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Last updated: 30/12/2004

National PGD website launched

A website about patient group directions (PGDs) has been launched via the National Electronic Library for Health. Its aim is to provide resources and examples to help health professionals develop PGDs and it supersedes the group protocols website.

The website was developed by the London and South East Medicines Information Service Team at Guy’s and St Thomas’ NHS Foundation Trust.
 

CSM supports extension of supplementary prescribing

Members of the Committee on Safety of Medicines (CSM) agreed at a meeting in October that they support the government’s proposals to extend supplementary prescribing to chiropodists, physiotherapists, radiographers and optometrists (see here for minutes).

They concurred with most of the respondents to the consultation (see news item) that patient safety would be ensured by the role of the independent prescriber and the requirement for a patient-specific CMP. The question of how to share records was, however, a concern.
 

MPs warned that prescribers rely on pharma support for CPD (07/12/04)

A lack of government support for continuing professional development (CPD) means that nurse prescribers have to rely on education sponsored by drug companies, according to evidence given by RCN joint prescribing advisors Matt Griffiths and Molly Courtenay to the House of Commons Health Select Committee. They emphasized that CPD must be rigorous and appropriately validated.
 
They said that the RCN values the support the pharmaceutical industry offers for sponsorship of professional events and provision of education programmes. Their evidence pointed out that the extended/supplementary training programmes prepare nurses for their relationship with the pharmaceutical industry and address the industry’s influence on prescribing decisions. The NMC Code of Conduct should ensure that prescribing decisions are evidence-based.
 

Conference update: Running nurse-led clinics (07/12/04)

A one-day conference on developing, running and monitoring nurse-led clinics will be held in London on 18 January 2005 at the Royal College of Nursing. It will include a session in nurse prescribing within clinics. See here for further details (accessed 1/12).


Conference update: Nurse-led care and clinics in respiratory care (07/12/04)

A one-day conference examining the role of nurse-led clinics and care in respiratory care will be held on 15 March 2005 at the Royal College of Nursing. It will include a session on nurse prescribing in respiratory care. See here for further details (accessed 1/12).


Nurse prescribing diabetes fact sheet published (07/12/04)

A fact sheet on diabetes and extended nurse and supplementary prescribing has been published by the Clinical Governance Support Team of the Modernisation Agency and can be downloaded here (accessed 1/12). It describes how the extension of prescribing, and particularly supplementary prescribing, can be used in caring for patients with diabetes in primary and secondary care.
 

Consultation: Ambulance technicians to administer Naloxone? (07/12/04)

The Medicines and Healthcare products Regulatory Agency (MHRA) has published a proposals aimed at allowing ambulance technicians to administer Naloxone in an emergency, in situations where there may be no registered paramedic available (download consultation here; accessed 2/11). Naloxone is a parenteral medicine used for opioid overdoses and is not listed in Article 7 of the POM Order, which provides exemptions from the restrictions affecting parenteral medicines for the purpose of saving life in an emergency. It is the subject of a separate POM Order exemption allowing registered paramedics to administer it, but this does not include ambulance technicians. Under these proposals it would be added to Article 7. The consultation points out that technicians, either singly or in twos, often provide the initial response to immediately life-threatening calls, and that making Naloxone available to them would represent a significant advance in patient care.
 
The consultation also proposes removing substances for the Article 7 list because they are not commercially available and making other changes that will reflect the move to the international naming system.

Comments are requested by 17 January 2005.


New guidance from Prodigy (07/12/04)

Prodigy has published new guidance on dental abscess, eating disorders, eczema (atopic), gingivitis and periodontitis, leg ulcer (venous), and seborrhoeic dermatitis. The guidance documents can be downloaded here  (accessed 1/12). Guidance on other topics has been updated: aphthous ulcer, asthma, chickenpox, colic (infantile), epilepsy, herpes simplex (oral), malaria prophylaxis, menorrhagia, and sore throat (acute).
 

NICE issues guidance on epilepsy in children and adults

NICE has issued guidance on the diagnosis and management of epilepsy in adults and children in primary and secondary care. The various guidelines and appendices can be downloaded here (accessed 2/11).
 

Welsh guide to supplementary prescribing implementation published

A guide to implementing supplementary prescribing in Wales has been published (download here; accessed 3/11).
 

MPs call for strategy over clinical areas in supplementary prescribing

MPs in the All Party Parliamentary Group on Skin have expressed concern that there is no national strategy to train pharmacist supplementary prescribers with expertise in dermatology or any other specialty, according to an article in ‘The Pharmaceutical Journal’ (see here; accessed 20/10).

The group’s report criticised the didactic parts of the course, saying it concentrated on organization and patient consultation, with specific aspects of therapeutics being addressed mostly through the hands-on training, reflecting the interests of the supervisor. Christine Clark, a consultant pharmacists and specialist advisor to the committee, is quoted as saying that in the absence of a national strategy setting out which clinical areas supplementary prescribers should prescribe in, and where areas of expertise need developing, progress will be made ad hoc.

A spokeswoman for the Royal Pharmaceutical Society said that specialist knowledge should be maintained through continuing professional development.
 

Conference Update: ANP Annual Conference 2005

A series of workshops and presentations on subjects such as antibiotic prescribing, clinical epidemiology, diabetes, primary care, the formulary, accountability and legal responsibility, emergency care, mental health care, patient group directions and evaluating nurse prescribing. See conference section for more details.
 

Nurse prescribing increases in Scotland and England

Nurse prescribing in England and Scotland is continuing to increase, according to the latest statistics.

In England, the Prescription Prices Authority (PPA) figures for the year to June 2004 (download here; accessed 5/10) show that overall prescribing by nurses increased by 11.1% compared with the previous year.

