News Round-Up Archive 2003

This section features a regular service containing the latest news about nurse prescribing. Please register with the site to receive, via e-mail, an electronic newsletter.

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Read archived news items:

2002 News round-up | 2001 News round-up

Last updated 14/01/2004

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Nurse yellow card reporting increases

Nurses made 2000 reports of adverse drug reactions using the yellow card system in the year ending October 2003, according to an article in ‘Nursing Times’ (2 December, p7). These made up 12% of the total submissions to the Committee on Safety of Medicines (CSM), and the CSM hopes there will be further growth as more nurses start prescribing.


Dressings not chosen on best practice basis

A survey of nurses by ‘Professional Nurse’ (November, p131) has indicated that their choice of dressings is determined more by availability than by best practice, with effectiveness audits being rare.

Of the 300 nurses who responded, 18% in acute hospitals and none in private hospitals chose dressings on the basis of best practice evidence. Of nurses in acute hospitals, 37% said they rarely performed audits of effectiveness and 26% said they never carried out follow-up checks.


Conference announcement: ANP annual conference

The 6th annual conference of the Association of Nurse Prescribing is entitled ‘Revolution or Evolution’ and will be held on 12-13 February 2004 in Manchester.

For further details, contact: conferences@markallengroup.com


Regulatory changes to extend nurse prescribing

On 3 December, the Department of Health (DH) announced several changes to legislation and regulations affecting both prescribing and the supply and administration of medicines (see here  - scroll to the bottom of the page).

One change is that from 1 January 2004 extended formulary nurse prescribers (EFNPs) will be able to prescribe the six controlled drugs that were recently the subject of Home Office legislation (diazepam, lorazepam and midazolam for palliative care, and codeine phosphate, dihydrocodeine tartrate and co-phenotrope; see here for news story). The Medicines and Healthcare products Regulatory Agency (MHRA) has laid the necessary amendments to the Prescription Only Medicines (POM) Order and the change is subject to Parliamentary approval.

EFNPs are already able to prescribe codeine phosphate and dihydrocodeine tartrate when they are part of a GSL or P medicine. The Prescription Pricing Authority (PPA) applied this change from 16 October 2003 and appropriate amendments will be included in the December edition of the Drug Tariff (see here).

The DH also announced that, following the Home Office consultation on proposals for the supplementary prescribing of controlled drugs, including opioids (see here for news story), nurses and pharmacists will be able to prescribe controlled drugs under supplementary prescribing arrangements by March 2004. This is subject to the necessary changes to Home Office and NHS regulations and to Parliamentary approval.

Finally, the DH said that the MHRA will soon lay the necessary amendments to the POM Order to expand the nurse prescribers’ extended formulary (NPEF) by the additional medicines announced by John Reid recently (see here for news story). The changes are expected to take effect from 1 February, subject to Parliamentary approval, but nurses should check for updates.


RCN welcomes extensions to formulary

The Royal College of Nursing (RCN) has welcomed John Reid’s announcement about the additions to the conditions and medicines on the Nurse Prescribers’ Extended Formulary (NPEF; see here for news story). The RCN is also positive about the future inclusion of controlled drugs in the formulary and about midwives being able to administer diamorphine.

The RCN does, however, reiterate its policy that independent extended nurse prescribers should be able to prescribe any medicine available on the NHS that falls within their area of competence. It says that this would allow John Reid’s vision of non-medical prescribing moving into the “mainstream” to become reality.

Sara Richards, former chair of the RCN Practice Nurse Association, is quoted in ‘Practice Nurse’ (28 November, p6) as saying that she welcomed the additions but that the extension of nurse prescribing was still very slow and piecemeal. She expressed disappointment that no drugs for diabetes care were added to the list and that no financial help was offered for practice nurses taking the nurse prescribing training.

 

RCN and DH bust emergency care myths

The Royal College of Nursing and the Department of Health have developed a publication to show how the myths and obstacles preventing practice development in first contact, urgent and emergency care can be tackled (see here for document). It aims to clarify what nurses and allied health professionals are allowed and able to do within their Codes of Practice. It highlights how tackling these myths can help deliver faster, higher-quality care.

In the section on treatment, it comments that supplementary prescribing will allow nurses with specialist interests to provide continuity and convenience for patients and says that it is recognized that the current formulary for independent nurse prescribing is limited.

 

Conference announcement: Non-Clinical Prescribing - Sharing Experiences

Organised by: Royal Society of Medicine

Date: Wednesday 21 January 2004

Location: North Hall, The Royal Society of Medicine, 1 Wimpole Street, London, W1G 0AE

Programme: Download here

Contact:

Priya Rai
Academic Department
Royal Society of Medicine
1 Wimpole Street
London W1G 0AE
Tel: (+44) (0) 20 7290 3935
Fax: (+44) (0) 20 7290 2989
Email: pharmaceutical@rsm.ac.uk

Book on-line: www.rsm.ac.uk/pharmaceutical
 

Nurse prescribing grows in England and Scotland

The growth in volume of prescribing by nurses is continuing in England and Scotland, according to the latest figures.

A report from the Prescriptions Pricing Authority (PPA) for the year to June 2003 (see here) shows that in England nurse prescribers prescribed well over 250,000 items per month in March to June. The number of extended formulary items is still a small proportion of the total, but is growing. In June 2003, nearly 30,000 items were prescribed from the extended formulary compared with about 10,000 in December 2002.

In Scotland, in the year ending March 2003, over 295,000 items were prescribed by nurse prescribers at a cost of £4,224,857 (see here for report). This represents a growth in volume of 19% and in cost of 31% compared with the previous financial year ending in March 2002.


Consultation on optometrist prescribing in 2004

Consultation on supplementary prescribing for optometrists will begin early next year and will also include consultation on widening the exemptions already in place and the use of patient group directions (see here). Work on independent prescribing by optometrists is expected to begin in the second half of 2004. The current position and what will happen next was set out in a meeting between Department of Health officials and optometry organizations on 9 October.

The Royal College of  Ophthalmologists has set out its position on optometrist prescribing (see here). It makes clear that a change of attitudes will be necessary but supports the idea of optometrists sharing care in the community and in hospitals. It highlights some questions that will need answering: will the new arrangements be safe, cost-effective and reduce the workload for eye departments?
 

MIMs for Nurses to go monthly

There will be 10 issues of MIMs for Nurses next year, with publication in the middle of every month apart from January and August.
 

RPS opposes use of PGDs by additional groups

The proposal to extend the sale, supply and administration of medicines under Patient Group Directions (PGDs) to additional professional groups has been opposed by the Royal Pharmaceutical Society (RPS) in its response to a recent consultation. (See here for news item, here for consultation and here for the RPS response).

The consultation, issued by the Medicines and Healthcare products Regulatory Agency (MHRA), proposes that dieticians, occupational therapists, prosthetists and orthotists, and speech and language therapists are added to the list of allied health professionals using PGDs. The RPS points out that the regulation of these professions and their inclusion as allied health professionals is more recent but that the PGD supply route is only suitable where the supplier is “fully competent, qualified and trained”. It also says that considering the list it is hard to envisage the sort of urgent treatment with prescription-only medicines that PGDs are intended for (with the possible exception of prosthetists and orthotists). It is therefore opposing the proposal, believing that the public is well served by community pharmacies where GSL and Pharmacy medicines are available with professional advice from a pharmacist.
 

NPEF to expand following consultation

The government has announced that the Nurse Prescribers Extended Formulary (NPEF) will expand to include many of the medicines proposed in the recent consultation MLX 293 (see here for details of the consultation), with 10 new conditions now being treatable by Extended Formulary Nurse Prescribers (EFNPs).

In a speech at the Chief Nursing Officer’s conference in Brighton, the Secretary of State for Health, John Reid, announced the expansion of independent nurse prescribing by 10 new medical conditions and more than 30 additional medicines. He also said that nurse prescribing will be extended further next year to include emergency care. He said that his visions was that: “non-medical prescribing moves into the mainstream” (see DH press release).

The DH nurse prescribing centre has not yet, as of 17/11/03, been updated but check here for future information.

Formulary additions

The conditions, with the medicines that can be used to treat them, are:

  • Acute asthma attacks: salbutamol sulphate; terbutaline sulphate; prednisolone; and prednisolone sodium phosphate.
  • Hypoglycaemia: glucagon hydrochloride; and glucose.
  • Local anaesthetic for ophthalmic conditions, for suturing of lacerations and for occasions when procedure requires it: lidocaine hydrochloride.
  • Acne vulgaris: lymecycline.
  • Animal and human bites: amoxicillin trihydrate; clavulanic acid; doxycycline hyclate*; doxycycline monohydrate*; erythromycin; erythromycin ethyl succinate; erythromycin stearate; metronidazole*; metronidazole benzoate; and oxytetracycline dihydrate*.
    (NB *Substances are already on the NPEF but now also prescribable for bites).
  • Impetigo: erythromycin; erythromycin ethyl succinate; erythromycin stearate; fusidic acid; and sodium fusidate.
  • Soft tissue injuries: dicofenac sodium; and diclofenac potassium.
  • Laboratory-confirmed uncomplicated genital chlamydial infection, plus sexual partners of those patients: azithromycin dehydrate; doxycycline hyclate*; doxycycline monohydrate*; erythromycin; erythromycin ethyl succinate; and erythromycin stearate.
    (NB *Substances already on the NPEF but now also prescribable by nurses for uncomplicated genital chlamydial infection).
  • Trichomonas vaginalis infection plus sexual partners of those patients: metronidazole*.
    (*NB. Already on the NPEF but now prescribable by nurses for Trichomans vaginalis).
  • Contraception: etonogestrel (Implanon).
  • Menopausal vaginal atrophy (cream and pessaries): conjugated oestrogens (equine); estradiol; and estriol.
  • Neuropathic pain in palliative care: amitriptyline hydrochloride; imipramine hydrochloride; nortriptyline hydrochloride; gabapentin; and carbamazepine.

