RPS argues for prescribing rights for pharmacists

Additional prescribing rights should be extended to pharmacists, given the MCA proposals for the extension of nurse prescribing, claims the Royal Pharmaceutical Society (www.pharmj.com). According to the Society, if the length and type of training proposed imparts competence to prescribe for nurses, then pharmacists should be able to prescribe from the same list, given their training.

The Society has commented separately on the proposals themselves, stressing the need for training to include risk management and multiple pathology, and highlighting the importance of competency requirements and the practical difficulties of prescribing. Pharmacists will need a way of identifying the areas in which individual nurses are authorised to prescribe, and from which formulary.

It also raised the question of what resources could be made available to nurses, pointing out that the BNF would need modification to make clear which products can be prescribed by nurses and perhaps to take into account the differences between nurse education and that for physicians and pharmacists.

The RPS also reminded the MCA that the Crown report said that antibacterial antibiotics should not normally be available to new groups of prescribers because of the risk of resistance developing.

Competency framework published

An outline framework of the competencies that nurse prescribers should have or should develop has been published by the National Prescribing Centre (www.npc.co.uk). It was presented at a meeting in Birmingham in November and was received with enthusiasm (see editor's newsletter). The framework outlines the prescribing competencies that should, if maintained, help nurses continually improve their prescribing practice. They cover three main areas:

• The consultation: clinical and pharmaceutical knowledge; establishing options; communicating with patients.
• Prescribing effectively: prescribing safely; prescribing professionally; improving prescribing practice.
• Prescribing in context: information in context; the NHS in context; the team and individual context.

For example, two of the statements under prescribing safely are: knows the limits of own knowledge and skill and works within them; and prescribes a medicine only with adequate, up-to-date knowledge of its actions, indications, contraindications, cautions, dose and side-effects.

The document stresses that users of the framework should consider how each statement applies to individuals or groups. It is likely to be used in the first instance to guide training and development but could also be used in recruitment and appraisal. It should be relevant to all independent prescribers and to supplementary prescribers in the future.

Concerns continue regarding the extension to nurse prescribing

Nurses and others within the health service are still concerned about how the extension of nurse prescribing will work, although the new training programmes are due to start in January.

Some of the worries expressed at a meeting in Milton Keynes at the end of October, organized by training company medM, centred on the reasons why nurses are reluctant to prescribe from the current formulary, even after training.

The basic education nurses receive also gave cause for concern. Nurse lecturer Molly Courtenay pointed out that nurses are now taught much less basic pharmacology, anatomy and physiology than in the past, as part of the move away from a medical model of care.

There are also worries about how GPs will be reimbursed for acting as mentors, whether they will have the time, and how supportive they will be generally.

In its response to the government consultation, the RCN has suggested an extension of the time limit for the training programme from 3 to 6 months (see previous news item).

Locum cover worries

An editorial in Practice Nurse (November 2001, p12) has raised concerns about locum cover for practice nurses attending the new nurse prescribing courses. The article points out that there is no government funding to cover the 25 days teaching. A further potential problem is the lack of locums in most areas of the country.

RCN responds to consultation

The RCN has responded to the consultation about how the extension of nurse prescribing should be carried forward, with comments to both the MCA and the Department of Health. Although the RCN supported a much more radical extension of the formulary (option 5), it supports any measure that will extend nurse prescribing, and has raised a number of concerns with both bodies with a view to making the best of the chosen system.

Definition of nurses eligible to prescribe
The College stresses that, although prescribing rights should be accessible to as wide a range of nurses as possible, they should be exercised by nurses with specialist competencies that underpin prescribing practice. Guidance should highlight the importance of relevant experience.

