Updated: 31/05/2005

Trent produces patient leaflets

Patient information leaflets about nurse prescribing and supplementary prescribing have been prepared by the Trent Workforce Development Confederation and can be downloaded here.
 

Responses to consultations

The consultations on the future of independent nurse prescribing (MLX 320; see here for more information: 1, 2, 3) and on independent prescribing by pharmacists (MLX 321; see here for more information: 1, 4, 5, 6) have now closed and some of the formal full responses have now been made available. Not surprisingly, those from the nursing and pharmacy bodies support the more radical options.

PSNC
 
The Pharmaceutical Services Negotiating Committee (PSNC) supports Option 5 in the consultation on pharmacist prescribing (prescribing for any condition from a full formulary), believing that anything else will prove too restrictive (see here for response). It believes that the NHS, patients and pharmacists would all benefit from the introduction of independent prescribing by pharmacists. The experience of nurse prescribing has shown that formularies are too restrictive and frustrating, and that they need updating and can conflict with local formularies. To allow for changes in the future in the structure of care delivery, there should be no restrictions on the basis of setting, condition, medicine or section of the profession. Professional obligations and competencies will provide the necessary restrictions and frameworks. The PSNC also comments that independent pharmacist prescribers should have relevant access to patient records and raises issues of evaluation and monitoring, budgets, training and funding.

NPA

The National Pharmaceutical Association (NPA) supports Option D (any condition, full formulary) for extending independent prescribing for nurses (see here for response).

It believes that this will improve patient care and that independent nurse prescribers will be highly skilled professionals and should be able to prescribe any medicine for any condition within their competencies. Robust and comprehensive training will be necessary, however. Competence both in medication review and in the particular clinical field they practice in should be demonstrated before they can prescribe.

The NPA also supports Option 5 of the consultation about independent prescribing for pharmacists, which would allow prescribing for any condition from a full formulary (see here for response).

It lists many benefits to patients, the NHS and the profession and believes that pharmacists in all settings should have the opportunity to become independent prescribers, setting out the sort of services that community pharmacists could offer. It also believes strongly that prescribing should be competency-led rather than restricted by formularies, arguing that this will produce maximum benefits and higher standards (by, for example, allowing prescribing in accordance with the latest guidelines). Pharmacists will be restricted, by RPSGB (Royal Pharmaceutical Society of Great Britain) guidelines and their Code of Ethics, to prescribe only within their area of competence. The NPA also believes that community pharmacists who prescribe independently could diagnose and treat acute conditions. There is also no reason why they could not treat conditions diagnosed by a GP. It provides detailed suggestions about how to ensure probity and safety.

Again, the importance of robust training is stressed, including how to undertake a medication utilization review, and recognition of when prescribing or referral is appropriate. The NPA therefore proposes that there be a standard set of competencies to inform training programmes, and, more radically, that national competency frameworks should be established for all conditions which all independent prescribers, including GPs, would need to follow.

RCGP

The Royal College of General Practitioners (RCGP) believes that Options A (continuing present system) and B (fixed formulary, any condition) are most realistic for the future of independent nurse prescribing, with its preferred option being somewhere between the two: option A extended to cover a wider variety of specified conditions and a broader Nurse Prescribers’ Extended Formulary (NPEF). The College specifies a list of conditions that would be inappropriate for inclusion if Option B were adopted, including pregnancy, psychiatry, cancer, hypertension and severe asthma/COPD and several others. It stresses that if options B to E were adopted, training in safe prescribing and access to sophisticated decision support systems would be vital.

The reason for this approach, argues the College, is patient safety. It says that the prescription of medicines is “a highly complex activity that is associated with considerable risk of morbidity and mortality” and that prescribing safely can be challenging even for an experienced GP, particularly where there are co-morbidities and multiple medications. It feels that expanding non-medical prescribing to all conditions and/or a full formulary will put patients at increased risk. It does believe that given appropriate training and review, it is reasonable for nurses to prescribe controlled drugs independently.

The College raises other concerns: the financial costs may have been underestimated, particularly given the increased targeting of nurses by pharmaceutical companies, and the risk assessment ignores the possible risks to the public of inappropriate medication. Questions of legal accountability and responsibility require consideration too: medical defence organizations currently make large payments as a result of prescribing errors by doctors. It points out that the proposed definition of an independent nurse prescriber is actually that of a generic independent prescriber but in any case proposes an amended version: “Independent prescribers are professionals who are responsible for the assessment, diagnosis and management of patients within their own areas of clinical competence”.

On the question of independent prescribing by pharmacists, the College favours Option 1 (current system of patient group directions, supply and sale of P and GSL medicines and supplementary prescribing) or Option 2 (certain conditions from a limited formulary). It feels that if a change is to be made, Option 2 is the most sensible but that the nursing formulary will be inappropriate and that the list reflects confusion about the role of the pharmacist prescriber: several conditions require diagnostic history and examination in a suitable location, injections are inappropriate for pharmacists and so on. It feels that the more radical options require further evaluation and discussion, particularly of the safety issues.

Separation of prescribing and dispensing is a major concern, as the check provided by the pharmacists is important for safety reasons, with many errors being spotted at this stage. Conflict of interests in a predominantly commercial environment are another concern.

RCN

The Royal College of Nursing (RCN) supports Option D (any condition, full formulary). It is confident that the requirement to work within the Code of Professional Conduct will ensure that nurses do not stray outside their areas of competence and that restrictions on the conditions or medicines will not benefit patient care. It believes that the proposal for advanced practice nurses with higher levels of competence having full prescribing rights could cause confusion and be difficult to regulate.

BPS

The British Psychological Society (BPS) writes in support of a competency-based approach to new roles, believing that it will allow consultant psychologists to join with nurses and pharmacists in using skills to the full. It believes that extending prescribing rights to nurses will strengthen the multidisciplinary delivery of care.
 

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