Controlled drugs

MLX 293 also proposed the addition of diamorphine for midwifery practice and for patients in coronary care units with suspected myocardial infarction, and a range of controlled drugs for pain relief in palliative care.

The Committee on Safety of Medicines (CSM) and Ministers have agreed in principle that EFNPs should be able to prescribe some additional controlled drugs, but this is also subject to Home Office legislation. The proposals will be considered next spring and legislation will follow as appropriate.
For midwives, the existing exemptions in medicines legislation allowing the supply and administration of certain medicines by midwives will be extended to include diamorphine for pain relief.

Symptoms of the menopause

Since MLX 293, which proposed several medicines for symptoms of the menopause, the Million Women Study report has been published. It provides new information about the increased risk of breast cancer associated with hormone replacement therapy (HRT) and makes the decision about the most appropriate form of HRT less clear-cut than in the past. The CSM will reconsider this issue in 2004.


 

BNF 46 published

The new edition of the British National Formulary, BNF 46, has now been published. An online version, with both the Nurse Prescribers Formulary for District Nurses and Health Visitors and the Nurse Prescribers Extended Formulary. The medical conditions for which independent nurse prescribers can prescribe from the extended formulary are listed (click here) and the wording makes clear that nurses should not prescribe independently for conditions not on this list.
 

DH issues PGD templates for emergency care

The Department of Health (DH) has issued 18 national templates for Patient Group Directions (PGDs) for emergency care (see here for templates). They include PGDs for adrenalin, ibuprofen, emergency contraception, tetanus immunoglobulin, oral rehydration solution, aspirin and chlorpheniramine.

The accompanying information says that staff working in emergency care and first contact services were consulted about the myths and obstacles that hinder effective delivery of good, timely, patient care. Overwhelmingly, delays in supplying or administering medicines were cited. It could be difficult to develop PGDs locally and in any case their development placed an administrative burden on staff. Therefore, these national PGD templates were developed for the most common medications used in first contact and emergency care in a range of settings.

Local trusts can adopt these templates and authorize their use, after adaptation to local guidelines and practices if appropriate. It will be for local services to determine the most appropriate use of these PGDs but they can be used in wide range of settings such as Accident and Emergency Departments, walk-in centres, general practice, out-of-hours services, and minor injury services.

Further national templates for emergency care are being developed and will include other medicines used for respiratory and cardiac conditions, a wider range of analgesics and diamorphine for chest pain, following the recent change in the law (see news item).
 

Journals focus on concordance

Both the ‘British Medical Journal’ and ‘The Pharmaceutical Journal’ have published special themed issues on concordance (see BMJ editorial and Pharma Journ editorial). They highlight the need to understand the nature of concordance: it is not “compliance with bells on”. The waste involved in prescribed medicines not being taken on the current scale should make professionals review their perceptions that they do not have time for concordant consultations. More understanding of what is going on is needed and this does not just mean issues of language and listening but something about history, beliefs and culture.
 

DH advises nurses on gifts and benefits

The Department of Health (DH) has reminded nurse and supplementary prescribers about the importance of choosing medicinal products on the basis of clinical suitability and value for money alone (click here).

Suppliers may provide inexpensive gifts, for example pens, diaries or mouse mats but personal gifts are prohibited and it is an offence to solicit or accept a prohibited gift or inducement. Similarly, hospitality offered by companies at meetings should be at a reasonable level and subordinate to the main purpose of the meeting.
 

Home Office changes law on controlled drugs supply

Changes in the law about the supply of controlled drugs have been announced by the Home Office . A circular explaining the changes can be found here on the Home Office website. One is to allow the supply of controlled drugs under Patient Group Directions (PGDs) and the other paves the way for the independent prescribing of some controlled drugs by nurses. The Statutory Instrument to implement changes in the Misuse of Drugs Regulations 2001 comes into effect on 15 October.

PGDs can now include: diamorphine (but only for the treatment of cardiac pain by specialist nurses in accident and emergency and coronary care units in hospitals), all controlled drugs listed in Schedule 4 (except anabolic steroids), and Schedule 5. This move follows a Home Office consultation about the supply and administration of some controlled drugs under PGDs (see news item).

The second change to the regulations paves the way for specialist nurses in the future to prescribe:

  • diazepam, lorazepam, midazolam (Schedule 4 drugs) for use in palliative care
  • codeine phosphate, dihydrocodeine and co-phenotrope (Schedule 5 drugs)

The circular from the Home Office says that the Department of Health requested that nurses be allowed to prescribe these six drugs, after a consultation on the original extended independent nurse prescribers formulary in 2001. However these are only now being added as it has taken time to change the legislation. Changes to the POM Order will in any case be necessary before these drugs can be prescribed. This task is performed by the Medicines and Healthcare Products Regulatory Agency (MHRA) and it is anticipated that this will occur next month.

The outcome of the consultation document, MLX 293, which have not yet been announced may well add further controlled drugs to the formulary.

These changes apply to England, Wales and Scotland; separate amendments will be made to legislation in Northern Ireland.

 

Nurses to issue computer-generated prescriptions from next Spring?

The Department of Health expects that nurses will be able to begin issuing computer-generated prescriptions from Spring 2004 (http://www.doh.gov.uk/nurseprescribing/faq.htm). It says that computer suppliers have been asked to make the necessary amendments to the GP computer system by early next year.


Doctors lag behind pharmacists and nurses on concordance

Although pharmacists and, to a lesser extent, nurses have “a relatively well developed interest in and awareness of concordance, this is not replicated across the medical profession”, according to the Year 1 Annual Report of the Task Force on Medicines Partnership.
 
The director of the partnership, Joanne Shaw, is quoted in the British Medical Journal as saying that it had failed to convince doctors that they need to make changes to their practice and that the changes need not be time-consuming.


Patient leaflets on supplementary prescribing

The Faculty of Prescribing and Medicines Management has produced two leaflets intended to help patients understand nurse or pharmacist supplementary prescribing. They can be downloaded here:

1. Pharmacist or Nurse Supplementary Prescribing: A patient's guide (leaflet 1) 

2. Pharmacist or Nurse Supplementary Prescribing: A patient's guide (leaflet 2)  


Additions to next edition of NPF

The Nurse Prescribers Formulary 2003-2005 will include the following changes to the
Nurse Prescribers' List for District Nurses and Health Visitors:
 

Additions

Medicinal preparations, appliances, and reagents added to Nurse Prescribers' List since 2002 (some appliances and reagents are not prescribable by nurses in Northern Ireland and Scotland)

  • Cervical Collar, Soft Foam
  • Ear Wax Softening Medical Devices

Emollients as listed below:

  • Decubal® Clinic
  • Gammaderm® Cream
  • Hydromol® Ointment

Emollient Bath Additives as listed below:

  • Ashbourne Emollient Medicinal Bath Oil
  • Eurax® Dermatological Bath Oil
  • Imuderm® Bath Oil
     

Other:

  • Head Lice Device
  • Ibuprofen Oral Suspension, BP
  • Ibuprofen Tablets, BP
  • Macrogol Oral Powder, NPF
  • Vacuum Pumps and Constrictor Rings for Erectile Dysfunction
  • Water for Injections, BP

Wound Management and Related Products as listed below:

  • Conforming Bandage (Synthetic)
  • Wound Management Dressings (including polyurethane matrix, protease modulating matrix, silver-coated and silver-impregnated, and soft polymer dressings)
     

Deletions

Preparations deleted from the Nurse Prescribers' List since 2002

  • Alcoderm® Cream
  • Alcoderm® Lotion
  • Boric Acid Lint, BPC 1963
  • Iodine Brush
  • Lactitol Powder
  • Rectal Dilators
  • Tapeless Dressing Holders
  • Tapeless IV Holders


Change of Title

Old: Lidocaine Ointment/ Lignocaine Ointment, NPF

New: Lidocaine Ointment/ Lignocaine Ointment, BP


Website: BNF


Drug workers, doctors and pharmacists can supply drug paraphernalia

On August 1, a Statutory Instrument came into effect which allows doctors, pharmacists and drug workers (including nurses and employees of needle exchange schemes) to supply the following articles to drug users: swabs; utensils for the preparation of a controlled drugs (including spoons, bowls, cups, dishes); citric acid; filters; and ampoules of water for injection. As water for injection is a Prescription-Only Medicine, it can only be supplied when prescribed for an individual or when approved for supply under a Patient Group Direction (download further information).


Ask About Medicines Week

This initiative is to help promote partnership in medicine taking between medicine users, carers and health professionals and takes place on 12-18 October. It wants to create more opportunities for people to ask questions and raise concerns about their medicines.

See website for details.


Mental health supplementary prescribing – position statement

Only specialist mental health pharmacists should undertake supplementary prescribing in mental health, according to a ‘Joint Position Statement on Specialist Pharmacists Supplementary Prescribing in Mental Health and Learning Disabilities’ from the United Kingdom Psychiatric Pharmacy Group (UKPPG) and The College of Mental Health Pharmacists (CMHP) - which can be downloaded here.