POMs to be included
The RCN believes that the POM list proposed by the MCA (see previous news item) is too limited and questions whether an analysis of GP prescribing habits from 10 years ago was the best yardstick to use.
It suggests that the MCA and Department of Health should canvass opinions from would-be nurse prescribers about which additional items for treating the four areas - minor injury, minor ailment, health promotion and palliative care - should be included. It also believes that the link between specific conditions and choice of medicines is too rigid. In some cases quality care could be compromised.
According to the RCN, nurse prescribing should be extended on the basis of nurses having the ability to select a particular medicine for a condition on the basis of their knowledge of the condition and the appropriate product.
As for antibiotics, it agrees that the original list (in annex C of the MCA consultation) is adequate but again thinks that the link between condition and antibiotic is too rigid. Likewise, nurses should be able to prescribe from the list of controlled drugs across all four areas rather than just palliative care.
The RCN would like to see a logical system for introducing new items into the formulary and also asks for details about how the existing NPF will work alongside the new formulary.

Training
The RCN raises some concerns about the proposed training programme and in particular recommends that the time limit for completion be extended from three to six months. It also queries the policy that the nurse prescribing course will not be incorporated into existing programmes. The nurse practitioner course, for example, contain similar content to that in the new outline ENB curriculum.

Independent sector
Extending nurse prescribing to nurses working in the independent sector should be considered as a matter of urgency.

Will managers release nurses for training?

Although managers may be reluctant to send nurses on the new three-month nurse prescribing courses because they will leave staff shortages behind them, only a small number from each organisation or area will be away at the same time, according to the chair of the Association of Nurse Prescribers, Anthea Clegg (Nursing Standard October 3-9; www.nursing-standard.co.uk).

UKCC responds to MCA consultation

At a meeting in September, the UKCC agreed its response to the MCA consultation on the expansion of nurse prescribing. Although on the whole it welcomed the proposals, it said that the definition of those able to prescribe should include health visitors and midwives. Following recommendations from district nurses and health visitors that water for injection should be included in the formulary and midwives that diamorphine be included, the UKCC will seek these additions.
It also agreed revised competencies for practitioners who wish to record a prescribing qualification against their UKCC entry. The free-standing courses will cover: legal issues underpinning prescribing; principles of drug dosage; side effects and reactions; drug abuse; record keeping and communication; accountability; team working especially with pharmacists; and audit.

Outline curriculum approved by ENB

In September, the ENB approved the outline curriculum for the extended nurse prescribing course, which can be found on its website (www.enb.org.uk/epl0101.htm). The curriculum will not be integrated into other education programmes and courses are expected to be in place by January 2002.
The curriculum sets out the requirements for entry to the course and then sets out the areas of study that should be developed into the detailed curriculum for prescribers: consultation, decision-making and therapy including referral; influences on and psychology of prescribing; prescribing in a team context; clinical pharmacology including the effects of co-morbidity; evidence-based practice and clinical governance in relation to nurse prescribing; legal, policy and ethical aspects; professional accountability and responsibility; and prescribing in the public health context. The medical practitioner who provides supervision, support and shadowing opportunities for the student must be familiar with the requirements of the programme.
Both theory and practice must be assessed and the assessment requirements must be made explicit. The following methods will be used in assessment: review of portfolio or learning log (maintained by student as a way of facilitating and recording critical thinking and reflection); Objective Structured Critical Examination (OCSE) in a simulated learning environment; satisfactory completion of period of practice experience, assessed by supervising medical practitioner; and written final exam (both MCQs/short answers and essays).
The theory component is allocated 25 days over 3 months and students are expected to shadow the medical practitioner for the equivalent of one day a week during this period, making about 37 days in total.
The current preparation for prescribing from the current NPF will continue to be integrated into the community specialist practitioner programme. Current prescribers who are going to extend their responsibilities under the new arrangements must complete the programme and assessment, although it is expected that previous learning and experience will be given some recognition.

