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Nurse prescribing: origins and implementation

Anthea Clegg
RGN HV NP
Health Visitor/Team Leader, Regional Nurse Prescribing Project Manager Premier Health NHS Trust Tamworth Health Centre Staffordshire
Chair
Association for Nurse Prescribing

Nurse prescribing is not additional prescribing. It is substitute prescribing. It is the same drug or appliance for the same patient in the same circumstances, but prescribed rather than recommended by the practitioner making the clinical assessment. It requires the nurse to be legally accountable for the prescribing commissions or omissions and stops the practice of rubber-stamping by GPs which was so prevalent in the past.
Before 1994, the convention was that doctors prescribed, ­pharmacists dispensed and nurses administered.(1) These traditional professional boundaries were overturned when a limited number of nurses were eventually able to prescribe, a fundamental change resulting from a process that began in 1986 with the publication of the Cumberlege Report.(2)

1986 to 1994: the long haul to ­implementation
The origins of nurse prescribing lie in the 1986 report of the community nursing review chaired by Julia Cumberlege.(2) The report concluded that: "the DHSS should agree a limited list of items and simple agents which may be prescribed by nurses as part of a nursing care programme." 
The recommendation to prescribe and its implications were later reviewed by a Department of Health group chaired by Dr June Crown. The first Crown Report recommended that community nurses with a health visitor or district nurse qualification should be authorised to prescribe from a limited formulary.(1)
Small pilot programmes which progressed to larger regional schemes took place between 1994 and 1998. Finally in 1998 full national implementation of nurse prescribing was announced. The programme of training around 20,000 qualified district nurses and health visitors is on schedule and will be completed by the summer 2001.

Proposals to extend nurse prescribing
A review of prescribing, supply and administration of medicines (again chaired by Dr Crown) was eventually published in 1999.(3) The report had two purposes:

  • To develop a consistent framework to determine in what circumstances health professionals could undertake new roles with regard to the ­prescribing, administration or supply of medicines in the course of clinical practice.
  • To consider implications for legislation and for ­professional training and standards.

The need for flexibility in making the best use of the skills and experience of the professions working in primary care was to be emphasised.
This report contained a number of recommendations, among which was the extension of independent nurse prescribing. The government responded to this aspect of the report by publishing a consultation ­document in October 2000.(4)
The topics consulted upon were:

  • Principles:
  1. Response to patient and local service need.
  2. Faster access to services.
  3. Professional boundaries to be eroded.
  4. Patient safety to be paramount and nurses to take full clinical responsibility for their ­decisions.
  • Potential medical conditions:
  1. Treatment for minor ailments and injuries.
  2. Health maintenance.
  3. Chronic disease management.
  4. Palliative care.
  • Extension to the Nurse Prescribers Formulary (NPF) - five options are outlined in the ­document. The more radical the option the greater the opportunity for nurses to undertake a wide range of clinical conditions within their own area of expertise. The options range from ­leaving the NPF in its present limited range, to making the entire British National Formulary (BNF) available to nurse ­prescribers.
  • Identifying nurses to prescribe - the ­underlying principles should guide employers to identify which nurses are appropriate to train to become nurse ­prescribers. Certain areas will clearly be obvious, for example nurse-led clinics, where patients will be able to access their medication more promptly and ­doctors will be freed to ­concentrate on areas that demand their ­specialist medical knowledge. This will clearly have ­implications for practice nurses delivering ­primary care services in both chronic disease ­management and nurse triage.
  • Educational preparation and training - work is currently underway with the Department of Health and the English National Board to ­determine the suitable ­educational preparation and training required for nurses to prescribe, both clinically and cost-­effectively. It is expected that nurse prescribing training will be at level 3 and that it will also become an integral part of the ­specialist ­practice programme.It is expected that other aspects of the report will be considered in the future.

