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Nonmedical prescribing: securing success

Simone Alhassan
Human Nutrition and Dietetics
Clinical Practice Development and Nonmedical Prescribing Lead
Directorate of Quality and Service Improvement
City and Hackney Teaching Primary Care Trust
London

Nonmedical prescribing has come a long way since 1999. It remains an essential part of the government's plan to modernise care for patients and to improve access to care. Nonmedical prescribing supports the "care outside hospitals" agenda, can be utilised in first-contact services, and equally it can enable the management of long-term conditions in the community where appropriate.

Since 1 May 2006, suitably qualified nurses and pharmacists have been able to prescribe any licensed medicine for any medical condition within their clinical competence, with the exception of most controlled drugs.(1) At present, other allied health professionals, such as physiotherapists, podiatrists, radiographers and optometrists are also able to train and qualify as supplementary prescribers.

This change to prescribing was the result of two public consultations on nurse and pharmacist prescribing, and it was generally well received by healthcare professionals.(2) For the nonmedical prescribing initiative it was certainly welcome news. Nationally, over 29,000 community practitioners have qualified to prescribe from the Nurse Prescribers' Formulary, and 6,500 nurses have qualified to prescribe from the Nurse Prescribers' Extended Formulary.(3) However, the British Medical Association voiced concerns over the changes on the grounds of the risks they pose for patient safety.(4)

National data for the second quarter of 2005/2006 show that, of the 176 million items prescribed in primary care, one million were as a result of nurse prescribing. The main items that were prescribed include wound management items, emollients and preparations, skin cleansers and antiseptics.(4)

Local nonmedical prescribing developments have ranged from health visitors and district nurses prescribing for patients in the community, practice nurses and nurse practitioners prescribing for patients in general practices, nurse specialists (such as tissue viability nurses) prescribing in specialist clinics, and pharmacists running warfarin and asthma review clinics.

So most nonmedical prescribers would agree that the upcoming expansion in prescribing for nurses and pharmacists can only lead to further opportunities for improving services for patients. However, in the same breath, most nonmedical prescribers, service leads and nonmedical prescribing leads will also agree that implementing these developments will require continued hard work, planning and coordination.

The continued success and further development of nonmedical prescribing in line with national requirements relies on several success criteria and considerations. From the organisational standpoint, patient need and safety must remain central to all developments. This requires that the organisation has a robust clinical governance framework in place to support prescribing. This should include aspects such as risk management and continuing professional development (CPD). Additionally, nurse prescribing needs to be monitored and managed. City and Hackney Teaching PCT ensures this through nurse leads and the Trust Nonmedical Prescribing Steering Group. The steering group reports directly to the Trust Medicines Management Committee, which in turn reports to the Trust-wide Clinical Governance Committee.

A potential risk to the organisational implementation of nonmedical prescribing is the lack of GPs who are willing or are able to act as mentors or designated medical practitioners. GPs have highlighted that the lack of national or local funding to fulfil this role doesn't help. This situation could worsen as interest in nonmedical prescribing increases. Primary care trusts need to ensure that GPs are engaged in the training of nurse prescribers by providing them with the support and information they require. They may also need to explore other incentives, through commissioning arrangements, for example.

National, sectorwide and local coordination of the initiative is critical to the success of nonmedical prescribing. This provides the leadership required to drive forward developments despite barriers and issues such as lack of GP mentors to support students in their training, shortage of staff making it difficult for managers to release staff to attend courses, resistance to change and competing agenda. With the NHS in financial crisis, this leadership role and strategic direction on the ground level is also at risk.

As more healthcare professionals gain the right to prescribe, organisations are required to establish robust processes, procedures and policies to support nonmedical prescribing (such as medication policies for nonmedical prescribers, record-keeping and communication processes). These policies and processes are increasingly required to be integrative and inclusive to reflect what is happening in the real world.

Trusts also need to provide an environment where nonmedical prescribers are able to develop their prescribing skills safely to the benefit of the patient. This may mean that members of staff are provided the time, opportunity and resources to engage in different types of continuing professional development (CPD).

Patients want choice and access to care when they need it, and they need to be assured that nonmedical practitioners can provide this care holistically and safely. Services, individual professionals, the Department of Health and trusts need to provide adequate information to achieve this assurance. The benefits of the initiative need to be shared with everyone.

From the professional perspective, opportunities need to be provided for staff to gain these skills in prescribing. Right from the start when the decision is made to utilise nonmedical prescribing to support service provision, the right member of staff with the interest and potential needs to be supported to access the right training, and then to maintain and develop the skills attained.

Although the recent expansion of nonmedical prescribing will mean full access to the BNF with the exception of some controlled drugs, nurses will only be expected to prescribe within agreed specific disease areas that are in line with their level of competence and service needs. Nonmedical prescribers and potential students need to be very aware of the fact that they are and will always be accountable to their professional body and their employers, and must adhere to standards such as record-keeping, communication and CPD.

As more alternative healthcare providers enter the UK healthcare market, nurse prescribing is also happening in a variety of settings. It is crucial that nurses ensure that their prescribing activities are covered by appropriate professional indemnity insurance through membership of a union or professional body, or that insurance arrangements made by their employer provide adequate cover.

The NMC has recently released its standards of proficiency for nurse and midwife prescribers.(5) These standards are in line with the professional code of conduct and require nurse prescribers to engage in CPD to maintain their registration. The standards also advise organisations to ensure that staff are trained and competent in diagnosis and physical assessment before they access the prescribing training programme.

Potential students will benefit from developing their knowledge and skills in physical assessment and basic pharmacology before applying for the course. This will clearly have implications for education commissioning.

Higher education institutes will also be required to be more responsive to keep in pace with the rapidly changing world of nonmedical prescribing. In addition, training programmes will need to represent good value for money, especially since the future funding of nonmedical prescribing is currently uncertain.

Overall, the continued success and viability of nonmedical prescribing will require organisations to keep the initiative high on the agenda, especially in this climate of change and uncertainty. It will require nurses to continue to champion the cause of nonmedical prescribing and be open to its challenges.

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References

  1. DH. A prescription for patient satisfaction. London: DH; 2006.
  2. Royal College of Nursing. Nurse and pharmacist prescribing powers extended. London: RCN; 2005.
  3. National Prescribing Centre. Non-medical prescribing data from the Prescribing Support Unit. Connecting Prescribers Newsletter 2006;2:4.
  4. Avery AJ, Pringle M. Extended prescribing by UK nurses and pharmacists. BMJ 2005;333:1154-5.
  5. NMC. Standards of proficiency for nurse and midwife prescribers. London: NMC: 2006.

Resources
Department of Health
The Non-Medical Prescribing Programme
W:www.dh.gov.uk/PolicyAndGuidance/MedicinesPharmacyAndIndustry/Prescriptio...
Royal College of Nursing
W:www.rcn.org.uk
Nursing and Midwifery Council
W:www.nmc-uk.org
National Prescribing Centre
W:www.npc.co.uk
Royal Pharmaceutical Society of Great Britain
W:www.rpsgb.org.uk