The position statement stresses that the competence of specialist mental health pharmacist supplementary prescribers must be assured in the area of mental health as well as in prescribing practice, ideally by nationally recognized organizations. It also concludes that:

  • these prescribers will work autonomously, taking full responsibility for their actions;
  • the employing trust or equivalent should consider the resources implications before allowing specialist mental health pharmacists to become supplementary prescribers;
  • that the employing trust or equivalent should develop policies and procedures to ensure a safe working framework for both independent and supplementary prescribers;
  • that local and/or regional training schemes be developed to facilitate ongoing development of these prescribers;
  • and that competent specialist mental health pharmacists supplementary prescribers will be in an ideal position to take on the role of independent pharmacist prescriber if this develops in future.

The position statement was developed to support and advise mental health pharmacists who could become supplementary prescribers and to help trusts understand the requirements for supporting specialist mental health pharmacist supplementary prescribers. It discusses current roles, and how supplementary prescribing could complement them, the calibre of pharmacists undertaking this role, resourcing issues, recruitment, training, finance, local policies and protocols, and how practice will develop.

 

PGD and nurse prescribing conference in November

A conference on ‘The new era of PGDs and nurse prescribing – Exploiting extended opportunities for improving patient care’ will be held in London on Tuesday, November 25th. It is organized by ‘Nursing Times’, ‘Professional Nurse’ and the ‘Journal of Wound Care’ and further details can be found here.


EFNPs prescribed nearly 30 000 items in June

Extended formulary nurse prescribers (EFNPs) prescribed nearly 30 000 items in June this year compared with about 10 000 items in December 2002, according to the September report from the Prescription Pricing Authority which covers the period to June 2003.

Practice nurses prescribe more items from the extended formulary than community nurses. Prescribing from the extended formulary still represents a small percentage of all prescribing by nurses, with a total of about 275 000 items being prescribed in June.


Nurse cautioned about prescribing without qualification

A nurse from Staffordshire has been cautioned after she prescribed drugs without being qualified to do so and did not make adequate notes. The caution from the Nursing and Midwifery Council (NMC) will remain on the entry for five years.

Liz McAnulty, the NMC’s Fitness to Practice Director, said, “While the role of nurses is expanding, it is important that practitioners obtain appropriate training and qualifications to carry out new areas of practice…”.


Courses for pharmacists start this autumn

At least five courses in supplementary prescribing for pharmacists will start this autumn, according to an article in Prescribing and Medicines Management (July/August, p5). The Robert Gordon University in Aberdeen has already started its course and the University of Keele, King’s College London, Homerton College Cambridge and the London Metropolitan University will start soon. Further courses have applied for accreditation.


Nurses call for responsibility for prescribing mifepristone

Some nurses are calling for prescribing responsibility for mifepristone – the drug used to terminate pregnancies up to 63 days of gestation, according to a report in Nursing Times (16 September, p3). Katy French, the Royal College of Nursing’s sexual health advisor is quoted in the article as saying that she believes that nurses should be able to prescribe the drug and to sign the consent forms, pointing out that they already do the counselling and manage the care.

This follows publication of the Department of Health’s response to a critical select committee report on sexual health services. The Department of Health points out in its report that, legally, only registered medical practitioners are allowed to terminate pregnancies but that there is scope within the current legal framework for nurses to expand their roles. It has said it will work with nursing bodies to extend the role of nurses working in these services.


Pharmacist prescribing conference in October

A ‘Hospital Pharmacist’ conference on Pharmacist Prescribing will be held on October 30 in London. It will consider the professional, legal and political issues surrounding pharmacist prescribing. Download details here.


RCGP welcomes proposed NPEF additions

The Royal College of General Practitioners (RCGP) has welcomed the proposals in the consultation to extend the Nurse Prescribers’ Extended Formulary (NPEF; see here for proposals), although it expresses some concerns.

In its reply to the consultation, the College stresses the importance of appropriate training and supervision and of good communication between nurses and GPs. It comments that nurses will have to be relied upon not to exceed their training or competence.

It has concerns about ‘off-label’ prescribing in palliative care by extended formulary nurse prescribers (EFNPs), shared by some of the other groups to respond to the consultation (see here for news report). It also highlights the “urgent necessity” for appropriate training for nurses prescribing controlled drugs if the proposed legislative changes go ahead to allow them to do so. Prescribers should be able to prescribe and administer antidotes whenever morphine and similar agents are in use.

It says that the Medicines and Healthcare products Regulatory Agency (MHRA) and the Department of Health (DH) must urgently consider general advice and guidance for prescribers on ‘off-license’ prescribing, including medication for children and that in ‘orphan’ therapeutic areas. These are areas where the number of patients affected is unlikely to justify the pharmaceutical companies applying for licenses.

The College also recommends that: dosage limits for drugs of multiple use need to be more explicit and related to the indication for which they are being used; that a reasonably wide range of antibiotic choices for a condition should be available to prescribers; and that the transdermal route be left in although the proposal to delete this route for hyoscine hydrobromide is understandable.


Results of NPEF consultation under discussion

Comments received as a result of the consultation about extending the Nurse Prescribers’ Extended Formulary will be discussed in September with the Committee on the Safety of Medicines before recommendations are put to Ministers, according to the Department of Health. Watch this space!


Meeting announcement: The Future of Nurse Prescribing: Key Issues, New Developments

Date: Friday 31 October 2003
Venue: Central London
Conference Chairs: Dr Molly Courtenay and Matt Griffiths

This will be a key meeting for organisations interested in learning more about this new market. Organised by the publishers of www.nurse-prescirber.co.uk, the UK's largest community of nurse prescribers, the meeting brings together key figures in nurse prescribing from the Royal College of Nursing, the Association of Nurse Prescribing and the National Prescriber Centre as well as leading specialists in disease areas such as respiratory medicine and diabetes. It will provide delegates with an authoritative overview of the current state of nurse prescribing, point to future developments and indicate how industry and the nursing profession can work together to empower nurses to prescribe.

Numbers to this meeting are strictly limited to 30 and will be filled on a first come, first served basis. To find out more information and to book your place please contact

Jamie Hutchins
Electronic Projects Manager
Greenwich Medical Media Ltd.
Tel: 020 7388 544
 

Conference announcement: Non-doctor prescribing, is it making a difference to patients?

Date: Wednesday 29 October 2003
Venue: Central London
Conference Chair: Dr June Crown CBE

See website for details: http://www.irsonline.co.uk/
 

PRODIGY releases new guidance
 
New guidance on coronary heart disease risk (identification and management), diabetes (foot disease, hypertension, lipid management, and renal disease), Molluscum contagiosum, schizophrenia, and warts and verrucae, has been issued by PRODIGY. Guidance on hyperlipidaemia and insomnia has been revised.
 

Proposals to extend formulary mostly welcomed

Responses to the consultation on proposals (consultation MLX 293) to extend the Nurse Prescribers’ Extended Formulary appear to have been welcomed by some of the professional bodies, although concern was expressed about off-label prescribing.

The Royal College of Physicians of Edinburgh (RCPE) welcomed the proposals to extend the range of prescription-only medicines in its response (click here). It said that the proposed additions to the conditions that can currently be treated under the NPEF are acceptable, as is the addition of pain relief for midwifery practice and in coronary care units, and the treatment of two types of emergencies – acute asthma and hypoglycaemia – providing that the prescriber is “sufficiently happy” with the degree of diagnostic certainty.

The RCPE says that although the Committee on the Safety of Medicines concluded that ‘off-licence’ prescribing by Extended Formulary Nurse Prescribers (EFNPs) in palliative care would be safe and effective, it would expect the EFNP to be aware of the meaning of ‘off licence’. It would also expect this practice to be discussed and agreed with a registered medical practitioner in each individual case. Although the College says that the amendments to the Prescription-Only Medicines (POM) Order are acceptable, it would also expect the use of controlled drugs on the list in palliative care to be discussed and agreed with a registered medical practitioner in each individual case.

The Royal College of Nursing (RCN) has welcomed the proposed additions to the formulary in its response, although it still proposes that, “nurses should have full prescribing rights from the entire British National Formulary limited only by their Nursing and Midwifery Council’s Code of professional conduct”.

The RCN conducted a consultation about the proposals and says that many respondents said they were dismayed that EFNPs could not prescribe P and General Sales List medicines for conditions not listed under the treatment areas in the NPEF. It believes that they should be limited by their level of competence. Because nurse prescribers cannot prescribe for conditions not listed in the NPEF they may instead advise about medicines the patient can buy for themselves over-the-counter. This could limit access to medicines by poorer patient groups.

It proposes the following additions to the formulary:

  • More antibiotics for more conditions including ear infections, pin site infections and minor infections diagnosed in Accident and Emergency Departments, as well as Cefalexin for urinary tract infections;
  • Inhaled steroids for respiratory conditions;
  • Anticholinergic and antispasmodic medication for continence problems;
  • Fluorescein stain for corneal abrasions and homatropine eye drops for pain relief in eye trauma;
  • Treatments for cellulitis, lymphagitis and skin infections;
  • Diazepam for torticollis or neck injuries;
  • Antihistamines for minor allergic reactions;
  • Oral/subcutaneous Hydromorphone (Palladone) in palliative care;
  • Oral contraception for ‘off license’ indications such as dysmenorrhoea;
  • Both P and POM category medicines for moderate analgesia (subject to Controlled Drug legislation). Co-codamol is a P category medicine but is not prescribable by nurses under current Controlled Drug legislation.

It also suggests that osteoporosis should be added to the list of conditions in the Health Promotion treatment area.

The RCN also lists some medicines included in the consultation under the pain relief in palliative care area which it says are rarely used in palliative medicine, and are not in keeping with the World Health Organization (WHO) analgesic ladder (step 3) or the guidelines produced by the National Council for Hospice and Specialist Palliative Care 1998. These medicines, which it says should not be included on the NPEF are: buprenorphine hydrochloride; meptazinol (all types); pethidine hydrochloride oral/parenteral; nalbuphine hydrochloride oral/parenteral; and methadone.