The consultation phase
During the informal consultation period the Department of Health sought the views of ­organisations relating to nurses, doctors and pharmacists.
The UKCC supported the most radical of the extension options, whereby all general sales list and pharmacy medicines that can be prescribed on the NHS would be added to the NPF. UKCC President Alison Norman explained: "The Council supports a radical extension of the scope of prescribing by nurses because we believe that it is in the best interests of patients and clients. The option favoured by the Council will work in the best interests of patients, clients and the health services."(*)
*UKCC press release, 2000

This view was shared by the RCN, the District Nursing Association, the Community Practitioners' and Health Visitors' Association, and the Association for Nurse Prescribing (ANP).(†)
†Joint response to consultation document 2001 ­(unpublished)

The brief remains the same but the scope has widened
The NHS Plan refers to the old hierarchical ways of working and their replacement with more flexible teamworking practices and improved accessibility for patients.(5) Indeed the authors say the new approach will "shatter" the old demarcations that held back staff and slowed down care. The recognition and utilisation of nursing skills, so emphatically endorsed in The NHS Plan, will have the additional benefits of raising staff morale and improving the image of the profession. 
These attributes, however, are incidental to the core issue - the improvement of patient care. Nurses are not seeking the "right" to prescribe; their concern is the ­delivery of better, more appropriate and faster services to patients, whose requirements and safety must be ­paramount. The brief for nurse prescribing may remain the same today as it was in 1986 - to make more ­effective use of resources and to improve patient care - but it has come a long way since the time of the Cumberlege Report. In 1986 the review was directed at people ­receiving care at home, whereas today it is directed at those ­receiving care in any area of the NHS.
It is important to note that of the 20,000 nurses and health visitors whose nurse prescribing training will be completed later this year, only 5% are practice nurses. This is a reflection of the very different situation that applied in 1986 when the Community Nursing Review took place. In 1988 there were 3,480 whole time equivalent practice nurses employed in general practice in England.(6) By 1998 the number was 10,358. With this dramatic growth have come significant extensions of their role and expertise. A recent report published by the Centre for Innovation in Primary Care, concluded that practice nurses perform an increasingly vital task within primary care as they take on new roles (chronic disease management, triage of minor illness and so on) and extend old roles (health promotion, extended vaccination programmes for influenza and so on).(7) Indeed the study found that 78% of all nurse ­consultations for diabetes were with the practice nurse, compared with 22% with the doctor. In the Consultation document on the review of workforce ­planning,(8) it is noted that: "decisions on who can provide care should start from the patient's needs, not professional background and training". Furthermore, the report welcomes the plans that are being developed to extend the scope of prescribing by nurses following the Review of prescribing, supply and administration of ­medicines: "this represents a positive move which will benefit patients and the NHS, though we also ­recognise the ­importance of ensuring that this work is taken forward in a way which does not ­compromise patient safety."(8)

Where are we today?
The nursing profession is awaiting a ­ministerial ­decision upon the outcome of the ­consultation ­document and the future of nurse prescribing.

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References

  1. Department of Health, Crown J. Report of the Advisory Group on Nurse Prescribing [Crown Report]. London: Department of Health; 1989.
  2. Cumberlege J. Neighbourhood nursing: a focus for care [Cumberlege Report]. London: Department of Health; 1986.
  3. Department of Health, Crown J. Review of prescribing, supply and ­administration of medicines: final report [Crown Report 2]. London: Department of Health; 1999.
  4. Department of Health. Consultation on proposals to extend nurse prescribing. London: Department of Health; 2000.
  5. Department of Health. The NHS Plan: a plan for investment, a plan for reform. London: HMSO; 2000.
  6. Department of Health. Statistics for general medical practitioners in England 1988-1998. London: Department of Health; 1999.
  7. Centre for Innovation in Primary Care. What do practice nurses do? Leeds: Centre for Innovation in Primary Care; 2000.
  8. Department of Health. A Health Service of all the talents: developing the NHS workforce. London: Department of Health; 2000.

Resources
National Prescribing Centre
W:www.npc.co.uk
Royal Pharmaceutical Society of Great Britain
W:www.rpsgb.org.uk
National Institute for Clinical Excellence (NICE)
W:www.nice.org.uk

Further reading
Humphries JL, Green J. Nurse prescribing. London: Macmillan; 1999.
Courtenay M, Butler M. Nurse ­prescribing: ­principles and ­practice. London: Greenwich Medical Media; 1999.