News Round-Up Archive 2002

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Big increase in nurse prescribers on NMC register

The number of nurse prescribers recording their qualification on the NMC register had reached 28 744 by 31 March 2002, according to the latest statistics released in November.
 

Online Drug Tariff includes extended formulary

The online version of the Drug Tariff now includes, in draft form, the Nurse Prescribers Extended Formulary and the list of conditions for which independent nurse prescribers may prescribe (click here to view).
 

PGDs needed to meet thrombolysis target

A lack of PGDs allowing nurses to start thrombolysis for heart attack patients without a doctor’s prescription is preventing some hospitals meeting targets on thrombolytic treatment, according to a report in Nursing Times (26 November, p8).

The Royal College of Physicians (RCP) has carried out the first national audit for hospitals in England to show how they are performing against National Service Framework targets for Coronary Heart Disease (see the audit report). The article points out that only 52 out of 214 hospitals met the April 2002 target that 75% of eligible patients should receive thrombolytic drugs within 30 minutes of arriving at hospital. It quotes an executive director of nursing whose hospitals failed to meet the target as saying that the whole nursing team needs training and PGDs need to be in place.

The RCP said that emerging data for July to September show that the 30-minute target was achieved for almost 70% of patients.

 

Extended formulary may be expanded

Additional medicines to be added to the extended formulary for nurse prescribers will be the subject of a further consultation, Health Minister John Hutton told the Chief Nursing Officer’s Conference in Torquay on 15 November. He has also asked the Committee on the Safety of Medicines to review some of the medicines that have already been the subject of consultation to see if any can now be added to the formulary, given the experience of nurse prescribing so far.

The Minister also told the conference that he had asked the Home Office to speed up the changes that will allow nurses to prescribe controlled drugs. He said that the Department was “actively considering” the principle of allowing nurses to prescribe controlled drugs including opiates and others from Schedule 2 and 3.

He explained the idea of a skills escalator for nurses relating to the use of medicines, with newly qualified nurses going on to supply medicines using PGDs and many then qualifying to prescribe as independent or supplementary prescribers, as their career develops.
 

Medication review guide published

The Department of Health has published what it describes as a practical guide to medication review, produced by the Medicines Partnership Task Force and the National Collaborative Medicines Management Services Programme. It is designed to help improve treatment for older people and people with long-term conditions. Click here to visit website and download the guide. 
 

Prescribing formulary included in MIMS for nurses

A useful formulary for nurse prescribers is included in the November 2002 edition of MIMS For Nurses, published by Haymarket Medical Publications. The publishers have listed in alphabetical order all the conditions for which nurses may prescribe. Under each condition, they have then listed all P, GSL and POMs in the extended formulary indicated for that condition. Nurses prescribing from the extended formulary can prescribe all the products listed; products for those prescribing from the District Nurse/Health Visitor formulary are so indicated. Drug Tariff-approved dressings are also listed.

The second part of the book contains detailed information for nurses running clinics on diabetes, asthma and chronic obstructive pulmonary disease, mother and child health, health promotion and travel. MIMS For Nurses is a quarterly publication supplied free to practice nurses, nurse practitioners, district nurses and health visitors. To register for copies, call 020-8606-7500, or for enquiries write to: MIMS For Nurses, PO Box 270, Southall, UB1 2WF.
 

Chronic obstructive pulmonary disease CD-ROM

The British Thoracic Society has launched a CD-ROM to raise awareness of chronic obstructive pulmonary disease (for copies, e-mail: copd@imc-group.co.uk). BTS research suggests that more than 40% of nurses have difficulty distinguishing between COPD and asthma.
 

Supervision for nurse prescribers inadequate?

Trusts are not making arrangements for newly qualified nurse prescribers to receive adequate supervision, according to Colin Dale, RCN primary health care advisor, quoted in Nursing Times (3 December, p2). He said that although nurses were being sent on the courses, the structural alterations needed to support them were not being made. He also said that some trusts had not ordered the correct prescription pads.
 

Supplementary prescribing plans announced

Supplementary prescribing for nurses and pharmacists will start in England next year, following an announcement on 21 November by Health Minister Lord Philip Hunt. Training for nurses will begin early in the new year, with courses for pharmacists starting in the spring of 2003. The aim is to train up to 1000 pharmacists and up to 10,000 nurses by the end of 2004. Similar plans have also been announced for Scotland and Wales.

The announcement follows the public consultation earlier this year (see "MCA publishes response article") and recommendations to Ministers by the Committee on Safety of Medicines. The responses to the consultation raised a number of issues about resources, training, and the practical arrangements for supplementary prescribing.

Principles of supplementary prescribing: Supplementary prescribing will be defined as: “a voluntary prescribing partnership between an independent prescriber and a supplementary prescriber, to implement an agreed patient-specific clinical management plan with the patient’s agreement”. The government suggests that it is likely to be most useful for long-term medical conditions such as asthma, diabetes or coronary heart disease or for long-term health needs such as anti-coagulation therapy.

Supplementary prescribing should be underpinned by some key principles including the importance of communication between the prescribing partners and the need for access to shared patient records. Access to records was an issue raised by many of the professional bodies that responded to the consultation, with patient-held records proposed as a possible solution in the absence of electronic records. The legal criteria for supplementary prescribing specify access to shared records, but practical solutions to the problem are not included in the announcement, although the government does comment that remote prescribing partnerships may only be possible if shared electronic patient records are in use.

Patients must be treated as partners in their care and be involved in decision-making, including whether their care includes supplementary prescribing.

Legal criteria and medicines to be included: The guidance lists the criteria for lawful supplementary prescribing:

  • the independent prescriber (IP) must be a doctor (or dentist)
  • the supplementary prescriber (SP) must be a registered nurse, registered midwife or a registered pharmacist
  • there must be a written Clinical Management Plan (CMP) relating to a named patient and to that patient’s specific conditions. Agreement to the plan must be recorded by both the IP and SP before supplementary prescribing begins.
  • the IP and SP must share access to, consult and use the same common patient record.

There will be no legal restrictions on the clinical conditions SPs may treat. No SP should be required to enter into a prescribing partnership nor to prescribe any medicine they feel is outside their competence.

There will be no specific formulary for supplementary prescribing. Provided that medicines can be prescribed by a doctor or dentist at NHS expense and that they are included in the CMP, SPs will be able to prescribe:

  • all GSL and P medicines, appliances and devices, foods and other borderline substances approved by the Advisory Committee on Borderline Substances.
  • all POMs with the current exception of controlled drugs
  • ‘off-label’ medicines (medicines for use outside their licensed indications), ‘black triangle’ drugs and drugs marked ‘less suitable for prescribing’ in the BNF.