The Faculty of Pharmaceutical Medicine of the Royal Colleges of Physicians of the United Kingdom says that it is satisfied that the training provided to nurses prescribing from the extended formulary is appropriate to safeguard patient safety. It finds both the proposed new treatment areas and the new conditions within existing treatment areas, including controlled drugs, acceptable.

It does, however, state that independent nurse prescribing for “off-license” indications is not safe in principle and that establishing patient group directions is not appropriate. It goes on to say, however, that it is accepted that many medicines are used outside their strict licensed indications (for example amitriptyline as adjunctive therapy in pain management) and such uses should not be prevented.
 

Consultation launched on additional professional group using PGDs

The Department of Health and the Medicines and Healthcare products Regulatory Agency have launched a consultation on enabling further groups of Allied Health Professions (AHPs) to sell, supply and administer medicines under Patient Group Directions (PGDs) as named individuals (see here for the consultation document). These groups are: dieticians; occupational therapists; prosthetists and orthotists; and speech and language therapists.

At present nurses, midwives, health visitors, pharmacists, optometrists, chiropodists and podiatrists, radiographers, orthoptists, physiotherapists and ambulance paramedics are covered by the PGD legislation.

The consultation states that adding these professional groups would remove uncertainty about the use of PGDs by these professionals, would allow a current safe and effective practice with advantages to patients to continue, and could confer cost savings and safety advantages.

Responses to the consultation should be received by 30 September.
 

MeReC bulletin on asthma in primary care

The new topical products tacrolimus and pimecrolimus have a limited role in primary care at present, according to the conclusions of an MeReC bulletin published in July. The bulletin also points out that the evidence base in general for prevention and treatment of atopic eczema is poor.

Trial data on tacrolimus and pimecrolimus are limited, their long-term safety is unknown, and they are at least 10 times as expensive as topical corticosteroids. Tacrolimus is effective in atopic eczema and could be used as a second-line treatment instead of topical corticosteroids but treatment should be initiated and supervised by a specialist. Pimecrolimus is moderately effective but its place in therapy is not clear. Although it is licensed for first-line use, the evidence of its clinical advantages over less expensive topical corticosteroids is insufficient and it seems sensible to make a recommendation against its general use.

Emollients are important in the management of this condition and all patients should use them regularly, although there is a lack of good quality randomised trials (RCTs). There is reasonable RCT evidence for the effectiveness of topical corticosteroids and when they are used appropriately side effects such as skin thinning are rarely seen in primary care.

Oral antibiotics should be used to manage moderate to severe infection but management is less clear for non-clinically infected eczema or borderline infection. Topical antibiotics, either with or without corticosteroids, have little place in therapy.

Avoiding exacerbating factors where practical and the use of emollients, topical corticosteroids and oral antibiotics (where indicated) should allow atopic eczema to be kept under control in most patients. Patients and their families should be kept well informed about their condition and appropriate treatments.

MeReC publications are produced by the National Prescribing Centre and are funded by the National Institute for Clinical Excellence.
 

Discussions on independent prescribing by pharmacists to begin next year

The Department of Health is planning to begin discussions early next year with the professions, the NHS and patient organizations to develop a framework for independent prescribing by pharmacists, according to its new pharmacy strategy ‘A Vision for Pharmacy in the New NHS’

“To prescribe medicines and to monitor clinical outcomes” is one of the Chief Pharmaceutical Officer’s 10 Key Roles for Pharmacy outlined in the document. The strategy also says the range of medicines that pharmacists can supply without prescription will continue to be expanded.
 

Home Office consults on controlled drugs and supplementary prescribing

The Home Office has issued a consultation about government proposals to allow nurses and pharmacists to prescribe controlled drugs under supplementary prescribing, by amending the Misuse of Drugs Regulations (2001). The consultation document can be downloaded here  and the closing date for comments is Friday 12 September.

The Home Office is proposing that all controlled drugs could be included in Clinical Management Plans, apart from those listed in Schedule 1 of the 2001 regulations, which are not intended for medicinal use.

Subject to the comments received, legislative changes would be made early next year. They would take effect in England, Scotland and Wales, although the document says that it understands that corresponding amendments will be made to the Northern Ireland regulations.

Both the independent and the supplementary prescriber would need to have a licence from the Home Office to prescribe cocaine, diamorphine or dipipanone for the treatment of drug addicts.
Join in the forum discussion on this topic and let us know your views.


MeReC briefing on strong opioids in palliative care

The MeReC has issued a briefing on the use of strong opioids in palliative care (click here to download).
 

All nurse prescribers to receive NPF incorporating BNF this year

It has been decided that all nurse prescribers will receive a copy of the Nurse Prescribers Formulary incorporating the British National Formulary (BNF) this autumn, instead of the BNF. It will consist of the full autumn 2003 BNF preceded by information about nurse prescribing.

The Department of Health guide to implementation for extending nurse prescribing states that extended formulary nurse prescribers (EFNPs) will receive a centrally funded copy of the BNF every six months. As supplementary prescribers will also be trained as EFNPs this will apply to them too. District Nurse/Health Visitor prescribers prescribing from the Nurse Prescribers Formulary (NPF) will receive an updated NPF every two years, with the next edition due this autumn.
 

Call for PGDs for early thrombolysis

Patient group directions (PGDs) should be in place for appropriate Accident and Emergency staff with the core competencies to provide thrombolysis for people having heart attacks, according to the recommendations of a Department of Health review of early thrombolysis. This was just one of the list of recommendations.


First supplementary prescribing course for pharmacists gets go-ahead

A Keele University course has become the first supplementary prescribing course for pharmacists to be given the go-ahead by the Royal Pharmaceutical Society, although a final formalization has still to follow, according to a report in The Pharmaceutical Journal (see 28 June, p 884). The head of the department of medicines management, Professor Stephen Chapman, is quoted as saying that they anticipate training 100 pharmacists in three courses by the end of 2004. A number of other courses at other institutions are in the accreditation or development processes.


RCN Diabetes Nursing Forum Annual Conference

‘Insulin issues’ will be the focus of the Royal College of Nursing Diabetes Forum Annual conference and Exhibition, to be held in Oxford on 26-27 September this year. It includes parallel sessions designated as ‘novice’ and ‘expert’. For further information, contact Victoria Langley: e-mail: diabetes@rcn.org.uk; or tel: 020 7647 3579.
 

RCN Nurse Practitioner conference

The RCN Nurse Practitioner Association Annual Conference and Exhibition will be held in Lincolnshire on 25-26 September this year. For further information, e-mail: exhibitions@rcnpublishing.co.uk.
 

New supplementary prescribing materials available on DrugInfoZone

Resources about supplementary prescribing are now available on the DrugInfoZone website. They include: information about training to be a supplementary prescriber in London, guidance for designated supervisory medical practitioners and trainee pharmacist supplementary prescribers, and a collection of resource documents about supplementary prescribing by pharmacists.
 

BNF 45 available online

BNF 45 is now available online (see here). It contains the Nurse Prescribers Formulary for District Nurses and Health Visitors, the Nurse Prescribers Extended Formulary, and the list of conditions for which extended nurse prescribers can prescribe. All these are in the appendix labelled ‘Nurse Prescribers’ Formulary’.
 

June PPA report shows further growth in EFNP prescribing

Extended formulary nurse prescribers (EFNPs) prescribed more than 12 000 items in March 2003 compared with about 10 000 in January and less than 2000 in August last year, according to the June report from the Prescription Pricing Authority (PPA) which covers the period to March 2003.

In March, there were just over 700 qualified EFNPs, with a fairly equal split between practice nurses and community nurses. Prescribing from the extended formulary is still a very small proportion of nurse prescribing as a whole.
 

New edition of MIMS for nurses

The June 2003 edition of MIMS for nurses has now been published. The editorial points out that according to the recent Department of Health guidance, extended formulary nurse prescribers cannot prescribe all the products in the MIMS formulary, but may wish to refer to it for reference or when recommending products to patients. Drug tariff-approved dressings and hosiery, stoma products and incontinence products that nurses may prescribe are also included and the clinics section has been expanded.

Nurses can register for a free subscription (at www.mimsfornurses.co.uk or by obtaining a registration card on 020 8606 7500).
 

Computer-generated prescriptions for controlled drugs?

The Home Office issued a consultation on 21 May about whether prescribers should be able to generate prescriptions for controlled drugs on computers (download consultation). Comments must be received by 22 August.

At present, certain details on such prescriptions must be in a prescriber’s handwriting. If these requirements are removed, prescribers would still need to state the quantity of the drug in words ands figures and sign the prescription themselves.

The consultation also proposes that controlled drug registers for Schedule 1 and 2 drugs should be allowed to be kept on computer, rather than in a bound book as at present (some people are exempt from this), that records relating to controlled drugs can be kept on computer, and that requisitions for Schedule 2 and 3 drugs can be generated by computer.

If proposals to allow some nurses to prescribe controlled drugs become reality, this would provide further impetus for them to be able to generate prescriptions using computers as they would then have access to the additional safety checks for controlled drugs that can be built into the computer packages. Let us know what you think of the proposals using the forum.

 

BNF published but digital version delayed

Although the latest edition of the British National Formulary (BNF 45) has now been published, the production of digital versions has been delayed because of changes to the database underpinning the BNF. Further information can be found on the BNF website.


Widespread and intentional nature of non-compliance

Non-compliance in medicine-taking is a problem across all therapeutic areas and often results from a considered decision by patients rather than forgetfulness, according to a new report by the Medicines Partnership, ‘A question of choice: compliance in medicine taking’.