In June 2004, nurses prescribed more than 300,000 items, with most being prescribed by district nurse/health visitor nurse prescribers. There are more than 1900 extended formulary nurse prescribers on the PPA database, of whom over 1400 are also registered as supplementary prescribers. The report comments that the PPA has started to process prescriptions from pharmacist supplementary prescribers and that implementation of supplementary prescribing for other health professionals (see news item here) is likely to follow next year.

In Scotland, nurses prescribed 335,826 items in the year ending 31 March 2004, at a gross ingredient cost of £5,110,590. This represents an increase of 13.8% in volume and 21.0% in cost between the last two financial years.
 

MeReC briefings on diabetes

The MeReC has published two briefings on Type 2 diabetes, one on the management of blood glucose and the other on the management of cardiovascular risk factors (download both from here; accessed 5/10).
 

Nurses should urge suppliers for action on computer-generated scrips

The Department of Health (DH) says that it is continuing to press suppliers for action on changing GP computer systems so that nurses can use computer-generated prescriptions but that it may be useful for users with concerns to contact their suppliers as well. The DH says that it had understood that roll-out of the new systems would be relatively quick and simple once testing was complete but that uptake among GP computer suppliers has been variable.

For further information, see the updated DH list of FAQs here.
 

Supplementary prescribing of controlled drugs unlikely before Spring 2005

Changes to the regulations to allow supplementary prescribing of controlled drugs by nurses and pharmacists are unlikely before Spring 2005, according to the Department of Health (see updated FAQs here). Work is continuing on proposed changes to the Misuse of Drugs regulations following the Home Office consultation, in the context of the Shipman Inquiry.
 

Extending the formulary: responses to consultation

Although the proposals to extend the Nurse Prescribers’ Extended Formulary (NPEF) have generally been welcomed, various bodies have also expressed some concerns (see here for news item about consultation; and here for responses so far news item, and news item). Issues about prescribing of controlled drugs and antibiotics, ‘off-label’ prescribing, diagnostic skills, experience, and training are often raised.

The Royal College of General Practitioners (RCGP; copy of response can be requested here) supports the proposals overall but raises some questions, including, for example: which specific treatments for poisoning are included; why such a narrow definition of cellulitis is included; why no treatments for psoriasis or complex topical infections are included; and what are the checks and balances will be for off-licence prescribing, if it starts (as the inclusion of salicylic acid for Molloscum contagiosum would imply. After listing what it sees as the omissions and anomalies, the College suggest that the proposals should be reviewed by a panel of primary care nurses.

The College also comments on the proposed additions specifically from a primary care/general practice perspective, although the proposals are more relevant to nurses working in secondary care or atypical primary care settings. For example, some emergency situations will present only rarely in a treatment room where there is no doctor on the premises, and the lack of experience and familiarity of nurse prescribers in these situations may swing the balance of advantage towards waiting for medical or paramedical assistance. In an Accident and Emergency department, for example, individual prescribers are more likely to have acquired the necessary experience.

The College also suggests that: diagnosis of psoriasis is a function of the GP; the proposed treatments for acute exacerbation of chronic bronchitis should perhaps be condensed to amoxicillin and either erythromycin or oxytetracycline; if parenteral hydrocortisone sodium succinate is added for acute reversible airways obstructions it should be clearly stated that this is for situations when the patient is unable to swallow or absorb the oral preparation, and that ipratropium is not added.

The RCGP does not support the proposal to include ‘off-label’ and controlled drugs in palliative care, as good practice in primary care already includes the prescribing doctor signing up necessary treatments in advance on a “when necessary” basis. It supports the limitation of antimicrobial prescribing to minimise antibiotic resistance.
The College believes that there is benefit in maintaining a clear distinction between medical (diagnosis and decision to prescribe) and nursing (triage and provision of nursing care) care. It also comments that General Practice has a value that is greater than the sum of its technical functions, and that this value will be lost of the functions are constantly “nibbled away”.

The Faculty of Pharmaceutical Medicine of the Royal Colleges of Physicians of the UK also supports the proposals, making some suggestions and highlighting the need to follow up with suitable medical care, for example after the emergency treatment of meningitis (see website; accessed 12/10). It agrees that: the restriction on ‘black triangle drugs’ is overly restrictive; that ‘off-label’ prescribing is appropriate in some circumstances; that the prescribing of controlled drugs should be extended; and the proposals about antibiotics are appropriate. It makes some suggestions, for example commenting that the types of poisoning and treatments used need clarifying.

The National Pharmaceutical Association (NPA) welcomes the proposed additions to the NPEF (download here; accessed 12/10), and the proposed extensions in some circumstances of ‘off-label’ prescribing, provided that nurse prescribers and their employing Trusts are fully aware of the legal and professional indemnity issues. It believes that nurse prescribers should be able to prescribe ‘black triangle’ drugs and agrees with the proposal to add a restricted range of controlled drugs, suggesting that in future morphine should be added for palliative care, as is proposed for acute severe pain after trauma.

The Scottish Specialists in Pharmaceutical Public Health (SSiPPH; download here; accessed 12/10 ) believe that the areas of care should be restricted to the four current areas: minor ailments, minor injuries, health promotion and palliative care and suggests amendments to the proposed list of conditions accordingly. The group argues that diagnosis and prescribing are parts of complex processes and cannot happen in isolation. In some cases, differential diagnoses would require extensive specialist knowledge, as medical history and laboratory support may not be available in some of the proposed locations. Before nurse prescribers would be able to prescribe the proposed conditions, extensive in-depth training would be needed, extensive technical diagnostic and clinical support will be required, and clear care pathways must be in place. Until it is clear that nurse prescribers can diagnose in this way, the list of conditions should be restricted as described.