Unlicensed drugs may only be prescribed if they are part of a clinical trial with a clinical trial certificate or exemption.

The consultation paper proposed that the use of unlicensed medicines in paediatric care would be allowed provided that the IP and SP agreed that their use was appropriate and justified by best practice and particularly sought views on this (see news items: RPS and RCGP response article and MCA publishes responses article).

Changes to the Prescription Only Medicines Order and NHS regulations will be laid in December to allow supplementary prescribing from early next year.

The clinical management plan: The guidance sets out criteria for the CMP, which should:

  • be patient-specific.
  • be agreed by the IP and SP before supplementary prescribing begins. The arrangement should be endorsed by the patient.
  • specify the range and circumstances within which the SP can vary the dosage, frequency and formulation of the medicines identified. Medicines can be listed by class, formulation or specific product, at the discretion of the IP, or they can be identified using reputable guidelines or protocols for a specific condition.
  • specify when to refer from SP to IP.
  • include any known sensitivities of the patient to particular medicines and include arrangements for ADR notifications.
  • specify the start date for the arrangement and the review date. This should not usually be more than one year away, and much shorter if antibiotics are being prescribed.

The Department of Health website includes two CMP templates which can be downloaded and adapted for individual patients (see DoH website).

The time and effort involved in drawing up a CMP has been one of the issues concerning those who actually be using supplementary prescribing and several bodies suggested referring to protocols or guidelines. A study by the National Prescribing Centre (NPC) into how supplementary prescribing might work in practice brought together a group of doctors, nurses and pharmacists from a range of settings and specialties. They invented some patients and ‘tried out’ supplementary prescribing on them, drawing up CMPs.

Their work showed that CMPs must be relatively simple and quick to complete and should not duplicate information in the shared record. If relevant guidelines or protocols for a specific condition are readily available to the SP, the CMP can refer to them rather than reproducing lists of medicines.

The prescribing partnership: Another issue has been how the prescribing partnership will work in practice in different settings. The NPC study also found that different ways of working within the partnership might apply when the SP and IP are in close contact (for example, pharmacist working in a GP practice and GP; nurse practitioner and GP) to when they are more remote (for example, peripatetic diabetes specialist nurse and consultant diabetologist). The use of shared electronic records might be necessary for some remote partnerships.

Team partnerships may be more appropriate than one-to-one partnerships when this reflects how service delivery is organized. There will be situations where supplementary prescribing is not suitable, for example for patients with multiple health needs or multiple professional carers.

Training: Training for supplementary prescribing for nurses will be based on the course for prescribing from the extended formulary, with the addition of the equivalent of 1 or 2 days. The taught element of the course combining extended formulary and supplementary prescribing will therefore need to be at least 26 days long. Nurses who have already completed the extended formulary course will just need to need to complete the additional supplementary prescribing module if they want to become SPs. The supplementary prescribing element can also be integrated with the current course.
The supplementary prescribing element will include training on:

  • general context of supplementary prescribing;
  • developing CMPs;
  • prescribing in partnership;
  • records and documentation;
  • and knowledge of therapeutics.

(See DoH website for further details of the framework for preparation).

The NMC has published its training standards for extended independent nurse prescribing and supplementary prescribing (see DoH website).

Higher education institutions will need to develop appropriate and robust assessment strategies, although the assessment of competence in practice will occur automatically, given the partnership nature of supplementary prescribing. The Department of Health also says that the mode of delivery of the taught element of the combined course can be decided by the institution, although it should include “some University contact time”. This may give institutions more flexibility in the way they deliver the course.

Pharmacists: The obvious pharmacy candidates in the short term will be those who already have close links to doctors, including hospital pharmacists or those who work in health centres or GP practices, according to the government.

The Royal Pharmaceutical Society of Great Britain (RPSGB) and the Department of Health have worked closely on the development of supplementary prescribing preparation for pharmacists and an outline curriculum for pharmacists is available (see RPSGB website).

The programme should include content on:

  • consultation and decision-making;
  • influences on and psychology of prescribing;
  • prescribing in a team context;
  • basic and applied therapeutics;
  • principles and methods of monitoring;
  • evidence-based practice and clinical governance;
  • legal, policy, professional and ethical aspects;
  • prescribing in the public health context.

The programme is expected to be at least 25 days long and a “substantial proportion” should be direct contact time but other methods, such as open learning, will be considered. The period of learning in practice should not be less than 12 days. The programme should contain some directed private study on the conditions for which pharmacists will be expected to prescribe. At least some of the learning experiences should be shared with nurses and SPs from other disciplines.

 

NICE issues blood pressure and lipid management guidelines for diabetes

NICE has issued a clinical guideline on the management of blood pressure and blood lipid levels in people with type 2 diabetes. This is the fourth in a series of guidelines on diabetes (the third was on blood glucose management).

The guideline includes recommendations about: estimating the risk of cardiovascular disease in people with type 2 diabetes; ways in which the risk can be reduced; and about monitoring and managing blood pressure and blood lipid levels. It also includes recommendations about using medicines to help lower blood pressure and blood lipid levels.

Website: www.nice.org.uk


Pharmacist prescribing could move fast

There are no theoretical obstacles to pharmacists prescribing by the autumn of next year, according to a report of the British Pharmaceutical Conference 2002 in The Pharmaceutical Journal (28 September; p 450).

Pharmacist prescribing will formalise and regulate what is already happening in diabetes and hypertension clinics, for example, according to Dr Jim Smith, chief pharmacist for England. A watertight legal definition for pharmacist prescribing is needed so that the new role can be legally accredited, he said. There must be an identified local need for pharmacist prescribing, and local pharmacists must agree to the new responsibilities.

Dr June Crown said that pharmacists will be able to start prescribing more quickly than nurses were able to. As they recommend a course of action in response to patients’ descriptions of their symptoms, there is a sense in which they are already prescribing independently: the shift of POM medicines to P medicines will increase the scope for this. With supplementary prescribing, community pharmacists will find it harder than their hospital-based colleagues to get a full clinical picture of the patient. Patient-held records could help, with electronic records being a long-term aim.

Training and continuing education were also raised by these and other speakers as issues that need addressing.

 

Nurse prescribing roles highlighted by CNO

Two nurse prescribers have been included in the case studies in the Chief Nursing Officer’s booklet Developing key roles for nurses and midwives (see DoH website). The aim is to provide NHS managers with practical examples of nurses and midwives working in new ways to provide services that patients want and which help meet NHS objectives.

One of the case studies is of a nurse prescriber whose elderly patients benefit from continuity of care, longer appointments and prescribing from the NPEF. PGDs have also been developed to support the service. The other nurse prescriber works with homeless and vulnerable people to offer them an appropriate service.