Beverly Malone on nurse prescribing

Nurses failed to achieve their goal of option five in the proposals to extend nurse prescribing because they didn't take enough notice of public opinion and use it to their advantage, says Beverly Malone, the new RCN general secretary. In an interview in Practice Nurse (14 September, pp11-12), she claims that a partnership with the public is needed because it is the public who are not getting the prescribing services they need. Nurses will get to option five if they make what they are talking about common knowledge and don't let prescribing remain a mystery. Practice nurses provide health promotion and disease prevention services very well and the whole nation could be healthier if they have more room to provide this function.

Selection of nurses for training

Employers of nurses have been asked to begin identifying possible candidates for the training courses expected to begin early next year. The part-time three-month training programme will include 25 taught days in a university and 12 days when a medical prescriber will provide the student with supervision, support and opportunities to develop competencies in prescribing. Both theory and prescribing competence will be assessed.
Nurses nominated for training must have both the wish and the opportunity in their practice to prescribe from the extended formulary. Nurses cannot be nominated because they wish to prescribe if their practice is not appropriate. Candidates are sought from primary and secondary care.
The government has set out criteria to identify possible candidates and has asked local health organisations to prioritise those nurses that meet the criteria on the basis of benefit to patients and then to nominate enough nurses to fill the centrally funded training places that are available. Any further places purchased locally should be filled using the same selction process.
The criteria fall into three groups: legal (must be 1st level registered nurse or midwife; with valid UKCC registration; and have a mark against name on professional register to indicate successful completion of nurse prescribing preparation), educational (be capable of study at degree level; have a medical prescriber willing to contribute before and after qualification) and occupational (agreement of employing organisation to allow completion of all course elements, supervised prescribing period and continuing professional development; commitment from employer about prescribing budget and other necessary arrangements post-qualification; a post in which the nurse is likely to prescribe in any or all of the four areas of minor injuries, minor illnesses, health promotion and palliative care).
Priority should be given to nurses whose prescribing will give maximum benefit to patients and best value for training resources. The maximum benefit principle will prioritise nurses who run their own clinics or services (e.g., nurse-led units), nurses who are isolated from other prescribers (e.g., working with the homeless or in intermediate care facilities), or nurses who could complete an episode of care by prescribing (e.g., family planning clinic nurses). The best value principle will prioritise nurses working in more than one of the four areas and those with additional qualifications likely to facilitate prescribing (e.g., specialist practitioners, nurse practitioners).
Organisations should also consider whether the supplementary prescribing option to be developed next year would be more appropriate for nurses working with chronic diseases and mental illness, for example. There may also be situations where patient group directions offer greater benefits for patient care than independent nurse prescribing.
Most of the £10 million of central funding announced for 2001-2004 will go towards the cost of training. Additional costs such as providing cover for nurses taking the course will have to be met by the employer. NHS organisations can also use their own training budgets to fund training places.
The Department of Health has also made clear that independent nurse prescribers will be professionally responsible for their actions. The employer of an appropriately trained and qualified independent nurse prescriber, prescribing as part of his or her nursing duties with the employer's consent, will be held vicariously responsible for the nurses actions. The issues of legal and professional responsibility for supplementary prescribing need further consideration.

Chief Nursing Officer explains latest training plans

Expanding the nurses' formulary means that many more nurses will be able to improve patient care, according to England's Chief Nursing Officer. Writing in Nursing Standard, Sarah Mullally explains that there is no suggestion that all eligible nurses should enter the new degree-level prescribing course. Local service need and potential benefit to patients will determine which nurses receive prescriber training (see recent postings on the News section for details of training).
She confirms that current nurse prescribers and ones who qualify in future through the health visitor or district nurse specialist practitioner programmes will continue to be able to prescribe from the current NPF. If their patients would benefit, they can apply for the new training programme and their prior learning will be assessed to take their existing skills and experience into account.

Consultation on list of POMs launched

The MCA has published a list of prescription-only medicines that it proposes should be prescribable by independent nurse prescribers after the appropriate legislation has been passed.

It proposes that all nurses undertaking these extended prescribing duties would undergo a 3-month programme at degree level, made up of about 25 taught days plus additional self-directed learning, and learning in practice with a prescribing mentor. This will be followed by theory and practice assessment.