The SSiPPH support the proposal for limited ‘off-label’ prescribing, emphasising the importance of nurse prescribers having full understanding of the responsibilities involved, as well as sufficient knowledge, information and experience. It suggests a pragmatic approach to the inclusion of controlled drugs, supporting the addition of treatment for acute alcohol withdrawal but suggesting that the addition of parenteral prescribing of morphine for acute severe pain after trauma should be reconsidered. It does not support the extension of antibiotics prescribing at present and questions some of the other additions.

The Royal College of Physicians of Edinburgh (RCPE) welcomes the proposed additions to the list of prescription-only medicines that nurse prescribers can prescribe but asks what is meant by the comment, “without the need for inappropriate or unnecessary reference to medical colleagues” (download here; accessed 8/10). It comments that nurses are not trained to make diagnoses and therefore has reservations about whether nurse prescribers could diagnose some of the conditions listed, without further specialist training. This raises questions about some of the proposed additions and the College stresses the importance of targeted training.
 

Supplementary prescribing for other professionals: responses to consultation

The consultation proposing that chiropodists, physiotherapists, radiographers and optometrists should be able to become supplementary prescribers (see news story here) appears to have been largely well received.

The Royal College of Physicians of Edinburgh supports the proposal in general, but sets out various conditions for its approval, including the collection of data to show that supplementary prescribing by pharmacists and nurses has proved to be safe and beneficial to patients, that independent prescribers should be doctors or dentists (not nurses or pharmacists) and that supplementary prescribers should not be able to prescribe unlicensed medicines but could use licensed medicines for unlicensed indications under supervision (see here; accessed 6/10).

The National Pharmaceutical Association (NPA), which represents community pharmacies, supports the principles behind the proposals and is confident that patient safety will not be an issue (download here; accessed 6/10). It points out that members of these professions already have experience of supplying medicines to patients. The NPA believes that all supplementary prescribers should be able to prescribe unlicensed medicines where appropriate, pointing out that the requirements of the clinical management plan agreed with the independent prescriber will ensure patient safety and that there is therefore no need to restrict the range of medicines.

Eyecare UK, which represents the professional optometry bodies and industry, also welcomed the proposal (see here; accessed 6/10). It believes that optometrists’ skills are under-used at present, but comments that the length of training may present an obstacle and that funding will be required. It argues that optometrists should be included in NHSNet so that the requirement for access to shared patient records can be met.

The Chartered Society for Physiotherapists has been pressing for the changes for some time, although it believes that independent prescribing by physiotherapists would offer particular benefits for some patients (see here; accessed 6/10). The Society believes that giving physiotherapists a greater role in prescribing has the potential to reduce waiting lists.

The Royal College of Ophthalmologists supports the concept of optometrists sharing care but comments that questions about safety, cost-effectiveness and workload need answers (download here). Commenting on the proposals to extend supplementary prescribing to optometrists, and to amend the range of medicines used by optometrists (see news story here), as well as the possibility of independent prescribing, the College says that there must be safeguards to protect patients and also to prevent primary care in the community from diverting resources to the commercial sector. Changes of attitudes by ophthalmologists, optometrists and the public would be needed.

The Royal College of General Practitioners (RCGP) supports the proposals in principle but its support is dependent upon how the principles are put into practice (copy of response can be requested here; accessed 12/10). It comments that careful evaluation and monitoring is crucial because lapses in safety are likely to be only occasional and hard to detect; nonetheless, the consequences could be serious for the individuals concerned. The College believes the prescribing skills cannot be acquired on a brief course and presumes that supplementary prescribers will need continuing updates and examinations. It is concerned about the prescribing of unlicensed medicines and about responsibility for drug interactions and any mishaps. The need for access to the same common patient record raises practical concerns, but there are also issues about patient confidentiality and the doctor-patient relationship.
 

DH clarifies supplementary prescribing arrangements
The Department of Health (DH) has provided further clarification about the operation of supplementary prescribing (see updated FAQs here; accessed 12/10).

BNF 48 published (01/10/04)

The latest edition of the BNF (BNF 48), has been published and details can be found here http://www.bnf.org/bnf/; accessed 28/9).

A new digital version of the BNF is also about to be launched. It will be free to NHS staff (accessed through NHSnet or an Athens account) and should provide a more robust service (see here for further details; accessed 28/9).
 

Outline curriculum for AHP supplementary prescribing training (01/10/04)

An outline curriculum for programmes for allied health professionals (AHPs) training as supplementary prescribers has been published as a preview edition by the National Prescribing Centre and the Department of Health (download document here; accessed 28/9).

This follows the consultation published in May about extending supplementary prescribing to chiropodists/ podiatrists, physiotherapists and radiographers (and also optometrists; see news item).

The Medicines and Healthcare products Regulatory Agency (MHRA) is considering the responses to the consultation and they will be put before the Committee on Safety of Medicines this autumn. Legislative and regulatory changes are not expected till early next year.
 

Atopic eczema guidance from NICE (14/09/04)

The National Institute for Clinical Excellence (NICE) has issued two new sets of guidance about the treatment of atopic eczema (access here: frequency of application of topical corticosteroids; and pimecrolimus and tacrolimus; accessed 2/9).

Tacrolimus and pimecrolimus are not recommended in the guidance as treatments for mild atopic eczema or as first-line treatments for any atopic eczema. They are recommended in certain (different) patients and circumstances, where topical corticosteroids have not been successful.

Topical corticosteroids should only be prescribed for application once or twice a day in atopic eczema and where more than one is clinically appropriate, cost should be considered, according to the guidance. This guidance does not relate to topical agents that combine corticosteroids with other active agents. Given the large number of patients with atopic eczema, this guidance may have the potential for significant cost savings.
 