Recording prescribing qualification will cost £25

The NMC is to charge £25 to practitioners for recording an independent or supplementary prescribing qualification on the register from 1 January 2003.

According to the NMC President, Jonathan Ashbridge, this will bring prescribing qualification in line with other recordable qualifications which attract a £25 fee. He also pointed out that the number of nurses recording these qualifications is expected to increase dramatically and the fee will cover the increased administration.

Rosemary McQuarrie, professional officer for the CPHVA, is quoted in Nursing Standard as describing the charge as “entirely inappropriate”.
 

MCA extends yellow card scheme to nurses

The yellow card scheme for reporting suspected adverse drug reactions has been extended to nurses, health visitors and midwives by the Medicines Control Agency and the Committee for the Safety of Medicines. An electronic yellow card has been introduced, to allow health professionals to send in their reports more quickly and easily.

The Chairman of the Committee on Safety of Medicines, Professor Alasdair Breckenridge, said: "Doctors up and down the country know the Yellow Card goes hand in hand with improving what we know about drugs and how they are used. And now a new generation of reporters to the scheme - nurses, midwives and health visitors, including nurse prescribers, in the frontline of patient care - will be able to play a full part in making sure that we keep learning and that patients benefit from experience."

Announcing the scheme, the health minister Lord Hunt said he planned to introduce patient reporting of adverse reactions through NHS Direct and NHS Direct Online next year.
 

Name changes for non-proprietary drugs

The names of non-proprietary drugs in the UK are to be changed in 2003, according to an article in Nursing Standard (30 October, p12). The MCA has to adopt the changes because of European Union (EU) legislation.

Some of the changes are substantial and could lead to confusion, although others involve only small spelling differences. The RCN primary care advisor, Colin Dale, is quoted in the article as saying that drug names are an increasingly important issue for nurses, with more nurses taking on prescribing responsibilities.


MCA publishes responses to supplementary prescribing proposals

The Medicines Control Agency has published summaries of some of the 800-plus responses to the government’s proposals about supplementary prescribing (see the MCA website for details).

Of the 765 replies that were not referred to the devolved administrations in Scotland, Wales and Northern Ireland, 678 supported the proposals overall, with some replies raising concerns, and 78 replies objected in principle.

The concerns raised in the replies cover a range of issues, to do with both the principles of supplementary prescribing and how it will work in practice. Some of these points are highlighted here:

  1. The clinical management plan. Seen as impractical or too time-consuming by some organizations, and as needing careful definition.
    • The BMA feels that the requirement to produce individual clinical management plans and conduct joint clinical reviews will substantially increase doctors’ workloads.
    • The RCGP feels that take-up may be hindered by the time required to draw up the plans, and that model plans might help.
    • The Association for Nurse Prescribing also fears that uptake among clinicians may be low because of the time and effort involved. Several replies suggest that some way should be found to use national or local pathways.
    • The Royal College of Physicians ( Edinburgh) and the British Pharmacological Society both suggest that a better arrangement would be one similar to a PGD but with more freedom for the actions included in it.
    • The Royal College of Nursing suggests that the model be extended to groups of patients as supplementary prescribing is extended.
    • The National Patient Safety Agency believes that an individual written clinical management plan will not always be necessary: a plan could be agreed for a group of patients, perhaps by teams of supplementary and independent prescribers.
       
  2. Specialities.
    • The BMA suggests that nurses with specialist skills in, for example, palliative care, be recognized, perhaps by being given independent prescribing rights or working within a general protocol to a higher level.
    • The Royal College of Paediatrics and Child Health feels strongly that there must be paediatric input to the training programme in supplementary prescribers are to prescribe in this area. It supports the inclusion of unlicensed medicines for paediatric care but was disappointed by the exclusion of controlled drugs. It suggests specialist input to draft ‘exemplar care pathways’ to form basis of partnerships.
    • The Neonatal and Paediatric Pharmacists Group (part of the College of Pharmacy Practice) feels that supplementary prescribing should ideally be carried out by ‘specialists’ in an area, particularly for paediatric practice.
    • The RCN Diabetes Forum suggests that there be two tiers of supplementary prescribers, to recognize that the specialist nurse may be the prescribing expert rather than the doctor. After diagnosis, the higher-tier supplementary prescriber could devise a management plan independently, consulting the doctor again only if necessary.
    • The RCN Nurse Practitioner Steering Group points out that many practice nurses and nurse practitioners have undertaken advanced training in the management of specific diseases and currently work independently. They will prefer to continue to work under the current system, of PGDs or getting scripts signed by a doctor, to drawing up management plans for individual patients.

     

  3. Timescale and rollout. Several replies comment on the speed of proposed implementation and the lack of testing at pilot sites to identify potential problems early.
     
  4. Training. Substantial training will be needed, with consequent funding and workload implications. Extent to which training will cover specialist areas is a concern for some. Whether the same training will suffice for independent and supplementary prescribing is discussed, and pharmacy bodies in particular stress the need for pharmacology training for nurse supplementary prescribers.
     
  5. Records. Difficulty of accessing and updating records until electronic systems are in use. Patient-held records may be a solution.
     
  6. Reviews. More detail required by some bodies. The Faculty of Prescribing and Medicines Management thinks that a supplementary prescribing arrangement should cease if joint clinical review does not take place. Others are concerned about the workload involved.
     
  7. Prescribing and dispensing. The principle that prescribing and dispensing of medicines is kept separate is not necessary, according to the Royal Pharmaceutical Society of Great Britain, and some, but not all, other pharmacy bodies.
     
  8. Teams. Several replies discuss how supplementary prescribing partnerships can reflect team-based working to one named independent prescriber and one named supplementary prescriber.
     
  9. Patient involvement. Some replies stress that patients must understand, and agree to, the partnership.
     
  10. Range of medicines. Many replies support the inclusion of unlicensed medicines for paediatrics and some would welcome the inclusion of controlled drugs in future.
    • The Pharmacy Substance Misuse Advisory Group supports the exclusion of unlicensed medicines (outside paediatric care) but says that it may prove unworkable in practice as these and drugs used outside their license are used widely and it is very difficult to identify them at the point of prescribing. In such cases, responsibilities and liabilities need to be clearly stated.
    • The RCN believes that nurses with specialist competencies, and specific educational preparation, should be able to prescribe any product required for their patients, but welcomes the proposals as a step in the right direction.

For further details of individual responses, see previous news items below.
 

Pharmacist prescribing task group reports on supplementary prescribing

Progress towards supplementary prescribing has been warmly welcomed in the first report of the Royal Pharmaceutical Society of Great Britain’s Pharmacist Prescribing Task Group, chaired by Dr June Crown (visit www.rpsgb.org.uk for the full report).

