Supplementary prescribing

The Royal Marsden Conference Centre, London, 9 June 2003

IBC UK Conferences

Molly Courtenay, Lecturer, University of Southampton, Joint Prescribing Adviser to the RCN and Editor in Chief of nurse-prescriber.co.uk.

The day was attended by about 100 delegates and chaired by Barbara Stuttle, Chair, Association of Nurse Prescribers (ANP), and Molly Courtenay.

Siobhan Gregory, Regional Nurse Prescribing lead, Ealing Primary Care Trust talked about the policy drivers behind prescribing, how many prescribers there are at present, supplementary prescribing (SP), the Clinical Management Plan (CMP) and how it will work in practice, the benefits to patients, and the future. Questions highlighted the increased interest in SP by nurses and other professions allied to medicine (PAMs).

It was emphasized that joint extended and SP prescribing courses will commence in the majority of higher education institutes (HEIs) in September. Many of these courses will be for both nurses and pharmacists. Some of the first pharmacists to go on the courses will be from secondary care (pharmacists involved in clinics for renal patients, patients receiving parenteral nutrition and those with cardiac problems). Pharmacists from primary care will include those working within GP access schemes (where patients are able to have a consultation with a pharmacist rather than a GP), and pharmacists working in close proximity to GPs (for example, dispensing practices).

Although there have been some problems about the availability of consulting rooms and shared records, these are being resolved. Boots the Chemist, for example, has introduced consulting rooms.

One delegate questioned the whether SP would be useful for neonatal nurse practitioners and it was thought that in this situation SP might not be the best mode of medicine supply and that it would be a good idea to wait and see how prescribing develops in the future.

Joy Wingfield, Professor of Pharmacy Law and Ethics, School of Pharmaceutical Sciences, Nottingham University, discussed SP, accountability and responsibility. The legal basis of prescribing and regulatory frameworks was described. She addressed professional judgement, professional liability, legally valid consent, documentation and confidentiality, prescription writing and prescription security. The presentation brought to light the many complex issues surrounding prescribing, with one delegate asking a question about consent for patients with mental health problems.

Maureen Williams, Professional Officer, Community Nursing and Health Visiting, Nursing and Midwifery Council (NMC), discussed CMPs, pointing people to the Department of Health supplementary prescribing website and emphasizing the need to be creative and flexible in their development.

Mary Ring, Clinical Lead for Nurse Prescribing, Coventry Primary Care Trust, discussed how to identify the right people for prescribing courses. The session was extremely informative, addressing the topic from a local perspective and including experiences to date. Areas covered included issues surrounding selection of students, support from managers and medical mentors, and the treatment areas for extended and SP prescribing. One questioner asked about payment of medical mentors and it was pointed out that this is very unlikely, given that nurses, pharmacists and the other PAMs would require mentors for SP. This would become extremely expensive for Trusts.

Dr Peter Wilson, Education Division, Royal Pharmaceutical Society of Great Britain (RPSGB), described SP training for pharmacists, looking at the recommendations of the Task Group, the development of the SP curriculum, learning outcomes, indicative content, programme delivery, duration and assessment. The role of the RPSGB in accreditation of programmes, maintenance of a register for SP and monitoring CPD was also highlighted. One questioner asked about how the different needs of pharmacist and nurses on prescribing programmes could be met. Responses emphasized the generic nature of the programme. In many HEIs, monitoring skills (an area covered on the combined extended/SP programme) would be attended by pharmacists but would be an area in which nurses would be competent. In contrast, pharmacology would be an area in which nurses would need to develop their knowledge but in which pharmacists were competent.

Dr Molly Courtenay looked at the support required by prescribers. Particular areas in which health visitors/district nurses (HV/DN) require support are pharmacology and medicines- related knowledge (research and anecdotal evidence). Although the evidence related to HV/DN prescribers, extended prescribing and SP involved more complex drugs and so this would remain a necessary area for continuing professional development. She also examined issues about prescribing for patients with multiple conditions and the different drugs taken.