Hypertension guideline from NICE (14/09/04)

The National Institute for Clinical Excellence (NICE) has issued a guideline on the management of hypertension in adults in primary care (see here; accessed 2/9). It covers the measurement of blood pressure (including asking patients to return for at least two subsequent clinics), lifestyle interventions, assessment of cardiovascular risk, pharmacological interventions (what and when), and continuing care.
 

Prescribing should be part of advanced practitioner role says consultation (14/09/04)

Prescribing competencies associated with the most advanced forms of prescribing (currently extended nurse and supplementary prescribing) should be part of the normal expectations for advanced practitioners, according to one of the many recommendations of a consultation issued by the Nursing Task Group chaired by the Chief Nursing Officer.

The consultation says that the NMC should consider this recommendation as part of its plans for a post-registration framework.

The report is about post-registration development and can be viewed here (accessed 8/9). Responses to the consultation should be received by 15 November. One issue is whether all advanced practitioners will have the opportunity to prescribe.
 

NatPaCT publishes supplementary prescribing toolkit (14/09/04)

The National Primary and Care Trust Development Programme (NatPaCT) has published a toolkit for pharmacist-led supplementary prescribing, including a competency framework (view here; accessed 2/9).
 

Conference announcement – November: The New Era of PGDs and Nurse Prescribing (14/09/04)

This meeting will be held on 2 November in London and will include topics such as legal issues and accountability, supplementary prescribing training issues, developing clinical management plans, and the latest developments in nurse prescribing and patient group directions (PGDs). Further information can be found here  (accessed 8/9).
 

Unlicensed drugs legislation for SP in 2005? (14/09/04)

Legislative changes that will allow supplementary prescribers to prescribe, order or administer unlicensed medicines (provided that such prescribing forms part of the formal Clinical Management Plan) will be introduced in early 2005, according to the Medicines and Healthcare products Regulatory Agency (MHRA) website (accessed 2/9). This is a new section of the MHRA website devoted to supplementary prescribing.
 

NICE guidance on Type 1 diabetes

The need for both patient-centred care and access to information are highlighted in new NICE guidance on the diagnosis and management of Type 1 diabetes in children, young people and adults (download here; accessed 13/8).
 

Medicines for children

Companies will be encouraged to develop more medicines designed specifically for children and a separate BNF for children will be published for the first time, under plans announced by the Department of Health (DH).

The paediatric medicines initiative, announced by Health Minister Lord Warner on 17 August, includes: strong encouragement for pharmaceutical companies to provide better paediatric clinical trial data, both for new and for existing medicines; better information on the use of medicines in children in patient information leaflets; the publication of a separate BNF for children (BNF-C), with the first edition planned for the middle of next year; and additional investment to promote research into paediatric medicines.

The aim is to achieve: better information about the use of medicines in children for patients/carers and prescribers; a measurable increase in the number of products that are labelled and formulated in a way that is appropriate for paediatric use; a change in the attitude of the industry; and the creation of positive conditions for conducting paediatric clinical trials in the UK. 

The Medicines and Healthcare products Regulatory Agency (MHRA) and the DH have developed the paediatric medicines strategy and Q and A (both accessed 18/8). Most medicines have only been tested for safety and efficacy in adults, and therefore few are specifically licensed for use in children. This forces prescribers to prescribe unlicensed or off-license medications for children, often in formulations that are unsuitable. According to the strategy, this may result in medication errors, inappropriate dosing, inadequate efficacy, unforeseen adverse events and reluctance to use new drugs.

Ethical, commercial and practical factors have all contributed to the reluctance to conduct trials in children, but there has been a recent shift in opinion, with an increasing number of US trials being carried out and US legislation providing an obligation to do so  where there is a therapeutic need. A European Regulation is being developed, drawing on this experience, which will aim to satisfy the need for appropriate formulations and labelling of paediatric medicines. It will also improve the provision of information, including that from clinical trials in children. However, it is unlikely to be adopted before 2006 and so the UK initiative is aimed at producing real improvements in the short to medium term and also to raise industry awareness of the need to label and formulate medicines for paediatric use appropriately.
 

Controversy over nurse prescribing progress

Following the recent call from three nursing organizations for the government to implement their recommendations so that nurse prescribing can make faster progress (see news story here), the Department of Health (DH) has responded by saying that the figure of 10,000 extended nurse prescribers by the end of 2005 was an aspiration not a target (Nursing Standard, 28 July p4; and editorial p3). Mark Jones, director of the Community Practitioners’ and Health Visitors’ Association (CPHVA), is quoted as saying that the figure had been used by many ministers on many platforms many times, and that the government was not doing enough to extend nurse prescribing, something to which it was committed. The DH also said that the report it commissioned into independent nurse prescribing was due to report by the end of the year.
 

Conference announcement - November 2004: A practical guide to nurse prescribing

A one-day conference looking at the role of nurse prescribing in improving the quality of care will be held on 18 November in Manchester. It covers independent and supplementary prescribing, patient group directions, legal issues, competency issues, and training. Further information can be found here (accessed 17 August 2004).
 

Independent nurse prescribing in drug dependency to be reviewed

The NHS National Treatment Agency for Substance Misuse has asked a nurse prescriber to lead a review into the risks and benefits of nurse and pharmacist prescribing in drug dependency (Nursing Standard, July 21, p6).

The review will include the following areas: the legislative framework, current position and practice on prescription signing; new legislation and its possible implications, benefits and disadvantages; clinical liability and responsibility; how national policy could be developed; other methods of prescribing such as patient group directions; and training needs of new prescribers. Alan Long, who is conducting the review, would like to hear from interested nurses with views on this subject.
 

More nurses need to prescribe in sexual health?