The report was used in preparing the RPS’ response to the consultation on supplementary prescribing (see below for details of the RPS’ response: "RPS and RCGP welcome supplementary prescribing plans"). In addition to addressing a range of issues about how supplementary prescribing will be introduced, the Task Force makes recommendations about undergraduate training and continuing professional development for prescribing pharmacists.

The Task Force is now preparing a report on independent prescribing.
 

Nurse prescribing report with Alan Milburn

The report on nurse prescribing by the chief nursing officer, Sarah Mullally, is now with Alan Milburn according to a report in Nursing Standard (October 9, p7).

In April, the Secretary of State told RCN Congress that he had asked her to draw up plans to increase the range of medicines that nurses can prescribe independently and to review nurse pre-registration training (see previous news item).

 

Supplementary prescribing is “exceptional opportunity”

Supplementary prescribing presents an “exceptional opportunity” to improve patient care and make better use of the skills of health professionals, according to the Task Force on Medicines Partnership. In its response to the proposals on supplementary prescribing, it stresses that patients must be recognized as equal partners in the relationship and that concordance should be included as a key element in the training and preparation of supplementary prescribers.

The Task Force on Medicines Partnership is a two-year initiative aimed at helping patients achieve maximum benefit from their medication. It has been allocated £1.3 million funding from the Department of Health and will explore the practicalities and benefits of putting the principles of concordance into practice.

The Task Force comments on four aspects of the proposals:

  • Patient involvement. The implications of concordance go beyond the proposals as they currently stand. The clinical management plan should belong to the patients as much as to the health professionals and must therefore be written in language that the patient can understand. The patient should have a copy of the plan.
  • Shared records. In the absence of electronic patient records available in every setting, creative use should be made of the clinical management plan as a patient-held tool for sharing information between the different professionals and the patient. Patient records should include the patient’s beliefs and preferences about their treatment and patients should have the right to restrict access to certain information if they so wish.
  • Continuity of care may be improved by restricting decision-making within the plan to a pair of named individual health professionals but at the cost of delayed and interrupted access. Exclusive continuity of care is becoming uncommon. Quick, convenient access to care is more important to many patients than continuity of care-giver. It might be better to aim for consistency of care for a patient, using the patient and the plan as the twin foundations.
  • Training in concordance. Health professionals need to be prepared for the cultural change that will accompany the successful implementation of concordance. Concordance training should be included as a core requirement in the training of supplementary prescribers.

For more about concordance, the Task Force on Medicines Partnership, or its response to the proposals on supplementary prescribing, see www.concordance.org

 

Six months for extended formulary course

The course to prepare nurses to prescribe from the extended formulary can now be run over six months rather than three. It has proved difficult for GP practices and trusts to provide cover for staff. Access should be easier now that it will now be possible for nurses to do the course one day a week for six months.


Supplementary prescribing training module produced

Nurses’ training for supplementary prescribing should be based on that for independent nurse prescribers training to prescribe from the extended formulary, but with the addition of a module on supplementary prescribing, according to Department of Health proposals. The National Prescribing Centre has now produced an outline framework for a supplementary prescribing training module.
The module will be tested among higher education institutions providing prescriber education. It will then be widely circulated so that institutions can prepare course curricula for the NMC to approve.


RCN: supplementary prescribing is step in the right direction

Although the RCN would like to see independent nurse prescribing introduced more extensively, with access to a much wider formulary with appropriate education, it says that the plans for supplementary prescribing partnerships are a “step in the right direction”. In its response to the consultation on supplementary prescribing, it suggests that supplementary prescribing should be reviewed and evaluated extensively and that those medicines that are prescribed frequently under this scheme should be added to the extended formulary for independent nurse prescribing.
It has made the following recommendations in its response:

  • Supplementary prescribing should be considered for professions other than nursing and pharmacy.
  • The range of drugs available to supplementary prescribers should be a matter for agreement between the supplementary and independent prescriber and not restricted in any other way. This principle should extend to controlled drugs.
  • Independent nurse prescribers should be able to support supplementary prescribing by nurses and pharmacists by 2004. Given the recent expansion of independent nurse prescribing, the RCN accepts that in the interim doctors and dentists will be the independent prescribers in a supplementary prescribing partnership.
  • The requirement for an individual management plan as specified makes sense within the proposed system. The RCN considers it a cumbersome mechanism, however. It suggests that the extension of the model to groups of patients (as with PGDs) should be considered during the evaluation of supplementary prescribing. Nurse-led clinics for asthma, diabetes and hypertension, for example, could be managed along these lines.
  • The RCN proposes that the independent prescriber is defined as the clinician with ongoing responsibility for assessment and care, not necessarily the initial diagnostician. In cases where a patient has been transferred from a hospital clinic to primary care, practice nurses could then form a partnership with the GP rather than the hospital consultant who made the initial diagnosis.
  • There should be a model of common training for both independent and supplementary prescribers, with graduates of the course able to prescribe independently and form supplementary prescribing partnerships as appropriate.

     

NICE issues blood glucose management guidelines

NICE has issued national guidelines for the management of blood glucose levels in people with type 2 diabetes. This is the third in a series of four guidelines on the care of people with diabetes.
The guidelines include the following recommendations for people with type 2 diabetes:

  • Haemoglobin A1C (HbA1C) should be checked at intervals of 2-6 months.
  • A target HbA1C level of 6.5%-7.5% should be set.
  • Weight loss and increased physical activity should be encouraged in those who are overweight or obese.

The guidelines also include recommendations for when glucose-lowering medicines such as metformin, insulin secretagogues, PPAR-g agonists, acarbose and insulin should be used.

Diabetes is one of the clinical conditions listed in the government’s proposals about supplementary prescribing.

Website: Nice
 

 

Call for research on independent nurse prescribing

The Department of Health has called for research proposals to evaluate independent nurse prescribing. It wants to know whether the extension of nurse prescribing is improving the quality of care and providing value for money by making best use of staff and resources. The information will be used to inform national policy development.

Full proposals are required and must be received by Monday 28 October.

Website: Department of health
 

ABPI highlights patients’ role in supplementary prescribing

The central role of patients should not be overlooked when defining the detailed roles of independent and supplementary prescriber, according to the Association of the British Pharmaceutical Industry (ABPI).

Dr Trevor Jones, Director General of the ABPI, said, “While we welcome these proposals overall, it is nevertheless of concern that they do not offer any suggestions as to how patient involvement and engagement will be ensured”.

In its response to the consultation paper on supplementary prescribing, the ABPI suggests that the clinical management plan, which patients should have a copy of, should be written in language that can be understood by them. Patients will require information about their condition and the medicines used to treat it and the ABPI is calling for companies to be allowed to provide non-promotional information about medicines to patients.