The MCA is seeking comments on the list of POMs that the Committee on Safety of medicines (CSM) considered safe for trained independent nurse prescribers to prescribe in the four areas being considered under the government’s proposals: minor ailments, minor injuries, health promotion and palliative care. It also wants comments on the list of oral antibiotics proposed for inclusion by the CSM, as the government has decided in principle that independent nurse prescribers should be able to prescribe oral antibiotics.

A list of minor ailments and injuries common in primary care was drawn up and POMs considered for inclusion or exclusion in an extended NPF. For the following conditions, at least some treatments are proposed for inclusion: haemorroids, phlebitis, aphthous ulcer, oral candidiasis, dental abscess, gastroenteritis, gingivitis, heartburn, blepharitis, allergic and infective conjunctivitis, furuncle, otitis externa and otitis media, acute uncomplicated neck and back pain, sprains, soft tissue injury, sore throat, allergic rhinitis, acute sinusitis, tonsillitis, skin abrasions, acne, animal bites, boils/carbuncles, burns/scalds, skin candidiasis, cellulitis, chronic skin ulcer, atopic, contact and seborrhoeic dermatitis, ringworm, herpes labialis, impetigo, insect bite/sting, lacerations, nappy rash, head lice, urticaria, lower uncomplicated urinary tract infection, bacterial vaginosis, vulvovaginal candidiasis, dysmenorrhoea and balanitis.

Under health promotion, folic acid is not recommended for inclusion as it is exempt from POM for a maximum daily dose of 500 micrograms and is available for nurses up to this dose. Women intending to become pregnant or in the first three months of pregnancy should take 400 micrograms daily. It is proposed that appropriately trained nurses can prescribe the combined oral contraceptive pill, the progesterone-only pill, caps, diaphragms, spermicides, injectable contraceptives and intra-uterine contraceptive devices.

For palliative care, some additional POMs are recommended for inclusion but strong opiod controlled drugs are not.

The recommended list of antibiotics includes amoxicillin, nitrofurantoin, trimethoprim and cefalexin (lower urinary tract infection in women), erythromycin (acne, otitis externa, throat infections), flucloxacillin (boil, impetigo, otitis externa), metronidazole (bacterial vaginosis), oxytetracycline (acne), and phenoxymethylpenicillin (throat infections).

Some more analgesics have been proposed for inclusion although the only NSAID recommended is ibuprofen, because of concerns that even small doses of any other NSAID carries significantly greater risk of gastrontestinal bleeding.

The proposals, lists of POMs and oral antibiotics, and a form to comment on the proposals can be found in the main document at the MCA website and a list of conditions with associated POMS and further information in the background document: www.mca.gov.uk/whatsnew/whatsnew.htm. The deadline for comments is 9 October 2001.

Nurses can prescribe more appliances and reagents

As promised in the announcement about the extension of nurse prescribing, the list of products that qualified nurse prescribers can prescribe has now been extended to include nearly all the appliances and chemical reagents listed in parts IXA and IXR of the Drug Tariff. Nurses in England can now prescribe nicotine replacement therapy products after further training.

Some nurses reluctant to prescribe

Some nurse prescribers have still not prescribed three months after their training and form part of what appears to be a group of reluctant prescribers, stalled because of anxiety and lack of confidence, according to Alison While, professor of community nursing at King’s College London. At a seminar on prescribing issues held in May, she highlighted the difficulty in translating the lessons learned from pilot projects into practice.

The specialist community nurses who have now trained as prescribers are a heterogeneous group, with different educational backgrounds and previous experience. The rollout of nurse prescribing will not necessarily match what happened in the pilots, which were based within integrated teams in areas with a stable workforce. It is not clear what enables or inhibits prescribing by nurses because of a lack of research, but nurses working in stable long-established teams do seem more likely to prescribe.