The review of recent literature concludes that - even with new medicines that are more convenient to use and have fewer side effects - many people do not use them as prescribed, even if the consequences could be life-threatening. The treatment of cancer, arthritis, depression, prevention of transplant rejection, and lowering of heart attack and stroke risks are all affected.

Among the conclusions of the report:

  • Lower compliance rates are linked to more complex medication regimens and above-average rates of unwanted side effects.
  • Those whose beliefs about their illness are in conflict with those of their doctor or pharmacist are less likely to follow their medicines recommendations than those who have reached agreement.
  • Populations affected by cognitive and/or physical impairments have higher rates of non-intentional non-compliance.
  • Preventive medicines are least likely to be taken as intended, perhaps because there is no immediate threat or incentive.
  • Although there are situations where adherence to recommended regimens clearly results in better outcomes, there are others where it is less clear cut, either because the health benefits could be slight or because of counter-balancing social and psychological considerations.
  • Among all groups, support which builds self-confidence and self-efficacy is likely to promote effective medicine taking. In some groups, particularly young adults with long-term conditions, denial of illness may lead to problems and interventions which they see as critical, judgmental and/or blaming are especially likely to be unhelpful.
  • Interventions with multiple components are most effective. There is a common assumption that providing more and better information will in itself promote more effective medicine taking. At certain times, such as after diagnosis, this may well be true but the evidence suggests that efforts should also focus on enabling people to act on the information that is already available to them. For this, they need more confidence in their ability to manage their care and cope with challenges.
  • Although the evidence is incomplete, it supports the view that patient-centred holistic approaches such as concordance are needed to address poor compliance. An informed respect for patient autonomy must be the basis of such strategies. Recognizing this is one of the most important challenges facing health professionals and managers.

The potential impact of reducing levels of non-compliance in many areas of medicine can deliver significant new benefits to individuals and populations.


DH publishes supplementary prescribing guidance

A guide for implementing supplementary prescribing by pharmacists and nurses in the NHS in England can now be found on the Department of Health website.

It draws together much useful information about supplementary prescribing: how it will work, who should undertake training, what the training will be, clinical governance and audit, Clinical Management Plans, medicines prescribable, patient reviews, good practice and ethics, record-keeping, reporting adverse reactions, liability, dispensing, verifying prescribing status, dispensing by appliance contractors, urgent dispensing, dispensing in Wales, Scotland and Northern Ireland, dispensing in hospitals, and budget setting.
 

DH warning about prescribing for other conditions

The Department of Health has warned that extended formulary nurse prescribers (EFNPs) who prescribe for medical conditions not included in the list of specified conditions could potentially be subject to disciplinary proceedings by their employer and to action by the Nursing and Midwifery Council should a charge of professional misconduct follow (DH website). Supplementary prescribers who prescribe outside the Clinical Management Plan (CMP) could also be subject to these sanctions. Legal sanctions under the Medicines Act could also apply if a prescription-only medicine is involved.

The statement points out that, legally, EFNPs are able to prescribe all licensed P and GSL medicines prescribable on the NHS apart from controlled drugs. The Committee on Safety of Medicines and the Medicines Commission have, however, advised that EFNPs should only prescribe from the specified conditions set out in the BNF and the Drug Tariff. If they prescribe independently outside these conditions, they will be acting outside DH guidelines.

There has been much confusion about this issue and although clarification may be welcome, the restrictions implied in the warning may be less so. Nurses could have undertaken the course and developed their practice in the belief that they could prescribe P and GSL medicines if competent to do so. Join in the forum discussion on this issue.
 

NPC publishes supplementary prescribing resource

The National Prescribing Centre has published a resource about supplementary prescribing to help professionals, managers and educators maximise its potential (download the resource). The resource examines the context and concept of supplementary prescribing and its development so far, explaining the aims of extending prescribing authority. It looks at the role of pharmacists, and says that this may include independent prescribing in the future.

It also examines how the integrity of the prescribing partnership can be maintained, particularly given changing roles and responsibilities, possible areas of conflict and how to manage perceived poor prescribing practice. Risk management and the adoption of a ‘safety’ – rather than a ‘blame’ – culture is discussed.

The NPC has also updated its outline framework for nurse supplementary prescribers (download here).


NICE recommends patient education models in diabetes

NICE has issued guidance recommending that structured patient education is made available to everyone with diabetes at the time of diagnosis and thereafter as required on the basis of a regular and formal needs assessment (see here for the guidance in full).

Although the evidence is not sufficient to recommend a specific type of education, or to provide guidelines on session setting and frequency, the guidance outlines some principles of good practice.
 

Proposal to extend range of POMs in NPEF announced

The long-awaited consultation about further extension of the Nurse Prescribers Extended Formulary (NPEF) was announced at the RCN Congress, Harrogate, on 30 April. Proposed additions to the list of prescription-only medicines (POMs) include controlled drugs and more antibiotics for more conditions.

The full proposal can be downloaded from the Department of Health or Medicines and Healthcare
products Regulatory Agency (MHRA) websites and has been sent to the organisations that consulted on the NPEF. The consultation period ends on 23 July and comments are invited on issues including: the new treatment areas, new conditions, additional POMs, and the principle of off-label prescribing in palliative care.

The editorial board of Nurse Prescriber is very interested to hear your opinion of these proposals. Depending upon the response, the editorial board will consider responding to the consultation. Please use the forum or feedback facilities to send us your comments. What do you think about the proposed additions, and will an NPEF based upon them meet your needs? This is your chance to be
heard!

Outline of proposed changes:

The proposed additions to the Prescription Only Medicine (POM) Order fall into several categories but particularly notable is the introduction of controlled drugs for pain relief in specific areas and in palliative care, and the number of antibiotics being added to the list or having their indications extended. These areas of the Nurse Prescribers Extended Formulary (NPEF) have perhaps been the most controversial and the new additions are significant, although still tied tightly to particular indications. Palliative care nurses in particular commented that, although they are highly specialized, often very experienced, and frequently advise doctors on the prescription of drugs, there were very few items of real use to them in the original NPEF.

The inclusion of controlled drugs will require an amendment to Home Office regulations. The consultation document says that although the Home Office will want to consider the advice of the Advisory Council on the Misuse of Drugs before considering such a change, comments in response to this aspect of the consultation are welcome.

Apart from palliative care, the conditions or treatment areas specified will not become part of the legislation but will be the subject of guidance.

New treatment areas:

The consultation proposes that two new treatment areas – pain relief in midwifery practice and coronary care units, and emergency treatments for acute asthma and hypoglycaemia - are added to the existing four (minor injuries, minor ailments, health promotion and palliative care).

  • Pain relief: The consultation proposes that diamorphine be added to the list of POMs prescribable by extended formulary nurse prescribers (EFNPs) for use in pain relief in midwifery practice and for patients in coronary care units with suspected myocardial infarction. The exclusion of controlled drugs on the existing NPEF has been the subject of debate and some criticism (see below for additions to the list of POMs prescribable in palliative care).
     
  • Emergency treatments: For acute asthma attacks, the following additions to the POM Order are proposed:

- salbutamol sulphate
- terbutaline sulphate
- prednisolone
- prednisolone sodium phosphate

For hypoglycaemia, the following are proposed:

- glucagon hydrochloride
- glucose

Existing treatment areas:

The consultation also proposes additions to the list of POMs for the existing treatment areas of the NPEF. Some new conditions have been added with various treatment options: animal and human bites, Trichomanas vaginalis infection, laboratory-confirmed uncomplicated genital Chlamydia infection (and the sexual partners of those patients), menopausal vaginal atrophy and menopause symptoms. In other cases the range of treatment options for conditions already listed in the NPEF has been extended, for example impetigo.

  • Minor injuries and ailments: The additional POMs in this treatment area cover animal and human bites, lacerations, soft tissue injuries, infections, skin and eye conditions:

- Lidocaine hydrochloride as local anaesthetic for suturing lacerations and in ophthalmic conditions
- amoxicillin trihydrate, doxycycline hyclate, doxycycline monohydrate, metronidazole, oxytetracycline dihydrate, erythromycin, clavulanic acid, erythromycin ethyl succinate, erythromycin stearate and metronidazole benzoate are the proposed POMs for the treatment of human and animal bites
- diclofenac sodium and diclofenac potassium are the suggested additions for the treatment of soft tissue injuries
- lymecycline for acne vulgaris
- erythromycin, erythromycin ethyl succinate, erythromycin stearate, fusidic acid and sodium fusidate for impetigo
- azithromycin dihydrate, doxycycline hyclate, doxycycline monohydrate, erythromycin, erythromycin ethyl succinate, erythromycin stearate for laboratory-confirmed uncomplicated genital chlamydial infection plus sexual partners of those patients
- metronidazole for Trichomanas vaginalis infection

  • Health promotion: These proposed additional POMs cover contraception, menopausal symptoms and menopausal vaginal atrophy:

    - etonogestrel (Implanon) for contraceptive use
    - conjugated oestrogens (equine), estradiol and estriol cream and pessaries for menopausal vaginal atrophy
    - levonorgestrel, conjugated oestrogens(equine), dydrogesterone, estradiol, estradiol valerate, estriol, estrone, estropipate, medroxyprogesterone acetate, norgestrel, norethisterone, norethisterone acetate and tibolone for symptoms of the menopause
     
  • Palliative care: The proposals here are for neuropathic pain and pain relief and include a number of controlled drugs:

    - amitriptyline hydrochloride, imipramine hydrochloride, nortriptyline hydrochloride, gabapentin and carbamazepine for neuropthic pain in palliative care
    - morphine sulphate, buprenorphine hydrochloride, dextromoramide tartrate, dextropropoxyphene hydrochloride, diamorphine hydrochloride, dihydrocodeine tartrate, fentanyl, meptazinol, meptazinol hydrochloride, methadone hydrochloride, nalbuphine hydrochloride, oxycodone hydrochloride, pethidine hydrochloride and tramadol for pain relief in palliative care
    - it is proposed that the transdermal route for hyoscine hydrobromide is deleted as no such product is used in palliative care

    * The consultation proposes that EFNPs should be able to prescribe “off-label” (i.e., for the use of a licensed product outside its licensed indications) specific medicines in palliative care.