Other concerns raised by the ABPI include:

  • potential conflict of interest for community pharmacists if they are both prescribing and dispensing;
  • the practical difficulties of sharing records and other information in the primary care environment. It points out that there are no proposals as to how this can be done in the absence of electronic patient records. Supplementary prescribing should not be permitted where prescribers do not have immediate and contemporaneous access to health records;
  • the system should not compromise patient access to innovative medicines. The ABPI suggests that audit measures be used to safeguard the quality of clinical care and ensure that keeping costs down is not a driving factor;
  • how professionals are to know when they reach, and risk exceeding, their level of competence;
  • nurse prescribers may not be aware that an unlicensed or off-license medicine is being used;
  • clear lines of professional accountability and protocols are needed, as not all partnerships will work effectively. There must be adequate cover for independent and supplementary prescribers;
  • if the new GP contract is accepted, patients will register with a practice rather than an individual doctor. Practices should perhaps consider how to introduce supplementary prescribing on this basis as it would seem inappropriate for the independent prescriber to be one individual in primary care.
     

GP practices lack PGDs

Nearly half of GP practices lack PGDs, according to this risk management survey of 330 practices from 20 primary care trusts by the Medical Defence Union.

Nurses administering medication or vaccines without a prescription and without the patient seeing a GP should only be doing so under a PGD. The author of the report, MDU Senior Research Fellow, Dr Patrick Hoyte, pointed out that PGDs have been mandatory since August 2000 and advised the 42% of practices that do not have them to put them in place.

He is quoted in Nursing Times (10 September 2002; p12) as saying that if there are legal proceedings, lawyers will usually ask to see protocols. If these are not in place, the nurse is more likely to face disciplinary action from the NMC.

Sara Richards, chair of the RCN Practice Nurses Association, is quoted in Practice Nurse (13 September 2002; p7) as saying that the figure could be even higher than 42%. Although nurses not covered by PGDs are working illegally, primary care would grind to a halt if all nurses said they would not work without them. She also said that it was not clear whether the nurse of the GP is responsible for drawing up PGDs and whether they would get paid for doing so. Concerned nurses should contact their clinical governance lead at their primary care trust, she said.

Website: the-mdu.com
 

 

NMC to charge for supplementary prescribing registration?

The NMC has said that it will need to charge a fee to register a supplementary prescribing qualification, as thousands of practitioners could be registering under the new proposals. Nursing bodies are claiming this will be an obstacle to prescribing and are asking the NMC, the government and employers to look at the possibility of reimbursement.

The NMC supports the proposals but has stressed that adequate training and resources will be need to make them work. It has also asked the Department of Health to ensure that: a) the standards for independent prescribing are used to underpin the preparation of supplementary prescribers; b) that supplementary prescribers are first-level registered nurses or midwives; c) that the self-regulation principle is used in the prescription of unlicensed medicines and reporting of adverse drug reactions; and d) to consider having more than one named independent prescriber for each supplementary prescriber.
 

Emergency nurses should be prescribing

Nurses in emergency departments should be prescribing for patients and requesting diagnostic tests, according to an editorial in Emergency Nurse. Brian Dolan urges the Department of Health to take a stand on the minimum expected from competent practitioners in trusts. It should not be left to individual trusts, with the possibility that some clinicians will sabotage changes that are good for patients.

He points to the evidence that empowering nurses does make a difference and says that “nurse prescribing is the fulcrum upon which nursing development now pivots”. The recent Lancet commentary implies that having enough doctors will address the real problems in the health service, according to Mr Dolan. His view, on the other hand, is that the best doctors do much that is nursing and nurses who have expanded their roles into previously medical domains are practising good medicine. A focus on skills, not professional backgrounds, is required.

The RCN A&E Nursing Association has also countered the claims made in The Lancet. Grant Williams, an Association member, is quoted in Emergency Nurse as saying that it is demeaning to imply that nurses do not have the necessary critical thinking skills to appraise clinical trials and research reports. He points out that the ability to prescribe and administer opiate analgesia and thrombolysis for myocardial infarction would avoid delay in waiting for a doctor, who often then asks for the nurse’s advice.

 

RPS and RCGP welcome supplementary prescribing plans

Both the Royal Pharmaceutical Society of Great Britain and the Royal College of General Practitioners have welcomed the plans for supplementary prescribing in their responses to the MCA consultation. They raise a number of questions about how the proposals will be implemented in practice.

RPS response:

The RPS has broadly welcomed the proposals to introduce supplementary prescribing, saying that they should lead to better and more patient-focused services. It highlights the amount that needs to be done if implementation is to make rapid progress.

 

  • Resources for change management, patient and public awareness campaigns, education and training must all be adequate. Implementation must be integrated with other NHS developments such as shared and electronic records.
  • Safe and effective prescribing depends on full access to clinical and medication records by all prescribers.
  • It suggests a new definition of supplementary prescribing: “A voluntary partnership between the independent prescriber and a supplementary prescriber, to implement an agreed patient-specific clinical management plan with the patient’s agreement”.
  • It is strongly in favour of the proposal that there should be no legal restrictions on the range of medicines (apart from controlled drugs and unlicensed medicines outside paediatric care) and clinical conditions and suggests that there should be flexibility in the use of off-label medicines. It hopes that controlled drugs will be included as soon as possible.
  • More detailed guidance on the clinical management plan should include the need for: explicit arrangements for systematic review, the plan to be evidence-based and consistent with recognised clinical guidelines, and for it to be agreed by patient, prescribers and, where appropriate, carer or parent.
  • The RPS suggests three phases of training for prescribing pharmacists and that training for prescribing partnerships should involve all participants.
  • The prescribing partnership must recognise that care is delivered by teams, regardless of location: restricting the partnerships to one named supplementary prescriber and one named independent prescriber will severely limit its usefulness.

RCGP response:

The RCGP has said that it broadly agrees with the proposals on supplementary prescribing. In its response, the College makes a number of suggestions about the implementation of supplementary prescribing, highlighting in particular concerns over training and preparation and legal responsibility. It stresses that the operational details are crucial in determining how the proposals work in practice.