Recognition of the challenges in nurse prescribing was important and nurses' roles need adjusting to accommodate it. Robust training and ongoing education is required together with further research.

The seminar was organized by the South East Pharmaceutical Industry Group with support from the Wessex and the London and Thames Valley Pharmaceutical Groups.

Scottish doctors back expansion plans

The BMA in Scotland has welcomed the announcement of the extension of nurse prescribing, saying that doctors currently spend too long on some tasks, such as certain types of prescribing, that could be done equally well by other health professionals. Dr John Garner, Chairman of the BMA’s Scottish Council, said that the move, "will mean that many patients will be better served, as they will no longer have to first see the nurse and then wait for the doctor to agree the prescription. This is a recognition of the high levels of training and professionalism that nurses achieve and will hopefully reduce a little of the needless workload doctors often face".

Unison and CPHVA welcome move

Unison has welcomed the plans to extend nurse prescribing, saying that, "nurses are perfectly placed to provide high standards of professional practice in this area and can help ensure people receive care without unnecessary delays". Unison does, however, want to see the relevant courses for nurses in place as soon as possible.

The announcement has also been welcomed by the CPHVA as a step in the right direction, particularly in the context of the NHS plan and its emphasis on health professionals adopting different ways of working to provide a more responsive service.

Nurses to prescribe 200-plus POMs

More than 200 prescription-only medicines will be added to the list of treatments nurses can prescribe, according to a Department of Health announcement last week (Nursing Times 2001; 97(25); 5), which provides some more detail on May decision about the extension of nurse prescribing .

Independent prescribers will be able to prescribe all the POMs on the list whereas supplementary prescribers will be able to prescribe POMs for specific conditions (particularly in mental health and chronic disease management). All non-prescription medicines currently prescribed by GPs will also be on the extended nurse prescribers list. Discussions with the Home Office are said to be underway about controlled drugs, as they are covered by separate legislation.

A prescribing mentor, probably a doctor, will be assigned to students on the training courses and a period of supervised practice will follow.

There has been mixed reaction from nurses and the nursing press about the plans to extend nurse prescribing. Some nurses feel the changes do not go far enough and that the whole formulary should have been opened up, whereas others argue that nurses should not move further into medical roles. The quality of training and support is seen as crucial.

Joint effort over prescribing limits

The RCN is apparently planning to set up talks with other nursing organizations in an attempt to persuade the government to extend the nurse prescribing formulary more radically. At the RCN Congress, almost 98% of voting members backed an emergency resolution, condemning the government for not adopting option 5 (Nursing Standard 2001; May 30:5)

Supplementary prescribing should be welcomed

Supplementary prescribing is a constructive way forward, even though it will mean patients shuttling between doctor and nurse, according to Mark Jones, RCN Primary Care Policy Advisor (Nursing Standard May 16, p22; www.nursing-standard.co.uk).

After a doctor’s assessment it is feasible that nurses will be able to write a prescription for whichever drug they feel is appropriate, and the government has not limited the conditions that supplementary prescribing could apply to.

So, although the RCN feels that the government has missed the opportunity to get prescribing by nurses right once and for all, this move will give nurses more freedom and will also make legal a lot of current practice. In addition, there will be independent prescribing for many nurses working in minor illness, minor injury and palliative care settings.

New NICE guidance on wound debridement

The National Institute for Clinical Excellence (NICE) has recommended that the choice of debriding agent for difficult-to-heal surgical wounds should be based on patient acceptability, as well as type and location of wound, and total costs. The guidance says that there is some evidence that modern dressings may reduce pain and be more acceptable to patients.

It also says that there should be better education of healthcare workers, patients and carers and more sharing of expertise in the provision of specialist wound care services.

The total costs of wound care are very sensitive to the frequency of dressing changes, particularly if they are changed at home by a nurse. The Clinical Director of NICE, Professor Peter Littlejohns, said: "The guidance makes it clear to the NHS and patients that the method used should consider not only the cost but also the impact for patients." (See www.nice.org.uk for full guidance).

