following the publication of this report, the Health and Social Care Act (2001) was passed legislating extending prescribing responsibilities to other healthcare professionals, introducing the new concept of supplementary prescriber for nurses and pharmacists. Also at this time, independent nurse prescribing (mode 2) was developed to enable all appropriate nurses and midwives to train as extended nurse prescribers and prescribe from an extended nurse prescribers' formulary. There are currently approximately 5,000 extended formulary nurse prescribers recorded on the Nurse and Midwifery Council (NMC) register; a large proportion are also trained as supplementary prescribers.

How nurse prescribing has affected dermatology care
Skin disease affects between a quarter and a third of the population at any one time and accounts for up to a fifth of all GP consultations.(2) With these statistics in mind, one can assume that nurse prescribers in the community can contribute greatly in reducing skin morbidity.
Health visitor and district nurse (mode 1) prescribers can provide relief for many mild skin conditions by prescribing emollient therapy, for example for an infant with cradle cap or eczema, or an elderly client with general xerosis (dry skin) or gravitational eczema. Dry skin is a common feature in many dermatological conditions. Dry skin results in an impairment to the barrier function of the skin, thereby increasing water loss from the epidermis and increasing the risk of pathogens, allergens or irritants penetrating the skin. Dry skin can also cause itching and discomfort for the patient and increases the risk of morbidity. The application of an emollient will greatly improve the skin integrity and improve the quality of life for the patient. Emollients provide a protective layer on the skin, thereby decreasing natural water loss. They may also penetrate into the upper layer of the epidermis (stratum corneum) and mimic the barrier effect of the deficient lipids. Emollients also help to soften scale or hyperkeratosed areas of skin and expedite the removal of debris. For example, they may be helpful when washing the skin surrounding a leg ulcer.
Mode 1 prescribers can also treat infestations such as scabies or head lice using the nurse prescribers' formulary and have access to an extensive range of wound care products.
A wider range of prescription-only medicines (POMs) is included in the Nurse Prescribers' Extended Formulary (NPEF). In addition, extended nurse prescribers may prescribe all pharmacy (P) and general sales licence (GSL) items normally prescribable on the NHS and all items listed in the mode 1 nurse prescribers' formulary. However, this wide range of medicines may be prescribed only for a specified list of medical conditions (see NPEF in BNF). This list includes a large number of skin conditions and therefore provides considerable scope for managing a range of acute and chronic conditions that commonly present in primary care, such as acne, atopic eczema, seborrhoeic eczema, psoriasis, skin infections and infestations. As skin conditions are common and account for at least 15% of all consultations in primary care, there is clearly tremendous scope for nurses to contribute to patient management as nurse prescribers.(3)
 
Supplementary prescribing in practice
Supplementary prescribing is a prescribing partnership between an independent prescriber (GP in this instance) and supplementary prescriber (nurse or pharmacist). An individual patient Clinical Management Plan (CMP) is developed following diagnosis, and agreed between the independent and supplementary prescriber. The independent prescriber is responsible for the initial diagnosis and parameters of the CMP. The supplementary prescriber may review the patient independently for up to one year and has the discretion in the choice, dose, frequency and product of the medicine prescribed as long as it is listed in the CMP. Where available, guidelines should be adhered to and referenced within the CMP. The independent and supplementary prescriber must share access to and use the same shared patient record to ensure safety. As the NPEF is already fairly comprehensive for skin disease management in primary care, there may not be many occasions when the supplementary prescribing arrangement is required.

Developing nurse-led dermatology services in primary care
The GMS contract does not directly affect dermatology services. However, it is reasonable to assume that primary care contracting, which aims to increase the quality and range of services conveniently available in family practices near a patient's home, could result in more primary care-based dermatology service development. The Action On Dermatology project strongly supports the development of GPwSI services, and its Good Practice Guide provides examples of different models.(2) These services will invariably require support from nurses with some dermatological knowledge and skills too.
Some primary care nurses have already developed dermatology services and are using both forms of prescribing to enhance their service. In response to this, the British Dermatological Nursing Group (BDNG) has developed both primary care and nurse prescribing subgroups that provide specialist peer support and educational opportunities for nurses delivering care to skin patients.
To reflect the interest in developing dermatology services in primary care, a couple of courses have been designed for primary care nurses who wish to expand their clinical knowledge and scope of practice for skin patients. The University of Southampton School of Nursing and Midwifery runs a course entitled "Skin care for primary care nurses and health visitors" at both levels 2 and 3 (20 credits). The University of Wales at Gwent runs a distance learning course in practical dermatological nursing. This course incorporates six modules, which include nursing management of patients with psoriasis, eczema, acne, skin cancer, skin infections and infestations, acute and chronic wounds, and patients undergoing minor surgery. The course is at level 2 (45 CATS).

Resources to support prescribing 
The British Association of Dermatologists has a comprehensive list of publications on skin disease management, most of which are available via their website. Other useful resources include Prodigy and the National Prescribing Centre guidance. Prodigy guidance exists for atopic eczema (Nov 2004) and acne (Feb 2003). The Primary Care Dermatology Society (PCDS) also has a range of treatment guidelines written specifically with primary care practitioners in mind.
Continuing professional development (CPD) for qualified nurse prescribers is essential for ongoing competency in safety and effective prescribing. The CPD needs of nurse prescribers include ongoing education in pharmacology, product-related information and diagnostic skills. The National Prescribing Centre has developed a competency framework for nurse prescribers, which is also a useful tool for CPD. The BDNG in collaboration with the RCN has developed an integrated career and competency framework for dermatology nursing which guides the clinical skills development within specified clinical domains.

Future developments
At the time of writing we are awaiting the outcome of the Medicines and Healthcare Products Regulatory Agency (MHRA) consultation on options for the future of independent prescribing by extended formulary nurse prescribers (MLX 320). The result may be the inclusion of more medical conditions, less restrictions of prescription-only medicines or access to the whole BNF by extended nurse prescribers.

References

  1. Department of Health. Review of prescribing, supply and administration of medicines. Crown J (chairwoman). HMSO: London; 1999.
  2. NHS Modernisation Agency. Action on dermatology: Good practice guide. Department of Health Modernisation Agency; 2003.
  3. All Party Parliamentary Group. Report on the enquiry into primary care dermatology services. London: APPG; 2002.

Resources
Acne Support Group
W:www.stopspots.co.uk

National Eczema Society
W:www.eczema.org

Psoriasis Association
W:www.psoriasis-association.org.uk

Psoriatic Arthropathy Alliance
W:www.paalliance.org

British Dermatological Nursing Group
W:www.bdng.org.uk

The British Association of Dermatologists
W:www.bad.org.uk

Primary Care Dermatology Society
W:www.pcds.org.uk

National Electronic Library for Health
W:www.library.nhs.uk/skin

RCN competency framework
W:www.rcn.org.uk/publications/ pdf/Dermatology Competencies.pdf

National Prescribing Centre
W:www.npc.co.uk