The RCGP suggests that:

  • The MCA reconsider the decision to exclude controlled drugs. In the areas of palliative care and drug addiction and therapy in particular, there may be a case on safety grounds.
  • Despite the potential long-term time savings, clinicians may find it hard to find time in the short term to draw up individual management plans. Evidence-based model plans that could be modified for individual patients may have a place. Written agreements are needed to define responsibilities.
  • Restricting implementation to a few carefully monitored pilot sites at first might have allowed any implementation problems to be identified and dealt with before national roll-out.
  • Even for paediatrics, the RCGP has reservations about the inclusion of unlicensed drugs.
  • Further details are needed on whether the supplementary prescriber can significantly alter medication, or stop it altogether. [The proposals state that the plan must specify the “range and circumstances within which the supplementary prescriber can vary the dosage, frequency and formulation of the specified range of medicines as appropriate, and when to refer back to the independent prescriber”]. There is a risk that once prescribing has passed to the supplementary prescriber, it will not be holistically reviewed. [The proposals do specify that the plan must contain a review date, which should not usually be more than 1 year after the start date of the arrangements).
  • The legal responsibilities of the two types of prescriber are not sufficiently clear.
  • There should be more details about pharmacists’ training and training for independent prescribers.
  • An outline clinical management plan should be developed and used in individual plans to ensure that they are consistent, cover everything necessary and can be audited.
  • There is potential for abuse of these arrangements outside the NHS in particular.
  • Not many plans will be based on a single GP as independent prescriber, because cover must be provided, but the more partners there are the greater the potential for error and misunderstanding.

The College also asks whether there will be guidance on when supplementary prescribing should be instituted, for example in National Service Frameworks. Can specialist drugs be prescribed in specialist and general settings? How will supplementary prescribing be monitored and policed? Where will the management plan be kept and how will access to patient records be managed?

 

Nurse prescribing could free 2.5 million GP appointments

Patients being seen and treated by nurse prescribers has the potential to free at least 2.5 million GP appointments in 2002, according to a report from the Cabinet Office’s Regulatory Impact Unit. The report says that up to 3.2 million GP appointments can be freed up by reducing bureaucracy.

The team estimated that a full-time nurse prescriber, typically doing four independent surgeries a week, should see at least 1760 patients a year who would otherwise need a GP appointment. Team meetings, enhanced follow-up and nurse referrals to GPs may reduce these savings.

Click here to view the report.

 

Conference on extending nurse prescribing

“Extending prescribing responsibilities – working towards implementing the new regulations” is the title of a conference to be held on 18th July in London. It will be chaired by training and development consultant Breda Gibson. Speakers will include Maureen Williams (Professional Officer for Community Nursing and Health Visiting), Anthea Clegg (West Midlands Regional Nurse Prescribing Lead) and Trudy Granby (Nurse Prescribing Manager at the National Prescribing Centre). The conference is being organized by Capita.

The conference will focus on the implementation of the new regulations, with sessions covering legal issues, training, meeting service needs and pharmaceutical issues. It will also look at the wider issues raised by the extension of prescribing responsibilities and their impact on existing practice. The organizers say it is aimed at managers and directors of NHS Trusts and Strategic Health Authorities, directors and lead nurses of PCTs, managers of NHS Walk-in centres, GPs, higher education institutions providing nurse education, community pharmacists, patient representatives and nurse prescribing leads.

For more information see our new conference update section.

 

Are professionals letting children with asthma down?

Parents of children with asthma are not getting the support they need from professionals, according to a report from the National Asthma Campaign (NAC). The report identifies five areas as causing parents concern:

  • difficulties getting an initial asthma diagnosis
  • lack of support from school
  • negative experience of A & E admission
  • substandard healthcare from their GP
  • anxiety over medication

In each of these areas, the NAC believes that doctors, nurses and teachers are causing parents unnecessary anxiety.

The NAC makes a number of recommendations about giving asthma the priority and resources it needs within the NHS and also says that GPs and nurses should treat parents as equal partners in the care of children with asthma, carrying out regular assessments and monitoring, with longer consultation times.

Click here to read the report "Sleepless nights, anxious days".

Concerns over pre-registration education

Alan Milburn’s surprise announcement that pre-registration training will include nurse prescribing has raised concerns about how this can be done in practice. Prescribing is seen as a complex and time-consuming subject and it is not clear how space can be made in the curriculum to deliver the training. How the training will be funded, whether student nurses will be prescribing under supervision, and whether pre-registration training may need to be extended, all need addressing.

RCN education advisor Anne Eaton is quoted in Nursing Standard (May 8, p12) as saying that she feels this development is not being welcomed wholeheartedly, either by lecturers, or by qualified staff who are prescribing or hope to do so. Maureen Williams of the NMC is quoted as saying that the profession will wish to approach this with caution.

 

POM to P reclassification made easier

The Medicines Control Agency has introduced a new system which should make it easier and faster for prescription-only medicines (POMs) to be reclassified as P (available under the supervision of a pharmacist). All P medicines are included in the formulary for independent nurse prescribers.

A list of therapeutic categories and products that may be candidates for reclassification is available at the Royal Pharmaceutical Society’s website. Products that fall within the four areas suitable for independent nurse prescribing (minor ailments, minor injuries, health promotion and palliative care) include: some statins such as cholesterol-lowering therapy; amantadine for influenza A prophylaxis; hyoscine hydrobromide transdermal patches for motion sickness; some anti-malarial treatments; norethisterone for postponing menstruation; fusidic acid for impetigo; topical metronidazole for rosacea; topical antifungals for nail fungal infections; and oral and topical antifungals for skin fungal infections. Many other products for conditions such as asthma, migraine, and eye infections are included in the chronic or acute conditions categories.

Milburn announces plans to expand list of medicines

Alan Milburn has asked the Chief Nursing Officer (CNO) to draw up proposals to increase the range of drugs that nurses can prescribe independently. The Secretary of State made the announcement at the RCN Congress in Harrogate on 22 April. He said that there are now 23 000 independent nurse prescribers, that within two years, there should be 30 000, and that there is a need to go further and faster still.

He also stressed the breadth of the supplementary prescribing package proposals, which have now been published, saying that prescribing will be limited only by the individual patient’s clinical plan. There will be no formulary, and no restrictions on location or type of practitioner (other than that they are registered, qualified and safe to prescribe).

The proposals seem to have been well received. Mark Jones, primary care advisor for the RCN, is quoted in Practice Nurse (26 April) as saying that, “This is a very welcome step…. it is good to see the government taking quite a broad approach and not being too restrictive by limiting the formulary”.

Rosemary McQuarrie, of the Community Practitioners’ and Health Visitors Association, was reported as saying that patients will have access to better and more holistic care as a result, but that training issues need to be looked at. According to a report in Nursing Standard (24 April), both Mark Jones of the RCN and the Association for Nurse Prescribing raised concerns that independent nurse prescribers will not be able to draw up clinical management plans with supplementary prescribers.

Alan Milburn also said that he had asked the CNO to work alongside the new Nursing and Midwifery Council and higher education to review nurse pre-registration training so that nurse prescribing can, in future, be enshrined in the training of every newly qualified nurse.

Supplementary prescribing plans published

Proposals for the introduction of supplementary prescribing by nurses and pharmacists have now been published (www.doh.gov.uk/supplementaryprescribing). They stress the need for a partnership between the independent and supplementary prescriber and for a written individual clinical management plan.