RCGP wants shared medical records

Some kind of shared medical record is important for continuity of patient care under an extended nurse prescribing system, according to the Royal College of General Practitioners (RCGP).

In its response to the announcement, the RCGP says both doctors and nurses should be aware of what has been prescribed. Practice protocols should ideally give a single person – the GP or the nurse – responsibility; this is particularly important where nurses are prescribing for chronic diseases such as asthma and diabetes.

It also says that it expects systems to be put in place that provide the same safeguards and assurances that revalidation does for doctors.

More nurses to prescribe more medicines…but it’s not option five

The government has just announced a limited extension to nurse prescribing that stops short of the radical option five backed by the UKCC, the RCN and Unison. Health Minister Lord Hunt announced that appropriately trained nurses will be able to prescribe for: minor injuries such as burns, cuts or sprains; minor ailments such as hayfever or ear infections; health promotion items, such as preconception vitamins; and palliative care.

After training, independent nurse prescribers will be able to prescribe all GSL and P medicines currently prescribable by doctors under the NHS, together with a list of POMs linked to specified medical conditions. Consultation on the list of POMs by the Medicines Control Agency will follow later this year.

There will also be "supplementary prescribing", where nurses can treat more complex conditions and chronic diseases such as asthma, diabetes, hypertension, mental health and CHD, after initial assessment by a doctor. Clauses in the Health and Social Care Bill will allow the introduction of this new type of prescriber, who may be from other professions such as pharmacy.

Training programmes should be in place by the end of the year and £10 million has been allocated for 2001-2004 training costs. About 10,000 nurses are expected to have completed the training by 2004. The 20,000 current nurse prescribers may be eligible for further training.

Nicotine replacement therapy products have been added to the list of products that nurses can prescribe and the government intends that by later this summer, nurses in the community will be able to prescribe the same appliances and dressings as GPs.

The government stresses the scope this move has to reduce doctors’ workloads: up to 30% of GP consultations are for minor injuries and ailments. The nursing organizations have given it a cautious welcome. Mark Jones, RCN primary care advisor, is quoted as saying, "the government has missed the opportunity to ensure that patients get the advantages that would follow if nurses with specialist training and expert knowledge could prescribe from a wide range of medicines". Unison welcomed the announcement, and said it wanted to see the relevant education courses in place as soon as possible. The UKCC also welcomed the announcement, pointing out that it fell short of the radical extension in nurse prescribing proposed.

The government says that over 900 responses to the consultation were received, with the majority expressing strong support for change.

MAY 2001

Patients’ views on nurse prescribing

Nearly three-quarters of a sample of 50 patients treated in the community thought that their treatment began sooner when a nurse could prescribe, according to Nursing Times. Almost half of the patients thought it was more convenient to have nurses prescribing for them in their own homes instead of waiting for a GP appointment. About one-third of the patients thought nurse prescribing should be extended.

The patients were treated by staff from Leicestershire and Rutland Healthcare NHS Trust. Those with chronic health problems were frustrated by the restrictions placed on the help nurses could offer.

NHS Alliance wants prescribing rights for more professionals

In its response to the government’s consultation paper, the NHS Alliance supports the principle of extending prescribing rights to appropriate healthcare professionals, not just nurses. The NHS Alliance is a primary care organization that says it represents more than three-quarters of PCGs and PCTs.

Its view is that the only limits on prescribing should be competence and benefits to patients. Professional background, medical condition and type of medicine should not, in principle, constrain prescribing. Option five is therefore the most appropriate. This view would clearly have important implications for the training and development of primary care staff.

In the short-term, the Alliance supports one formulary for nurse prescribers but in the longer term there should be one formulary for all prescribers. Nurses should be able to prescribe ‘off-label’ in areas in which they have been fully trained (‘off-label’ refers to the use of a medicine for an indication for which the medicine is not licensed).