More nurses should be trained to prescribe antibiotics for chlamydia, according to the Family Planning Association (FPA; ‘Nursing Standard’, 4 August, p6), given the rapidly rising infection rates.

The article says that some nurses prescribe under patient groups directions but that many are not given the opportunity and the FPA is calling for nurses to be prescribing independently in nurse-led centres. The Department of Health pointed out that extended formulary nurse prescribers can prescribe antibiotics for uncomplicated laboratory-confirmed chlamydia.
 

MHRA consults on electronic signatures for prescriptions

The Medicines and Healthcare products Regulatory Agency (MHRA) has started consultation on the use of advanced electronic signatures on prescriptions that will be transmitted electronically (consultation document can be downloaded here; accessed 13/8). The consultation closes on 29 October 2004.

At present, prescriptions must be signed in ink, which prevents electronic transmission. Three pilot projects, for which specific legislation had been passed, were completed last year; the proposals in the consultation aim to allow electronic prescriptions across the UK. The benefits include greater convenience for patients, safety benefits from fewer illegible or incomplete prescriptions and also from the possible integration of prescription with other records, and efficiency gains.

An advanced electronic signature is more secure than an electronic signature: it is uniquely linked to the signatory, can identify the signatory, is created using a mechanism that the signatory can maintain under sole control, and is linked to related data in such a way that subsequent data changes are detectable.

These proposals put forward changes to the POM Order which would apply throughout the UK but legislative changes would also be needed in each UK country before NHS prescriptions could be transmitted electronically. They do not apply to prescriptions for Schedule 1,2 or 3 controlled drugs; separate Home Office legislation allowing computer-generated prescriptions – but not signatures – for Schedule 2 and 3 drugs is expected.
 

MeReC bulletin on constipation management

The MeReC has published a bulletin on the management of constipation, including advice on the use of laxatives. It stresses that after confirmation of constipation and reasonable exclusion of underlying conditions, the first step should be dietary and lifestyle changes and discusses the circumstances under which laxatives should be used. As comparative effectiveness and tolerability evidence is lacking, laxative choice should be based on patient preferences, symptoms, side effects and costs. The bulletin can be downloaded here (MeReC Bulletin 2004; 14(6); accessed 13/8).

Nursing bodies say end ‘stop-start’ approach

The Royal College of Nursing (RCN), the Association for Nurse Prescribing (ANP) and the Community Practitioners’ and Health Visitors Association (CPHVA) have called on the government to end the ‘stop-start’ approach to the extension of nurse prescribing.

The three organizations, representing 400,000 nurses, welcome the proposals to add more prescription-only medicines to the Nurse Prescribers’ Extended Formulary (see news item), but say that the consultation is an example of the ‘stop-start’ approach the government has adopted. They point out that the Department of Health set a target of 10,000 extended nurse prescribers in post by the end of 2005, but that only 20-30% of this will have been achieved by the end of this year.

To get things going, they have come up with an action plan:

• remove the link between condition and prescribable product;
• give nurse prescribers the freedom to use any medicine in the NPEF for any condition which they have the competence to treat;
• end the system in which the formulary expands as a result of policy initiatives rather than the expressed needs of nurse prescribers and their patients;
• and identify products that are used regularly as part of supplementary prescribing arrangements and develop a way for making them available for independent prescribers.

They said that the expansion of the formulary which they hope will follow the consultation provides an opportunity for the Department of Health and Medicines and Healthcare products Regulatory Agency to “take a radical new look at how nurse prescribing could be truly liberated”.
 

Shipman inquiry supports nurse prescribing

The Shipman murders should not deter the government from extending nurse prescribing to include controlled drugs, states one of the conclusions of the latest inquiry report by Dame Janet Baker, according to a report in ‘Nursing Standard’ (21 July, p4). The report recognizes that government policy is directed at extending the categories of health professionals who are allowed to prescribe and administer controlled drugs and says that its recommendations are not inconsistent with these plans. Only properly qualified nurse prescribers, “acting in the course of their duties in a specified post”, should be allowed to prescribe controlled drugs.

A decision on adding 13 more controlled drugs to the Nurse Prescribers’ Extended Formulary for pain relief in palliative care and diamorphine for pain relief in coronary care, following the consultation last year, is expected soon.
 

RCN wants post-operative pain relief added to formulary

Post-operative pain relief should be included in the list of conditions that extended formulary nurse prescribers (EFNPs) can prescribe for, according to the views of RCN members. The RCN has responded to consultation MLX 303 on expanding the list of prescription-only medicines that EFNPs can prescribe (see news item), following a consultation with its members.
 
The RCN points out that although the consultation proposes adding acute severe pain after trauma to the list of conditions (with morphine available to EFNPs for this condition), it says that post-operative pain relief is the responsibility of the anaesthetist. Under the proposals, EFNPs will be able to prescribe medicines for post-operative nausea and vomiting (although cyclizine is omitted), but not for pain. The College argues that excluding post-operative pain relief means that nurses in this area will not be able to make full use of their qualification and skills, nor will they be able to work within the recommendations of the NHS Plan, resulting in reduced access to treatment for patients.

The RCN response welcomes many of the proposed additions, such as the inclusion of nausea and vomiting outside palliative care, but reiterates its position that EFNPs should be able to prescribe from the whole British National Formulary, limited only by the NMC’s Code of Professional Conduct.

As well as post-operative pain relief, it also suggests the following should be included: off-label indications such as the oral contraceptive pill for menorrhagia and dysmenorrhoea and double-dosing of the ‘mini-pill’ to prevent breakthrough bleeding; cefalexin for lower female urinary tract infections (it is the first-line choice in some areas); antibiotics for tonsillitis (penicillin), otitis media and sinusitis; inhaled steroids such as beclometasone for asthma management, on the basis that the division of acute and chronic asthma is unworkable in practice; other drugs such as cyclizine and metoclopramide for the post-operative setting; and naloxone, given the proposed addition of parenteral morphine.
 