Some of the key points of the proposals are described here:

The partnership. An independent prescriber – for the time being a doctor (or dentist) – will diagnose the condition. The independent and supplementary prescribers can then, with the patient’s agreement, implement a patient-specific written clinical management plan. Both prescribers have responsibilities, outlined in the proposals. The supplementary prescriber must work within their Code of Conduct and clinical competence, referring back to the independent prescriber as necessary. In some circumstances, it may be more practical to have more than one named independent prescriber.

The clinical management plan. This must relate to a named patient and specific condition, and must be agreed and signed by both prescribers. It must contain: the range of medicines that may be prescribed by the supplementary prescriber; the range and circumstances under which the supplementary prescriber can vary the dosage, frequency and formulation of these medicines; when to go back to the independent prescriber; warnings about any sensitivities to particular medicines and arrangements for notification of adverse drug reactions; and a date for starting and for reviewing the arrangements, not normally more than one year apart.

Which conditions? The proposals state that supplementary prescribing will be of most value to patients with non-acute conditions or health needs such as asthma, diabetes, conditions related to mental health, those needing anticoagulation treatment, HRT, or prophylaxis against coronary heart disease. Supplementary prescribing will not, however, be restricted to particular conditions under these proposals.

Which medicines? Apart from controlled drugs and unlicensed medicines outside paediatric care, the range of medicines will not be restricted by legislation under these proposals. In paediatric care, the independent and supplementary prescriber will need to agree that the use of an unlicensed medicine is appropriate and justified by best practice. Similar criteria will apply to the use of a licensed medicine outside its licensed indications. Black triangle drugs will also be included. Until nurse reporting of adverse drug reactions (ADRs) is introduced, all ADRs should be reported to the independent prescriber by nurses. Pharmacists already report ADRs on their own authority.

Training. The training for supplementary nurse prescribers will probably be based upon that for independent nurse prescribers and the government is seeking comments upon whether completion of this training should allow nurses to qualify as both independent and supplementary prescribers. Training for pharmacists will involve the same principles. Doctors (and dentists) wishing to enter the prescribing partnership will also need some brief preparation.

Comments on the proposals are invited to arrive before 9 July. The government has suggested that training for nurses could begin by the end of this year, with pharmacists starting early 2003. It says that it expects many thousands of prescribers to be trained over the next few years.

According to the Department of Health, the proposals will improve patients’ access to medicines, improve NHS services and make better use of the skills of nurses and pharmacists. In the longer term, doctors’ time may be released for more complicated cases.

 

NICE recommends NRT and Zyban

The use of bupropion (Zyban) and nicotine replacement therapy (NRT) has been recommended by NICE (the National Institute for Clinical Excellence).

The guidance states that NRT or bupropion should normally only be prescribed when patients have made a commitment to stop smoking on or before a ‘target stop date’ and should be used in conjunction with advice and encouragement. First prescriptions should usually only last until two weeks after this date and second prescriptions should only be issued if smokers can show they are still trying.

Various factors should be taken into account in deciding on the most appropriate therapy, including intention and motivation to quit, medical factors, previous use of treatments and smokers’ preferences.

After an unsuccessful attempt, another course of treatment should not usually be prescribed within six months, although it may be reasonable to try again sooner if external events interfered with the initial attempt.

The guidance also states that there is not enough evidence to recommend the use of NRT and bupropion together.


Progress on pain management disappointing

Many nurses working in pain management and palliative care have been disappointed at the plans for nurse prescribing in this area, according to an article in Professional Nurse (March 2002, p 419). The author, a pain management nurse, points out that specialist nurses have experience in recommending and administering opioid analgesia prescribed by medical staff and that some provide expert training to medical colleagues but cannot prescribe themselves.

Guidance will list conditions for extended formulary

The Nurse Prescribers Extended Formulary (NPEF) will contain guidance listing the indications for which nurses may prescribe each medicine, according to a guide for implementation published by the Department of Health ("Extending Independent Nurse Prescribing within the NHS in England: a guide for implementation"). The guide contains much useful information, some of which is highlighted here:

Who may prescribe what? Nurses who have undergone the extended training may prescribe items on the NHS from the NPEF or the NPF. The list will be published monthly in the Drug Tariff and every six months in the BNF. Current district nurse and health visitor prescribers can continue to prescribe from the NPF, which will be reviewed regularly. The exemptions that allow midwives to supply or administer some medicines under the Medicines Act still apply. Nurses can still use PGDs where this is more appropriate for patients’ needs.

Resources. Nurses prescribing from the NPEF will receive centrally funded copies of the BNF twice a year. All nurse prescribers will be supplied with a Drug Tariff every six months by the Prescription Pricing Authority but should have access to up-to-date copies if required.

Indications and restrictions. Nurses should not prescribe any medicines for use outside their licensed indications. The NPEF will contain information on the conditions and indications for which each item may be prescribed and nurses are expected to prescribe in accordance with this. It is the basis on which employers have agreed to include prescribing in posts, and is also the basis of nurses’ educational preparation. Locally agreed formularies may also limit nurses’ prescribing. Many will not prescribe from all sections of the NPEF because of their professional obligation to act only within their competence.

Programme length. Once institutions have gained some experience with the programme, the Department of Health will consider a longer timescale.

Continuing Professional Development. Nurse prescribers will be expected to keep up-to-date and may use this learning as part of their PREP-CPD.

UKCC register. Nurses’ entries on the UKCC Professional Register will be annotated to indicate whether they are qualified to prescribe and from which formulary.

Prescription forms and the PPA. The guide contains information about obtaining prescription forms and the role of the PPA. All district nurse and health visitor prescribers should switch to using the lilac FP10P forms (annotated DISTICT NURSE/HEALTH VISITOR PRESCRIBER) by April at the latest. FP10P forms for primary care nurses prescribing from the NPEF will be annotated EXTENDED FORMULARY NURSE PRESCIBER. Nurses prescribing for hospital patients may use ward orders, internal hospital prescription forms (when the hospital pharmacy will dispense the prescription) or FP10HP forms (when a community pharmacist will dispense the prescription). Information on how to complete the forms and make them secure is also included in the guide.

Good practice and ethics. Nurse prescribers should not prescribe on behalf of nurses who are not qualified prescribers and should only order drugs for patients whom they have assessed for care. As for doctors and dentists, it is strongly recommended that nurses avoid prescribing for themselves or for close family members wherever possible.

Adverse reactions. Suspected adverse reactions to prescribed, OTC or herbal medicines should be reported to the GP or consultant immediately. The MCA is looking at the possibility of extending the Yellow Card scheme so that nurse and midwife prescribers have responsibility for reporting adverse reactions directly.