The consultation paper itself points out that doctors and dentists can currently prescribe from the whole formulary but constrain themselves to their areas of competence. The debate about nurse prescribing seems to hinge at present on whether this is appropriate for nurses – let us know what you think in our forum.

Health Quality Service supports option 3

Healthcare charity the Health Quality Service (HQS) has supported option 3 of the government’s proposals as the most workable under the suggested timeframe but questions whether it is realistic to have training in place by September this year. The HQS is a UK standards-based assessment, review and quality improvement organization associated with the King’s Fund.

Under option 3, all GSL items and P medicines together with certain prescription-only medicines such as those for asthma, diabetes and hypertension, would be added to the NPF. The HSQ proposes a framework to establish prescribing parameters for generalist nurses and says that specialist nurses should prescribe in their specialist areas only. Drugs prescribed by nurses should be reviewed after a certain number of treatments. Robust monitoring systems will be needed as nurses will be deciding upon their own competence to prescribe.

The HSQ raises the question of legal safeguards for patients and staff under the proposals. Unless the professional indemnity of prescribing nurses is re-examined, they should not be able to prescribe unlicensed and ‘off-label’ medicines.

Training is again highlighted as a crucial issue, as it has been in many of the responses to the government’s proposals.

MCA considering nurse reporting under yellow card scheme

The Medicines Control Agency (MCA) (http://www.open.gov.uk/mca/mcahome.htm) is said to be consulting with UK nursing officers about allowing nurses to report suspected adverse drug reactions via the Yellow Card scheme, according to Nursing Standard (http://www.nursing-standard.co.uk/index.htm). The aim is to develop a strategy for introducing nurse reporting, including appropriate training. Given the government’s proposed extension to nurse prescribing, it is important that nurses can make these reports and the RCN has apparently written to the MCA about the issue.

The London Standing Conference for Nurses, Midwives and Health Visitors has backed an extension to nurse prescribing along the lines of option five, the most radical of the government’s proposals. The response is a collective one from the 15 working groups of the Conference, which gives nurses in London a voice in relation to professional and healthcare issues.

It stresses that benefits for patients should be central and suggests that nurses should be able to prescribe in response to symptoms, for example chemotherapy-related nausea and vomiting, rather than on the basis of medical conditions alone.

Although nurses should be able to prescribe for children, recognition of the different diseases and health issues for children and young adults is important. The Conference also suggests that although mental health should be included in the list of conditions for which nurses can prescribe, it should be mental health nurses who do so, rather than general primary care nurses.

It believes that there should be a single formulary, with nurses using their professional judgement to decide which areas they should prescribe in. Option 3 (all GSL and P medicines except for Schedules 10 and 11 together with a specified range of POMs) should be the minimum change made, but option five was felt to be the one that will provide nurses with the greatest scope for providing the range and quality of care needed. ‘Off-label’ prescribing (prescribing a licensed medicine for an indication for which it is not licensed) was supported but the prescribing of unlicensed medicines was not.

The importance of training and education was again highlighted, with some support for preparation being at postgraduate level. Post-qualification continuing professional development is also extremely important.

• Guild of Healthcare Pharmacists raises legal concerns

In its response to the consultation paper on the extension of nurse prescribing, the Council of the Guild of Healthcare Pharmacists registers its concern that the "proposals may represent undue haste". It is concerned about using 30-year-old legislation because it provides an easier route.

It believes that the timetable for training courses may be overly ambitious and that the module must be at degree level at a minimum. If the basics of diagnosis to start of medication under option five are to be included, where does this differ from a medical degree?

It outlines the legal and practical issues it sees with each of the five options, and is particularly concerned about the question of accountability for overall care under options four and five.

The president of the Royal College of Physicians has welcomed the proposals to  extend nurse prescribing outlined in the consultation paper, according to the Department of Health. Professor George Alberti is quoted as saying, "We greatly welcome this initiative. It is a logical extension of the role of many nurses and will certainly improve the smooth management of a variety of conditions and diseases. Patients will certainly benefit.