Seminar announcement: Developing Treatment Options

The RCN Scotland is organizing a nurse prescribing seminar called, ‘Developing Treatment Options’. It will be held on September 14 in Edinburgh and the speakers include RCN prescribing advisors and a consultant paediatrician.

Contact naddow@hillandknowlton.com for further information.
 

Nurse prescribing in community increases

There was an overall increase in prescribing by nurses in the community of 12.4% in the year to March 2004 in England compared with the previous year, according to the latest prescription and volume cost report from the Prescription Pricing Authority (PPA; download report; accessed on 14 July 2004). The volume of items prescribed by extended formulary nurse prescribers or supplementary nurse prescribers is still a small proportion of the overall volume but it is increasing. In March 2004, over 45,000 items were prescribed by these nurses and more than 300,000 overall.
 

Hospital electronic prescribing by 2006 (05/07/04)

The government has brought forward the introduction of hospital electronic prescribing to 2006 from 2008-10 as part of a package of measures to ensure fairer access to drugs approved by the National Institute for Clinical Excellence (NICE).

Mike Richards, the National Cancer Director, has published a report showing that there are unacceptably high variations across the country in the uptake of the cancer drugs that NICE recommends. Health Minister Lord Warner has set out plans to improve the way in which NICE guidance is implemented in the NHS, including the intention to bring forward electronic prescribing in hospitals. See here for the report and Lord Warner’s letter.


Nurse prescribers can write private prescriptions (05/07/04)

The Department of Health (DH) has confirmed that extended formulary nurse prescribers and supplementary prescribers can write private prescriptions for medicines on the formulary or in the Clinical Management Plan (see here). As with nurses prescribing within the NHS, they should ensure they have appropriate professional indemnity cover.


Paediatric nurses ask for specialist courses (05/07/04)

Some paediatric nurses feel that the nurse prescribing course is not relevant to them, according to an article in Nursing Standard (June 16, p9). At a prescribing forum organized by the RCN and Crooks Healthcare, the nurses pointed out that exam questions required specific knowledge of adult diseases and that the course did not equip them to prescribe for children. RCN prescribing advisors Molly Courtenay and Matt Griffiths said that specialist courses were not necessary and were impractical, and that the specialist knowledge nurses required should be obtained through continuing professional development; the prescribing course is intended to teach the principles of prescribing.


More AHPs can use PGDs (05/07/04)

The Department of Health (DH) has added dieticians, occupational therapists, prosthetists and orthotists, and speech and language therapists to the list of professionals that can supply or administer medicines using patient group directions (see here). This follows consultation MLX 294 last year and the necessary legislative changes came into effect on 18 May (see MLX294 outcome).


CBE for Barbara Stuttle (05/07/04)
Barbara Stuttle, the Chair of the Association for Nurse Prescribing and Editorial Board member of Nurse Prescriber received a CBE in the recent Queen’s Birthday Honours for services to the NHS.


Researchers seek respondents for nurse prescribing studies (05/07/04)

Two researchers are looking for people to contribute to their studies.

Nurses, doctors or pharmacists working in secondary care are sought for interviews about their experiences and views by one project, looking at the barriers to nurse prescribing in this sector. See here for further details.

The other project, which is examining the impact nurse prescribing has had on District Nurse (DN) working relationships and practices would like to hear from any DN prescribers with anecdotal evidence. See here for further details.


Open learning programme will start in September (17/06/04)

The first students to enter an e-learning nurse prescribing programme, using materials developed by Emap Healthcare Open Learning in collaboration with the University of Stirling, will commence their studies in September. Although the amount of study required is the same as for the taught course, direct contact days are reduced to approximately six.

The first intakes are expected at the University of Stirling in September and University College Winchester in October. A number of other universities are actively pursuing validation and approval and will announce their plans in due course.

Further information can be obtained from open.learning@emap.com or tel: 020 7874 0600 (please quote reference NPCO).


Proposed changes to medicines that optometrists can supply (17/06/04)

A consultation proposing amendments to the range of medicines that optometrists can sell, supply or administer has been published by the Department of Health (DH) and the Medicines and Healthcare products Regulatory Agency (MHRA; download consultation here).

Exemptions set out in medicines legislation allow optometrists to sell or supply all GSL and P medicines and a range of prescription-only medicines (POMs), in the course of their professional practice and in an emergency. The specified POMs can also be sold or supplied by a retail pharmacy on presentation of an order signed by a registered ophthalmic optician.

These new proposals are not about prescribing per se, but should be read in conjunction with the consultation on supplementary prescribing (see news item here).

This consultation proposes:

• Updating the list of POMs that optometrists may sell, supply or write orders for (sale or supply being subject to the requirements that it is in the course of professional practice and in an emergency). Several deletions of substances that are no longer commercially available are proposed, along with the addition of fusidic acid.
• Allowing optometrists who have undertaken extended training and are accredited by the General Optical Council (GOC) to sell or supply additional POMs in the course of their professional practice and in an emergency, or to write orders for these POMs. The additional POMs include antibiotics and would allow optometrists to manage conditions including infective conjunctivitis, allergic conjunctivitis, blepharitis, dry eye and superficial injury.
• Removing the “emergency” requirement for the sale and supply of P and GSL medicines so that they could be sold or supplied direct to patients by an optometrist for non-emergency conditions.

The consultation period closes on 27 August.