BMA proposes nurses as NHS ‘gatekeepers’

Nurses could take over the ‘gatekeeper’ role from GPs in primary care, under suggestions published by the BMA’s Health Policy and Economic Research Unit. Nurse practitioners, delivering an expanded range of direct patient care, would be the first point of call for most patients, who would then be guided to the most relevant service as necessary. This could be a GP consultation but could also be a benefits advisor or community pharmacist, for example.

Community nurses should also expand their clinical role, undertaking a wider range of interventions. In secondary care, clinical nurse specialists would co-ordinate the care given by all other professionals and provide an advanced clinical nursing role.

All the changes are proposed are underway in some part of the NHS already and patients have been benefiting.

The impetus for the discussion paper is the increasing pressures on the medical workforce. Junior doctors’ hours will be covered by the European Working Time Directive and, in the longer term, advances in medical technology will mean that demand for services increases. The BMA says that its model will provide high quality care that is responsive to the needs of patients and their families, while making more efficient use of doctors’ time.

The discussion paper seems to have been greeted with reasonable enthusiasm by nurses, although issues of training, workforce and pay have been raised. A committee member of the Nurse Practitioners Association, Mike Walsh, is quoted in Nursing Standard (6 March, p4) as saying that the proposals underline the need to sort out nurse prescribing: he suggests that nurses should be able to prescribe anything in the BNF.

(Click here to view BMA discussion article)

Is the formulary still too limited?

Some nurses believe that the extended formulary is still too limited, despite the recent additions (see "Prescribing extended..." news item), according to an article in Nursing Standard (27 February, p13).

The list represents a wasted opportunity, says a primary care nurse practitioner: she will not be able to treat about one-quarter of the conditions she sees. Another view comes from Sara Richards, chair of the RCN practice nurses association, who believes that although it is a step in the right direction the list will not be very useful, and that patient group directions could be used to cover almost everything on it. She would like to see amoxicillin for middle ear infections, steroid inhalers for asthma patients and flucloxacillin for other skin infections as well as impetigo all included, for example.

Although there eight medicines are included specifically for palliative care, the painkillers which are often needed with them are not, according to RCN palliative care advisor Celia Manson, quoted in the article. The extended formulary will be useful for nurses in accident and emergency departments, but there are some important omissions of antibiotics and analgesics, according to a sister at Newcastle General Hospital.

Let us know your views on the extended formulary in the Nurse Prescriber forum

Prescribing extended to some antibiotics

The extended nurse prescribing formulary will now include some oral antibiotics and topical microbial agents, the Department of Health has announced (www.doh.gov.uk/nurseprescribing/).

Following further discussion, nurses who have successfully completed the extended prescribing course will be able to prescribe: amoxicillin, nitrofurantoin and trimethoprim for lower urinary tract infection in women; flucloxacillin for impetigo; metronidazole for fungating malodorous tumours and bacterial vaginosis; and oxytetracycline, doxycycline, tetracycline and minocycline for acne. In addition, aural gentamycin sulphate and aural neomycin sulphate and undecanoate will be prescribable for otitis externa.

Chair of the RCN practice nurses association, Sara Richards, is reported as saying that the formulary still does not give nurses enough scope, although it is a step in the right direction (Nursing Standard, February 20, p5). The link with specific conditions means that patient group directions could cover it, she said. The inappropriate use of antibiotics in the past is the reason why the drugs have been limited to particular conditions, according to Mark Jones, primary care advisor for the RCN (Practice Nurse, 22 February, p4). He is reported as saying that the restrictions, “will undermine the potential for nurses to treat patients in a better way”.

 

Doctors’ worries about extended formulary

Some doctors are highly critical of plans to extend the nurse prescribing formulary, according to an article in Nursing Standard (13 February, pp 12-13). The timescale for training is reported as giving particular concern, with the BMA calling it ‘totally inadequate’.

Some say that the schedule will not equip nurses to deal with concurrent conditions. Recent research has indicated that nurse prescribers themselves see pharmacology as one of their greatest training needs (see "Nurse prescribers want pharmacological training"). Dr Chaand Nagpaul, who is on the prescribing subcommittee of the BMA’s GPs’ committee, is reported as suggesting that the extension has the potential for nurses to be prescribing beyond their clinical remit, with the possibility of negligence claims. Concerns about budgets were also raised by some doctors.

Mark Jones, primary care advisor at the RCN, is reported as saying that the evidence is that nurses save money. Other research suggests that nurses are often reluctant to prescribe (see “Some nurses reluctant to prescribe”). An executive member of the NHS Alliance, Ron Singer, is quoted as saying that GPs have to let go of some of their current responsibilities and workloads and that team working in primary care will only work if nurses can work to full capacity.

Website: www.nursing-standard.co.uk

 

RCN says antibiotic exclusion not sustainable

The exclusion of antibiotics from the extended nurse prescribing formulary is not sustainable, according to Mark Jones, RCN primary care policy and practice advisor (Primary Health Care, February 2002).

According to the Department of Health, ministers wish to give further consideration to whether nurses should be able to prescribe oral antibiotics. In a House of Lords debate on nurse prescribing, the possibility that nurses would not be able to resist pressure from patients to prescribe antibiotics was discussed. Lord Filkin pointed out that trials have not revealed any differences in prescribing patterns between GPs and nurses (Nursing Standard, January 30).

Law on PGDs outside NHS to be clarified

Legislation has been proposed to ensure that nurses and other health professionals who sell, supply or administer medicines under PGDs in the private, charitable or voluntary healthcare sectors or in police custody suites, the prison service or the Defence Medical Services are acting legally. The legislation will also set out the information that should be contained in such PGDs for them to be lawful. The current legislation applies to NHS organizations. The full consultation paper can be found at the MCA website.

List of POMs agreed by ministers

Following the MCA consultation, the government has now published the list of prescription-only medicines that will be included in the extended formulary for nurse prescribers who have successfully completed the new training courses (the full list can be found at http://www.doh.gov.uk/nurseprescribing/).

Many of the medicines included in the consultation list have been approved but ministers have said they want to give more time to the question of these nurses prescribing oral antibiotics.

Some of the palliative care drugs included in the consultation documents have been omitted, including: amitriptyline hydrochloride, carbamazepine, diazepam, gabapentin, imipramine, lorazepam, midazolam and sodium valproate. Codeine phosphate and dihydrocodeine tartrate have also been omitted.

The MCA pointed out at the time of the consultation that some of the drugs included were listed under schedules 4 and 5 and their inclusion would therefore require legislation: this explains why some of the palliative care and other drugs have been omitted.

Some ophthalmic preparations are not on the list including chlortetracycline hydrochloride, ofloxacin and polymixin B sulphate.

Let other users of the site know what you think about the list of POMs using our forum.