The CPD needs of prescribers in the USA were then examined. These centre on pharmacological knowledge, and the need to keep up-to-date with drug information. The first year of prescribing is the time (in the USA) when the need for support is most intense. Advice and support, particularly from doctors, is vital.

She then looked at how external influences on prescribing in the UK influence the prescribing role, emphasizing the need for CPD programmes to update nurses on changes. The support systems currently available to prescribers were outlined.

Trudy Granby, Nurse Prescribing Manager, National Prescribing Centre (NPC), looked at the role of the NPC, prescribing competencies and the NPC competency frameworks. A competency framework for doctors was discussed after the presentation. Although such a framework does not currently exist, it was suggested that competencies for prescribing should be generic.

Patricia Wilson, Review Manager, Commission for Health Improvement (CHI), discussed Clinical Governance and how SP ‘fits’ within this structure. The principles and aims behind the development of the CHI were described. The role of the CHI and clinical governance, review methods, current themes, areas for concern, risk management were all topics addressed.

*Lecturer, University of Southampton, Joint Prescribing Adviser to the RCN and Editor in Chief of nurse-prescriber.co.uk.
†Senior Lecturer, School of Health, University of East Anglia

The conference was chaired by Barbara Stuttle, Chair, Association of Nurse Prescribers (ANP) and Judy Wayman and attended by 32 delegates.

Barbara Stuttle looked at prescribing achievements to date, prescribing in 2003 and the future. She emphasized the need for closer working relationships between pharmacists, nurses and doctors, and the need to be creative and flexible about supplementary prescribing. During the question period, Barbara said that computer-generated prescriptions will be available to nurses very soon.

Molly Courtenay described the Clinical Management Plan (CMP), presenting information on the role of the CMP in supplementary prescribing, who is responsible for producing the plan, and how the CMP will be implemented in practice. She emphasised that all the information presented could be found on the Department of Health (DH) supplementary prescribing website and showed the delegates a CMP and accompanying protocol developed by Anne Baird, Nurse Practitioner, Sheffield. Questions covered the use of supplementary prescribing in patients with multiple conditions, multiple prescribing partners and the review period of the CMP by the independent prescriber.

Annie Coppell, Director of Corporate Governance and Programme Management, National Prescribing Centre (NPC), explored the role of the NPC, prescribing competencies and the prescribing competency frameworks produced by the NPC. Discussion following Annie’s presentation included the use of these frameworks in Wales. Although the NPC does not yet cover prescribing in Wales, individuals can log into the NPC website. A competency framework for doctors was also discussed. Although such a framework does not currently exist, it was suggested that competencies for prescribing should be generic.

Mary Ring, Health Visitor, Coventry, discussed working with Patient Group Directions (PGDs), including a description of PGDs, the types of schemes and drugs that are appropriate for them, the process for developing a PGD, and the training/update requirements for nurses involved in using PGDs. Questions surrounded PGD development. It was highlighted that the DH will not accredit PGDs. However, there is an excellent PGD website.

Judy Wayman looked at the process of selection for prescribing programmes and eligibility of students and on-going professional development. The need for robust support systems for managers and prospective medical supervisors was highlighted along with that for good support systems and networks once programmes were completed. The talk was linked to clinical governance. Questions following this session included whether nurses should go down the route of PGDs or prescribing. It was emphasised that individuals must look closely at their own practice and identify the mode of medicine supply that is the best ‘fit’.

Caroline Pennels, Clinical Governance Co-ordinator, East Gloucestershire NHS Trust, spoke about clinical governance and the need for hospitals to catch up with primary care with regards to identifying which nurses to train for prescribing. Caroline described a confused picture surrounding prescribing and PGDs. The importance of risk management and audit and links between clinical and corporate governance were made. The need for effective documentation, including incident reporting and ‘near misses’, was emphasised.

Lynn Aglionby led a lively and informative session on managing the risks associated with prescribing, pointing out that adverse drug reactions are the fourth leading cause of death in the USA. She used case law to remind nurses about the pitfalls of prescribing and the required standards of care. The word ‘reasonable’ was used throughout the session. This was reassuring, although she also said that 20% of all civil claims against the NHS are drug-related.