NPC publishes competency framework for prescribing optometrists (17/06/04)

The National Prescribing Centre (NPC) has published an outline competency framework for prescribing pharmacists that can be adapted according to local needs (see here). It contains three competency areas:

• The Consultation - clinical and pharmaceutical knowledge; establishing options; communicating with patients
• Prescribing Effectively - prescribing safely; prescribing professionally; improving prescribing practice; information in context)
• Prescribing in Context - the NHS in context; the team and individual context.

It also contains modifications to the statements for optometrist supplementary prescribers.


Nearly 2400 EFNPs now registered (17/06/04)

Nearly 2400 nurses are now registered with the NMC as Extended Formulary Nurse Prescribers (EFNPs), with more than 1700 of these also qualified as supplementary prescribers, according to the Department of Health’s updated figures, published on 4 June (see here). Another 1000 or so more nurses are undertaking the training at present. About 100 pharmacists have qualified as supplementary prescribers, according to the document, which also says that the planned changes to allow the inclusion of controlled drugs in Clinical Management Plans are now expected later this year.


DH publishes updated standards and contacts for nurse prescribing (17/06/04)

The NMC has updated its standards for nurse independent and supplementary prescribing (see here). The document gives advice on deciding which nurses should be nominated for training as prescribers.

An updated list of Workforce Development Confederation contacts on nurse prescribing and an updated list of medicines prescribable through the Nurse Prescribers’ Extended Formulary are also now available on the Department of Health site.
 

Drug Tariff now online (01/06/04)

An electronic version of the Drug Tariff is now available online (between 08:30 and 16:30 Monday - Friday excluding Bank Holidays) on the Prescription Pricing Authority’s website (see here). It is searchable and has an index.
 

Conference announcement: 5th National Conference for Primary Care Prescribing Advisors (01/06/04)

This event, to be held in Nottingham on 17 and 18 June, includes a session on non-medical prescribing (http://www.npc.co.uk).
 

Independent prescribing for pharmacists to start next year (01/06/04)

The Department of Health (DH) has confirmed that independent prescribing for pharmacists will begin in 2005, according to a report in ‘The Pharmaceutical Journal’ (10 April, p435). Paul Robinson from the DH was speaking at a prescribing conference in Cambridge in April and said that a consultation would take place later this year.
 

CMPs do not need physical signatures (01/06/04)

Clinical Management Plans (CMPs) do not have to be physically signed by the supplementary or independent prescribers or the patient, the Department of Health policy lead for extending prescribing responsibilities told a prescribing conference in Cambridge in April (The Pharmaceutical Journal 10 April, p435). Paul Robinson said that the plan must include an indication that all parties have agreed to it and that the requirements for CMPs give “incredible flexibility”, with the doctor being able to delegate a little or a lot of responsibility. Trudy Granby of the National Prescribing Centre added that CMPs do not have to exist in paper format; electronic versions will be sufficient.
 

Mental health nurse prescribing needs more research (01/06/04)

More research is needed into mental health nurse prescribing, with the benefits for patients as yet unproven, according to a speaker at the Mental Health Nurses Association’s annual conference. Richard Gray, co-chair of the National Institute for Mental Health’s mental health nurses prescribing group, said that there is some US evidence that nurses prescribing in this field can perform as well as doctors but that it is not conclusive, said the report in ‘Nursing Standard’ (May 12, p6).
 

Concerns about simvastatin going OTC (01/06/04)

Both the ‘British Medical Journal’ and ‘The Lancet’ have published concerns about the decision to reclassify simvastatin 10 mg from a prescription-only to an over-the-counter (OTC) preparation (BMJ article: The Lancet article). It will be sold in pharmacies to people at moderate risk of coronary heart disease.

The concerns expressed include the lack of trials of OTC statins in the primary prevention of heart disease, whether the dose is too low, whether the pharmacist will be able to do a proper risk assessment, and a possible increase in inequality.
 

Children’s nurses frustrated at pace of prescribing change (01/06/04)

Legislation setting out what nurses can prescribe for children has failed to keep pace with clinical practice, according to delegates at a nurse prescribing workshop held during a British National Formulary conference ‘Good Medicine for Children’, held in London in May (‘Nursing Times, 25 May, p5).

The issue of ‘off-license’ prescribing was particularly frustrating, as nurses often give prescribing advice to doctors but are not able to prescribe themselves even when they have the relevant qualifications. Maureen Morgan, lead nurse in paediatrics for the Department of Health, confirmed that the Committee on Safety of Medicines was reviewing the prescribing of drugs off-license. She was also reported as saying, “Legislation has not kept pace with practice. But we’ve got to get it right so that means things move slowly”.
 

Prescribing nurses could replace SHOs in critical care units (01/06/04)

Nurses with extending prescribing responsibilities may be able to replace Senior House Officers (SHOs) in critical care units, according to the results of a pilot project to reduce junior doctors’ hours in line with the European Working Time Directive (EWTD) reported in ‘Nursing Standard’ (May 26, p7).

The three cardiac intensive care practitioners provide “first-line medical care” overnight, when the SHO has been withdrawn. They prescribe medicines, and have learned anaesthetic and intubation skills, according to one of the nurses, Lara Manuel, speaking at an NHS Modernisation Agency conference on the EWTD held in London in May.
 

Conference announcement: A Practical Guide to Nurse Led Care and Clinics in Cardiology (01/06/04)

A one-day conference entitled ‘A Practical Guide to Nurse Led Care and Clinics in Cardiology’ will be held on 12 July at the Royal College of Nursing and includes sessions on nurse prescribing in cardiology and case studies of nurse led care and clinics (see here for further details).
 

e-learning programme for pharmacist supplementary prescribers (01/06/04)

The Centre for Pharmacy Postgraduate Education (CPPE) at the University of Manchester has developed an e-learning supplementary prescribing programme for pharmacists (see here for further information). Accredited higher education institutions can arrange licensed access to the programme.
 