Exemptions applying in hospitals:

The consultation also proposes that the current exemptions to the POM Order, which mean that the usual conditions for supplying POMs do not need to be met when the medicine is sold or supplied in accordance with the written directions of a doctor or dentist in the course of the business of a hospital be extended to nurse prescribers and supplementary prescribers. This will ensure the legitimacy of the existing practice whereby instructions are written on in-patient drug charts as a means of supplying and prescribing medicines.

Remember: Please use the forum or feedback facilities to send us your comments. What do you think about the proposed additions, and will an NPEF based upon them meet your needs? This is your chance to be heard!

 

Patients to report adverse drug reactions

The government has announced that adverse drug reaction reporting by patients is being introduced at the NHS Direct call centre in Beckenham, covering South-East London. The intention is to roll this out to the 22 call centres in England, if successful. The Nursing Director for NHS Direct South East London , Chrys Short, said that they will be able to offer advice to deal with the problems patients are experiencing as well as completing the Electronic Yellow Card.
 

Supplementary prescribing developments in Wales and Scotland

A ‘Task and Finish Group’ is to be established to oversee the implementation of supplementary prescribing by nurses and pharmacists in Wales, supported by the All Wales Medicines Strategy Group (click here). Towards the end of 2002, it was announced that an extra £0.5 million would be made available to train up to 250 nurses and pharmacists to become supplementary prescribers.

In Scotland, the course fees for training pharmacists to become supplementary prescribers (expected to be about £1000 per student) will be met centrally, according to an article in The Pharmaceutical Journal (29 March, p 424), which says that funds will be allocated to NHS Education for Scotland.


RPS urged to press for independent prescribing for pharmacists

Professor Clare Mackie has urged the Royal Pharmaceutical Society (RPS) to press the government to include amendments that would allow independent prescribing by pharmacists when changes are made to the National Health Service Act in October, according to an article in The Pharmaceutical Journal (29 March, p424). She believes that this may be the only opportunity for the next 10 years to make these amendments and that it would only need 10 medicines or so, including one or two prescription-only medicines, to establish the principle.

Professor Mackie is head of the World Health Organization centre for partnerships in medicines for health at the Robert Gordon University, Aberdeen.
 

Legal changes bring supplementary prescribing into force and extend NPEF

Supplementary prescribing by appropriately trained pharmacists and nurses in accordance with individual patients’ clinical management plans (CMPs) is now legal under the terms of a Statutory Instrument (SI) which came into effect on 4 April (Prescription Only Medicines [Human Use] Amendment Order 2003, Statutory Instrument 2003 No 696).

The same SI also added six products to the nurse prescribers extended formulary (NPEF) and removed inactivated polio vaccine. The six additions are now listed on the Department of Health list of prescription only medicines (POMs) for prescribing by extended formulary nurse prescribers, together with their indications. They are: emedastine (ophthalmic), doxycycline monohydrate (oral), flucloxacillin magnesium (oral, impetigo), minocycline hydrochloride (oral, acne), mizolastine (oral), and water for injections (parenteral).

The same SI makes Patient Group Directions (PGDs) available in non-NHS bodies such as the police, prison services, armed forces, independent hospitals and clinics. This means, for example, that PGDs can be used to supply and/or administer medicines to detainees in police custody suites.

Some medicines containing aloxiprin, aspirin or paracetamol have become POMs under the SI, unless the quantity sold or supplied is less than 100 tablets or capsules. Also, certain homoeopathic products have been made exempt from the controls on POMs if they consist of some substances at defined high dilutions.

Three further SIs which make related amendments can be found here (No 697; No 698; No 699).
 

Growth in prescribing by extended formulary nurses

In December 2002, extended formulary nurse prescribers in England prescribed over 7000 items, compared with over 1000 in August 2002, according to the March 2003 update from the Prescription Pricing Authority (PPA; download here). There were just over 350 qualified extended formulary nurses on the PPA database and a further 500 were in training in December. The increase in the number of items prescribed each month reflects the increase in the number of trained nurses with time. Practice nurses are prescribing more extended formulary items than community nurses and extended formulary nurses are in general prescribing less than GPs, so at present it is not possible to say whether their activity is replacing GP prescribing or is in addition to it.

Items from the extended formulary still form a very small proportion of the items prescribed by nurses overall. In several months in 2002, the total number of items prescribed by nurses exceeded 250,000 per month, whereas at the start of 2000 it was under 100,000 items per month. In December 2002, there were almost 22,500 original formulary nurses recorded on the PPA database.
 

Merger between MCA and MDA

A new executive agency of the Department of Health – the Medicines and Healthcare products Regulatory Agency – has been formed by a merger of the Medicines Control Agency (MCA) and the Medical Devices Agency (MDA). Its main objective will be to protect public health by ensuring the safety of medicines, healthcare products and medical equipment.

Website: MHRA 


Consultation on NPEF additions to start soon

There will soon be a consultation on additions to the Nurse Prescribers’ Extended Formulary (NPEF) by the Department of Health and Medicines Control Agency, Sarah Mullally the Chief Nursing Officer has announced (http://www.doh.gov.uk/cno/bulletindetail_mar.htm#voice Jamie please add link). This follows her review of medicines in the NPEF requested by Alan Milburn (Jamie please add link to Nurse prescribing report with Alan Milburn 2002 item).
 

Competency framework for pharmacist supplementary prescribers published

The National Prescribing Centre has published a framework outlining the competencies that pharmacist supplementary prescribers should acquire during training, and then maintain, so that they can deliver safe, effective prescribing. It applies broadly to all pharmacist supplementary prescribers, regardless of the area in which they work, and is designed to be used as a starting point for discussion about the competencies required by particular individuals or groups.

The main areas of competency are defined as: the consultation; prescribing effectively; and prescribing in context. Each area contains three competencies (for example, for the consultation, the competencies are: clinical and pharmaceutical knowledge; establishing options; and communicating with patients).

The framework and documentation can be found here: NPC website.
 

Joint course developed for nurses and pharmacists

Nurses and pharmacists will study together on a supplementary prescribing course due to start in the spring. It will be run by the St Bartholomew School of Nursing & Midwifery, City University, London, and The School of Pharmacy, University of London. The organizations are creating a joint lecturer post in Prescribing in Healthcare to lead the programme.
 

SIGN guidance on otitis media

A clinical guideline for GPs and other health professionals about the diagnosis and treatment of acute otitis media and otitis media with effusion (‘glue ear’) in children has been issued by the Scottish Intercollegiate Guidelines Network (SIGN).

For acute otitis media it recommends that:

  • Children should not be routinely prescribed antibiotics as the initial treatment.
  • Delayed antibiotic treatment (where the parents collect antibiotics after 72 hours if the child is not improving) can be used in general practice.
  • If antibiotics are prescribed, the conventional five-day course at BNF levels is recommended.
  • Decongestants, antihistamines and oils should not be used.
  • Children with frequent episodes (more than four in six months) or complications should be referred to an otolaryngologist.

For otitis media with effusion (glue ear), it recommends that:

  • Antibiotics should not be used, nor should decongestants, antihistamines or mucoltics.
  • Children over 3 with persistent bilateral otitis media with effusion or who have speech and language, developmental or behavioural problems, should be referred to an otolaryngologist.

Professor John Bain, chairman of the SIGN group that developed the guideline, said that the evidence clearly shows that children over 2 should not be prescribed antibiotics, but that a “wait and see” approach should be used for 72 hours. The condition often resolves during this period without antibiotics.

For more information about both conditions, download the quick reference guide and the full guideline.
 

Prescribing learning in practice guidance issued

The Department of Health has published the requirements for supervised learning in practice for nurses and midwives wishing to prescribe from the NPEF or act as supplementary prescribers (DH website).

This supervised learning will be for a total of 12 days over a three-month period. The supervising medical practitioner should be willing and able to provide enough of his or her time during this period to provide appropriate guidance. The doctor may be one with whom the student usually works but arrangements can be made for another doctor to fulfil the role. The learning in practice should be related to the conditions and circumstances in which the nurse is likely to be prescribing.

The requirements for the supervising medical practitioner are listed and examples are given of how the nurse of midwife can receive supervision. These include: dedicated time and opportunities to observe a “consultation/interview” with patients and/or carers and development of a subsequent management plan; in-depth discussion and analysis of clinical management using a random case analysis approach; using student’s professional portfolio or learning log to facilitate learning by encouraging critical thinking and reflection; and opportunities for the student to carry out consultations and suggest clinical management and prescribing options to be discussed with the supervisor.

As part of the assessment requirements, the doctor will need to complete and sign the assessment of practice form, and return it to the higher education institution concerned.

Revised suggested templates for the Clinical Management Plan to be used in supplementary prescribing have also been issued and can be found here (download docuemnt).
 

Guidance to reduce medication errors

A guidance document has been published by the Department of Health setting out best practice for medicines labelling. Although 15 items of information are legally required, the guidance suggest that the five key pieces of critical information are brought together on the pack. These are: the name of the medicine, strength, route of administration, dose and warnings.

The guidance follows a review by the Committee on Safety of Medicines which concluded that improvements could be made within the current legal framework. It took effect on 1 March and can be found here (download here).
 