For more information download: http://www.doh.gov.uk/pdfs/nurseprescribing.pdf

The Royal Pharmaceutical Society says it welcomes to the proposals to extend nurse prescribing, provided that public safety remains the paramount consideration. It suggests that ideally nurse prescribing should be extended in stages, with the opportunity after each stage to evaluate what has happened and address problems.

The response to the government's consultation paper contains a list of conditions that it suggests could be managed by nurse prescribers and cautions against nurses prescribing off-label and unlicensed medicines except in particular circumstances for which national guidance was available. There are particular implications for such prescribing in paediatric care.

In the view of the RPS, all prescribing should be governed by the management of risk, assessment of competence, the breadth and depth of knowledge required by the prescriber and the existence of an appropriate framework for safe practice.

More information: http://www.pharmj.com

JANUARY 2001

• RCN and UKCC back radical extension of nurse prescribing

Both the RCN and the UKCC have supported the most radical of the options to extend nurse prescribing proposed by the government and have also called for the inclusion of controlled drugs. All general sales list and pharmacy medicines, with the exception of controlled drugs, that can be prescribed on the NHS should be added to the nurses formulary, according to option five of the consultation paper.

In its consultation paper, the government did raise the issue of nurses prescribing controlled drugs and pointed out that this would require separate legislation. Unison has also backed option five but is not insisting that controlled drugs are included at this stage because of fears that this might slow the process down and also because of ambiguity over whether practice nurses have full clinical responsibility for their decisions regarding prescribing. The UKCC says controlled drugs should be added to the formulary as soon as possible.

The RCM also backs option five, and points out that midwives currently prescribe some controlled drugs. This should continue, to give women choice over pain relief in labour. The RCM statement points out that special arrangements are in place for midwives to prescribe and that it is important that managers do not attempt to incorporate midwives into a process that is not designed for them.

"Nurses play a vital role in accident and emergency units, general practice and walk-in centres - yet their ability to provide swift and effective care is limited by having to seek out a doctor to endorse their prescribing decisions", said Mark Jones, RCN Adviser in Primary Care. The RCN stresses that only specialist nurses who have successfully completed prescribing education courses will be legally able to prescribe, and that their need to prescribe would have to be established before they were included on the UKCC register as a prescriber. The College says that nurses should be able to make their own decisions about competence to prescribe, in the same way that doctors and dentists do at present.

The UKCC says that care need, patient and client safety and the judgement and accountability of the qualified practitioner should be the decisive factors in determining what drugs can be prescribed and by whom. Nurses should have the choice not to prescribe. The UKCC also says that its registrants need to be able to influence the strategic application of prescribing in practice, as well as taking clinical responsibility for individual decisions.

Allowing nurses to prescribe specified prescription-only medicines for certain conditions such as asthma and diabetes is the option supported by the BMA, according to press reports. The shortage of nurses as well as doctors means that there is no question that nurses taking over doctors’ roles will help the workforce shortage, according to Dr John Chisholm, chairman of the BMA’s General Practitioners Committee.

• CPHVA welcomes extension of nurse prescribing

In its response to the government’s consultation paper, the Royal College of Psychiatrists says that the overwhelming feeling amongst psychiatrists is that psychotropic medication should initially only be prescribed by a psychiatrist acting on their own diagnosis. There may be scope for trained nurses participating in repeat prescriptions and minor modifications thereafter, it says.

The College points out that nurse prescribing in this area cannot easily be reduced to a few simple rules and that there are dangers of omission as well as commission. Patients should not suffer unnecessarily because of overly rigid rules preventing nurses adjusting medication on the spot.

Psychiatrists in the Child and Adolescent Psychiatry Faculty could not foresee any situation in which it would be appropriate for anyone other than a child psychiatrist to prescribe medication for children and adolescents. In the area of substance misuse, where models of shared care with GPs exist, there may be room for greater flexibility.