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Nurse prescribing: a help or a hindrance to the profession?

Marilyn Eveleigh
Consultant Editor

Nurse prescribing is an exciting concept. The profession has been talking about it since the Cumberlege Report in 1986; medical colleagues have been eager to share the prescribing load; and patient expectations have been raised. But over the last few months I'm beginning to feel that it is all getting very complicated, divisive and confusing, not least to the group it is intended for - nurses themselves.
There are a variety of ways patients can access prescription-only medicines (PoMs). They can be prescribed them from nurse prescribers, but not all nurse prescribers can prescribe the same things. They can get PoMs from nurses who are not prescribers through the use of Patient Group Directions (PGDs), but not all nurses supply or administer medicines through PGDs.
It does get complicated when you try to explain it. To date:

  • All district nurses and health visitors are nurse prescribers using the limited Nurse Prescribers' Formulary. This is now an integral part of their training. However, there is evidence that not all of these nurses exercise their right to prescribe.
  • Training for independent nurse prescribers has been in place since April 2002. They work in the specific fields of minor injuries, minor illnesses, palliative care and health promotion such as family planning - and not solely within the NHS. Not all nurses that work in these fields will prescribe; they will do so by local identification of patient need. They use an extended formulary, which includes childhood vaccinations and some antibiotics.
  • We are awaiting the criteria for supplementary prescribing for nurses. This is where a doctor or another independent nurse prescriber assesses and diagnoses the condition or need, and the supplementary nurse prescriber may alter doses and prescribe other medication, according to as yet undefined criteria. This is likely to suit community and practice ­nurses managing chronic disease registers.
  • Then we have PGDs, whereby local signed agreements to supply or administer specific medicines are used by nurses in the absence of patient assessment by a doctor. These are for specific medicines, and strict criteria are in place for ­training, referral and patient information.

That is quite a variety! I spend a lot of time presenting on nurse prescribing to mixed groups of clinicians, PCT managers, the pharmaceutical industry and nurses themselves - they are delighted with the concept but confused by the consequences. Personally, as a nurse and a prescriber, I feel a little embarrassed by the differences that abound. As a patient, it seems to be pot luck whether the practice nurse can provide me with the prescription I need for my hayfever medication or the "morning-after pill"!
As we go to press, the GP's Council has issued a statement (following legal advice) to say that practice nurses employed by GPs do not have to have a signed PGD in order to supply or administer a PoM. Discussion with the Department of Health nursing advisers and contact with the RCN indicates their concern with the differing interpretations of what constitutes a PGD. The issue has been referred to the Medicines Control Agency for clarification on the legal standing of practice nurses in this situation.
I hope we don't "throw the baby out with the bathwater" - most PGDs have provided the basis of a sound written protocol for extending the scope of the nursing role. Nursing in Practice will report on the outcome of this issue as soon as it is known.
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