DH issues guidance on supplementary prescribing

The Department of Health (DH) has issued guidance on supplementary prescribing which can be downloaded from the DH website. The guidance supplements the information previously provided, adds some details about how partnerships and Clinical Management Plans (CMPs) can work in practice, and covers training, clinical governance, ethics and legal issues.

Principles and characteristics of supplementary prescribing:

  • Independent prescriber (IP) must be a doctor or dentist and should determine which patients would benefit from supplementary prescribing, which medicines should be prescribed under it, and the extent of responsibility given to the supplementary prescriber (SP) under the CMP. IP needs to take account of the professional relationship between the IP and SP and the experience and expertise of the SP.
  • There must be an individual CMP before supplementary prescribing can begin. It should be as simple as possible. The templates on the DH website can be used or adapted, or CMPs can be developed from scratch. Reference to local and national guidelines may be included in a CMP but the guideline must be easily accessible, with the range of relevant medicinal products to be used in the treatment of the patient clearly identified, and the CMP should draw attention to the relevant part of the guideline. The guidance includes information about what information should be included in the CMP, although this may be changed in the light of amendments to the Prescription Only Medicines Order.
  • The IP and/or SP should obtain the patient’s agreement to supplementary prescribing and then discuss and agree the CMP. The principle of a prescribing partnership must be explained in advance to the patient. Supplementary agreement may not proceed without recorded agreement from the patient.
  • The IP is responsible for the diagnosis and setting the parameters of the CMP, although they need not draw it up. If responsibility for the patient moves from that IP, the SP must not continue to prescribe in the absence of a recorded agreement with the new IP.
  • The IP and SP must maintain ad hoc communication until the first formal clinical review, normally a maximum of 12 months of the start of the CMP. The review should be by both prescribers together or where this is not possible by the IP, followed by discussion with the SP.
  • The IP and SP must share access to, consult, keep up to date, and use, the same common patient record to ensure patient safety. Shared electronic records are ideal but paper and patient-held records may be used. The SP should record prescribing and monitoring activity contemporaneously in the shared patient record or as soon as possible and ideally within 24-48 hours.
  • The CMP comes to an end: at any time at the discretion of the IP; at the request of the SP or patient; at the time of the review unless renewed by both SP and IP. The IP can review the patient’s treatment and resume full responsibility for care at any time.
  • The categories of medicines that can be prescribed under supplementary prescribing are described in the guidance, which also highlights the responsibilities of the IP in the case of high-risk drugs. Any GSL, P or POM prescribable at NHS expense (with the current exception of controlled drugs) may be included in the CMP. This includes: antimicrobials; “Black triangle” drugs and those identified by the BNF as “less suitable”; and “off-label” drugs (provided the product has a UK license, both prescribers agree to the off-label use, and the status of the drug is recorded in the CMP). Unlicensed drugs may only be included as part of a clinical trials certificate or an exemption and where both prescribers agree and the status of the drug is recorded in the CMP. An SP should not agree to prescribe any medicines that he/she feels fall outside his/her area of competence.
  • The relationship between the prescribers is the key to safe and effective supplementary prescribing.
  • The responsibilities of the IP and SP are distinct and are outlined in the guidance.
  • The SP will need to arrange for access to a budget for prescription costs and to access to prescription pads or other prescribing mechanisms.

Legal, ethical and safety issues:

  • Amendments to the Prescription Only Medicines Order and NHS regulations are expected by April to allow supplementary prescribing by suitably trained nurses and pharmacists;
  • The IP is responsible for reporting adverse incidents within local risk management or clinical governance schemes and informing the National Patient Safety Agency (NPSA) via the National Reporting and Learning System due to be introduced in 2003/4.
  • Suspected adverse reactions should be reported via the Yellow Card Scheme and the SP should also inform the IP.
  • It is strongly recommended that, as for doctors and dentists, SPs should not prescribe for close family members wherever possible. They should not prescribe for themselves.
  • Arrangements and requirements for record-keeping are outlined in the guidance for nurse and pharmacists SPs. The mechanisms for sharing patient records should be put in place at the same time as the partnership is set up.
  • Employers are held vicariously liable for the actions of appropriately trained and qualified nurses, midwives and pharmacists prescribing as part of their professional duties with their employers’ consent. Nurse SPs are individually accountable to the NMC and must act in accordance with the NMC Code of Professional Conduct. Pharmacist SPs are individually accountable to the RPSGB and must act in accordance with its Code of Ethics and Standards. All SPs should ensure that they have professional liability insurance.

Clinical governance, evaluation and audit:

  • Supplementary prescribing should take place within a clinical governance framework. The model of clinical supervision for nurses should be agreed at local level and monitored and evaluated regularly. Mechanisms for peer review, support and mentoring need establishing for pharmacists. The RPSGB is developing clinical governance guidance for pharmacists SPs.
  • The SP and employer must establish specific mechanisms to evaluate regularly the safety, effectiveness, appropriateness and acceptability of their prescribing. A review of SP should be part of overall prescribing monitoring arrangements.

Training and CPD:

  • Local decisions will be taken about which nurses and pharmacists will receive training but no-one shall be required to undertake training against their wishes and everyone must have the opportunity to prescribe on completion of their training.
  • As well as the legal criteria for eligibility, candidates will need the following: for nurses, the ability to study at Level 3 (degree) and at least 3 years post-registration clinical nursing experience; and for pharmacists the ability to study as a minimum of QAA level 3; or at least 2 years experience as a pharmacist following the pre-registration year after graduation. Nurse nominees will usually be at E grade or higher. Candidates will need their employer to provide confirmation of their need and opportunity to prescribe, access to budgets in primary care, and continuing professional development (CPD) opportunities.
  • Potential applicants should be prioritised on the basis of: patient safety; maximum benefit to patients and the NHS; and better use of nurses’ and pharmacists’ skills.
  • The NMC is responsible for approving training for nurse prescribers and the RPSGB will be accrediting courses for pharmacists. Nurses completing the training successfully will also qualify to prescribe from the Nurse Prescribers’ Extended Formulary.
  • SPs will be expected to keep up-to-date with best practice in the management of conditions for which they prescribe and in the use of drugs, dressings and appliances. For nurses, this can be part of their PREP-CPD activity and for pharmacists it will contribute to the RPSGB’s CPD requirements.

Aims of supplementary prescribing:

  • Quicker and more efficient access to medicines for patients
  • Make best use of skills of trained nurses and pharmacists
  • In time, likely to reduce doctors’ workloads, freeing up time for patients with complicated treatments and conditions. The time spent on the CMP should be saved by avoiding return appointments.
     

Prodigy guidance in book form

Prodigy guidance is now available in book form. It contains guidance on 119 conditions, 203 patient information leaflets and other information. It has been sent free to various groups including GP registrars and trainers. Other health professionals, including nurse prescribers, can buy a copy for £30 (Email: bookenquiries@schin.ncl.ac.uk).
 

RPS issues guidance on working with industry

The Royal Pharmaceutical Society of Great Britain (RPSGB) has issued guidance for pharmacists on working with the pharmaceutical industry, prompted by the changing roles of pharmacists, including their involvement in prescribing and PGDs. The guidance can be downloaded from the RPSGB website.
 

RPS argues for access to patient records

The Royal Pharmaceutical Society of Great Britain (RPSGB) has put a case for pharmacists having access to shared patient records in the future, in its response to a consultation on patient privacy (download their response from the RPSGB website). It says that the exclusion or omission of pharmacists from arrangements for shared patient records in future will put up a barrier to the implementation of policies predicated on the development of pharmacists’ roles.
 

Consultation on supply of controlled drugs under PGDs

The Home Office has launched a consultation on allowing the supply of some controlled drugs under PGDs (download from Home Office website) by nurses and other health professionals.
The consultation proposes that the following drugs could be supplied under PGDs:

  • Diamorphine for the treatment of cardiac pain by nurses in Accident and Emergency and coronary care units;
  • Schedule 4 drugs (mostly benzodiazepines), but not anabolic steroids, in any situation (except injectable forms of these drugs used to treat drug dependence);
  • and Schedule 5 drugs (low-strength opiates such as codeine) in any situation.

The consultation states that the Home Office plans to make the required legislative changes later this year, subject to consideration of the responses to this consultation.
 

Substance misuse nurses to prescribe controlled drugs?

The Home Office is considering proposals for nurses working in substance abuse who have completed the extended formulary course to be able to prescribe schedule 2 and 3 drugs such as diamorphine, methadone and buprenorphine, according to a report in Nursing Times (25 February, p7). The article states that the necessary legislative changes will happen later this year and quotes the care co-ordinator of a drug and alcohol team as saying that having nurses, who work full time, able to prescribe these drugs will facilitate care.
 

Move towards joint accountability

The NMC has approached the General Medical Council about drawing up joint guidance on nurse prescribing to reduce concern about accountability, according to a story in Nursing Times (11 February, p8). Doctors have raised concern about accountability, given the lack of restrictions on the drugs that can be prescribed in a supplementary prescribing partnership.
 

Government describes forms of prescribing and medicine supply

The Department of Health has published definitions of the forms of nurse and pharmacist prescribing and supply of medicines currently available or in the pipeline (DoH website). It describes what the two types of independent nurse prescribers (District Nurses/Health Visitors and extended formulary nurse prescribers) may prescribe and sets out the arrangements for supplementary prescribing and Clinical Management Plans.

It also includes some guidelines about patient group directions (PGDs), stressing that the majority of clinical care should be provided on an individual, patient-specific basis and pointing out that if a patient-specific direction exists, there is no need for a PGD or Clinical Management Plan. Patient-specific directions are written instructions by a doctor, dentist or nurse prescriber for a medicine or appliance to be supplied or administered to a named patient. They could take the form of a simple instruction on a patient’s notes in primary care or instructions on a patient’s ward drug chart in secondary care.

At the end of October 2002, there were 400 extended formulary nurse prescribers recorded on the NMC register and a further 500 are in training; there were about 23,000 DN/HV nurse prescribers. For supplementary prescribing, the target numbers are up to 10,000 nurses and 1000 pharmacists by the end of 2004.

On the issue of controlled drugs, the document says that some will “probably” be prescribable under supplementary prescribing after changes to Home Office legislation, and that the use of PGDs to supply some controlled drugs has been agreed in principle with the Home Office and is now awaiting legislation.
 

Asthma guideline published

New guidance on asthma management has been issued by The British Thoracic Society and the Scottish Intercollegiate Guidelines Network (BTS/SIGN). It includes recommendations, indicating the strength of the evidence for them, on diagnosis, assessment, treatment and education in adults and children.

The guidelines state that patients should be maintained at the lowest possible dose of inhaled steroid and makes recommendations about what these should be (these have changed since the last guidance was issued). Add-on therapies should be started as an alternative to increasing the dose of inhaled steroids. A step-wise approach to treatment is laid out, with a patient’s drug doses being carefully reduced or modified when their asthma is well controlled. Non-pharmacological treatments are also included. The guidelines say that a customised individual asthma action plan should be offered to all asthma patients and that a nurse with training in asthma management should review patients regularly in a structured way in primary care.

A quick reference guide and the full Guideline can be downloaded from the British Thoracic Society's website (click on the links above to download PDF copies).
 

Smoking cessation recommendations published

The Health Development Agency has published recommendations about smoking cessation services for both PCTs (click here) and service providers (click here). The latter includes answers to common questions about issues such as NRT and pregnant smokers, services for special groups, and exactly how the medication available can be used.
 

Public health experts opposed inclusion of antibiotics in NPEF

Several public health groups advised the government against including oral antibiotics in the extended formulary for independent nurse prescribers because of concerns about increasing antibiotic resistance. Their comments can be found in a document published in January by the Medicines Control Agency detailing the responses to its consultation on the formulary (download PDF here). The MCA says that publication has been delayed by other work connected with legislation about the extension of prescribing responsibilities and the supply and administration of medicines.

The Specialist Advisory Committee on Antimicrobial Resistance advised that systemic antibiotics should be excluded from the list or restricted to a very few situations. It specified bacterial vaginosis and urinary tract infections as the only conditions for which nurses should prescribe antibiotics, and then within tight guidelines, because they can be easily and accurately diagnosed. The Public Health Laboratory Service noted “with regret” the decision in principle that nurses should be able to prescribe antibiotics and said it ran counter to the recommendations of professional and government groups. Other medical bodies including the BMA also expressed concern about the inclusion of antibiotics.

Ministers in the end decided to include nine antibiotics, each for specified conditions only. The conditions are: lower urinary tract infection in women, acne, impetigo, fungating malodorous tumours and bacterial vaginosis.
 

Research evidence needed on topical corticosteroids

Better quality evidence from clinical trials about the use of topical corticosteroids in atopic dermatitis is urgently needed, according to a report in Drug and Therapeutics Bulletin (January issue). Clearer evidence allowing topical corticosteroids to be ranked according to clinical outcomes, as well as long-term safety and efficacy studies and studies conducted in primary care, are all needed.
This evidence is needed to support the advice given to patients and parents about treatment with topical corticosteroids. Careful education and explanation encourages confidence in, and correct use of, these treatments.

Although topical corticosteroids are the standard therapy for controlling acute ‘flares’ of dermatitis, poor communication often means that they are not used as effectively as possible. In most cases, a mild or moderately potent corticosteroid is effective and clinically significant skin thinning or unwanted systemic effects are very rare when used correctly in these cases. If use is prolonged or a potent corticosteroid is being used, the patients should be referred to a dermatologist. Avoiding aggravating factors and daily emollient use are recommended for all patients.
 

Delivery strategy for NSF on diabetes published

The delivery strategy for the National Service Framework on diabetes has now been published and can be found on the Department of Health website. It sets out a framework of systematic reform that will allow the standards in the NSF to be met. In the section on occupational settings and roles, the strategy points out that, “Diabetes services are well positioned to take advantage of the extension of prescribing to nurses, pharmacists and allied health professionals”.
 

Volume of nurse prescribing grows in Scotland and England

Figures provided by the Prescription Pricing Authority (PPA) for England and NHS Scotland for Scotland show rapid growth in the volume and value of nurse prescribing in recent years.

In Scotland, over 247,000 items costing £3,234,981 were prescribed by nurses in the year ending March 2002 compared with fewer than 2000 items in the year ending March 1997 (for further data, click here). In the last two financial years, volume has risen by 41% and cost by 58%. The total number of nurse prescribers could grow significantly in future years under the scheme to extend nurse prescribing.

In England, 2.7 million items were prescribed by nurses in the year ending June 2002, at a cost of £35.5 million. The PPA has now started to receive prescriptions from nurses prescribing from the extended formulary and it expects faster growth in the volume of nurse prescribing as substantially more nurses will be prescribing a wider range of drugs.
 

New guidance on malodorous malignant skin ulcers and impetigo

New guidance on malodorous malignant ulcers of the skin and impetigo have been issued by Prodigy, the government-funded project to support GPs and other professionals (Prodigy website).

The guidance for malodorous malignant skin ulcers looks particularly at management of the malodour and the use of wound dressings and antimicrobial treatment. A comprehensive assessment of the patient is necessary and the areas to be covered are outlined. Activated charcoal dressings may help to contain offensive odours and oral metronidazole can reduce them. Topical metronidazole is an effective alternative to the oral form but is much more expensive.

According to the impetigo guidance, it is generally recommended that antibiotic therapy should be prescribed. Oral antibiotics are indicated if there is associated lymphoadenopathy or systemic illness although it seems reasonable to treat a small localized patch with a topical antibiotic. The first-choice oral antibiotic is flucloxacillin for 7 days or erythromycin in cases of penicillin sensitivity.

Several studies indicate that topical treatment with fusidic acid or mupirocin is as effective as oral therapy. However, there is a debate about whether all impetigo should be treated with systemic antibiotics as topical treatment is associated with greater antibiotic resistance than oral therapy.

Prodigy recommends that mupirocin be used as second-line therapy only, as it is an essential treatment for MRSA. Topical fusidic acid preparations should be offered for the treatment of localized superficial infection. Topical antibiotic agents should not be used to treat widespread lesions and courses should be limited to 5 days, to prevent the development of resistance. Advice on reducing transmission should also be given.

Nurse prescribers can check the current list of medicines that can be prescribed from the extended formulary here (DoH website).
 

Pharma companies urged to provide information for non-doctor prescribers

Companies that want to support better use of their products in the management of chronic diseases need to make sure that their training activities contain information about supplementary prescribing, according to Ray Rowden, writing in Pharmaceutical Marketing (www.pmlive.com, 3 December). They should also consider training and support packages about diseases for use locally in implementing prescribing partnerships. Sales teams will need to know which hospital doctors and GP practices are considering supplementary prescribing.

Although independent nurse prescribing will have less impact, he argues, the industry also needs intelligence about who these nurse prescribers are, what disease areas they prescribe for and what their support needs are.

He also points out that the proposed shift of products from POM to OTC by the government will expand the formulary. Likely candidates include statins, some topical antibiotics, and asthma and erectile dysfunction preparations.
 

PCT stops nurses using PGDs for Zyban

The Sussex Downs and Weald Primary Care Trust has said that nurses should not supply Zyban using PGDs. It should be prescribed by family doctors because only they have full medical histories, according to a story in The Guardian (31 December). According to the report, specialist nurses in a one-stop smoking cessation shop had been using a PGD for Zyban so that they did not need to refer individual patients back to GPs for a prescription.
 

Early PCT plans for training supplementary prescribers

Training places for hundreds of pharmacists and nearly 2500 nurses may be required in the first 18 months of supplementary prescribing training, according to early Primary Care Trust plans. The National Prescribing Centre carried out a preliminary baseline survey in September and October last year of all PCTs in England: a recent article by its chief executive Clive Jackson discusses its findings (The Pharmaceutical Journal, 4 January, p22).
 
There was a 65% response rate (197 questionnaires) from the PCTs, who were asked to provide early indications of their plans. The 140 PCTs who expected to include pharmacists in their early plans predicted they would need a total of up to 770 places in the first 18 months. For the 153 PCTs expecting to include nurses, the total was up to 2407. At this stage, PCTs are therefore expecting about three times as many nurses as pharmacists to move into supplementary prescribing.

In answer to a question about the types of pharmacists they would be putting forward: 89.5 % said they would be considering GP practice-based primary care pharmacists; 67%, hospital pharmacists; 54.5%, community pharmacists; 20.9% PCT-based primary care pharmacists; and 18.8% community services pharmacists. As for what sort of nurses PCTs thought would be most effectively used to deliver supplementary prescribing: 99.4% were thinking of training practice-based nurses; 54.1% district nurses; 25.1% health visitors; and 21.9% midwives.
 

NMC urged to improve checking procedures

The National Pharmaceutical Association (NPA) wants the NMC to provide unrestricted 24-hour access to registration details of nurse prescribers, as the GMC does for doctors on its website, according to a story in Nursing Times (7 January, p7). The NPA said that difficulties were arising for pharmacists in late-night chemists who want to check the credentials of nurses signing prescriptions. The code they need for the NMC website can only be obtained in office hours.
 

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