Safety deficiencies in GP computer prescribing systems (01/06/04)

The computer prescribing systems used in GPs surgeries have serious failings in their safety features, according to recent research (see BMJ article).

The researchers tested four of the commonly used systems against 18 prescribing scenarios to see what alerts they produced. The scenarios included aspirin being prescribed for a child aged 8 and methotrexate being prescribed in pregnancy. None of the systems produced alerts for all scenarios, and none produced warnings for all 10 of the cases where drug pairs with similar names were considered.

An accompanying commentary points out that all these systems could be improved but that listing every contraindication for a drug, for example, might overwhelm the user with alerts which are then ignored. Timely and relevant warnings are the key.

See here and here for news items about computer-generated scripts for nurses.
 

More computer systems seek accreditation (17/05/04)

Three more computer suppliers - EMIS, Seetec and Microtest - are apparently in a position to seek accreditation for their systems so that nurse prescribers using them can begin generating computer prescriptions (see here).

This follows the recent announcement that The Phoenix Partnership has received accreditation for its system (see here for news item).

This means that nurses will be able to use FP10SS prescription forms rather than FP10P handwritten forms, saving time and allowing patient records to be updated at the same time as prescribing.
 

Supplementary prescribing for other professionals? (17/05/04)

The promised consultation on extending supplementary prescribing to physiotherapists, chiropodists, radiographers and optometrists was launched by the Secretary for State for Health, John Reid, on 10 May (download consultation here). The Department of Health (DH) says that this would allow conditions such as glaucoma, chronic back pain, pain after radiography and multiple sclerosis to be managed more effectively.

The consultation points out that members of these four professions are experienced in the supply and administration of medicines and therefore well placed to extend their responsibilities into supplementary prescribing. They would need to complete and approved training course and have an annotation next to their name on the relevant professional register.

The consultation proposes amending UK medicines legislation to allow members of these four professions to become supplementary prescribers, with changes also being needed to NHS Regulations and guidance in the four countries.

The results of the consultation on allowing unlicensed medicines to be included in Clinical Management Plans is not yet known (see here for news item) but the consultation seeks views on allowing chiropodists, physiotherapists, radiographers and optometrists to prescribe unlicensed medicines as part of the supplementary prescribing arrangements.

The consultation was produced jointly by the DH and the Medicines and Healthcare products Regulatory Agency (MHRA) and responses are required by 9 August.

Let us know what you think of these proposals by contributing to the forum.
 

Update to asthma guideline published (17/05/04)

An update to the British Thoracic Society (BTS) / Scottish Intercollegiate Guidelines Network (SIGN) guidelines on asthma has been published (see here).

The key changes are:

• Inhaled steroids should be introduced in milder cases than previously recommended and detailed guidance on this is included.
• People with asthma should be offered individual education as well as written action plans. Those being discharged from hospital should receive an individualized action plan prepared by clinicians with expertise in the management of asthma. The importance of regular review is highlighted. There is now plenty of evidence that training patients to manage their own treatment improves outcomes.
• Primary care services delivered by clinicians trained in asthma management improves the quality of care.
• People with asthma admitted to hospital should be treated in specialist units wherever possible. Those attending hospital with acute exacerbations should be reviewed by clinicians with particular expertise in asthma management.
   

NICE recommends newer drugs for epilepsy in children (17/05/04)

The National Institute for Clinical Excellence (NICE) has recommended the use of the newer epilepsy drugs – gabapentin, lamotrigine, oxcarbazepine, tiagabine, topiramate and vigabatrin (as adjunctive therapy for partial seizures) – for the management of epilepsy in children who have not benefited from treatment with the older drugs, or for whom these drugs are unsuitable (see here for the guidance).
 

Patient reporting of adverse drug reactions (17/05/04)

Patients will be able to report adverse drug reactions directly to the Medicines and Healthcare products Regulatory Agency (MHRA) / Committee on Safety of Medicines (CSM), the government announced on 4 May. The MHRA says that it is considering the best way of implementing direct patient reporting and will pilot different methods to ensure its success. The scheme will be introduced as soon as possible.

Direct patient reporting was one of several recommendations made in a review of the Yellow Card Scheme and a consultation has been launched on the other proposals (see here for further information).
 

Warning to health professionals about medicinal names (17/05/04)

The Medicines and Healthcare products Regulatory Agency (MHRA) has issued a warning (News, 30 April) to health professionals about the recent changes in medicinal names (see news item). As a result of the changes, alphabetical lists of medicines may have changed, and the MHRA has received reports of three serious errors involving confusion between two drugs.

The MHRA will soon publish guidance with examples of situations where errors could occur and professionals can also refer to a leaflet by the National Patient Safety Agency (see here).
 

MeReC briefing on supplementary prescribing and PGDs (17/05/04)

The MeReC has produced a briefing on supplementary prescribing and patient group directions (PGDs), which can be downloaded here.
 

Anxiety hampers nurse prescribing growth (17/05/04)

The roll-out of nurse prescribing continues to be restricted by reluctance to take on responsibilities and a lack of support, according to preliminary research presented at the RCN international nursing research conference (‘Nursing Standard’, March 31, p8). Although nurses are enthusiastic about nurse prescribing, these responsibilities are associated with ‘high levels of anxiety’. The results emerged from interviews with 27 healthcare workers attending focus groups, of whom 20 were nurses.
 

Conference announcement: Governance and the policy agenda for practice nurses

These three one-day workshops, organized in association with ‘Practice Nurse’, will be held on 13 May, 9 July and 14 October in central London. They cover the changing role of the practice nurse and include sessions on non-doctor prescribing and clinical and research governance (see here for further details).
 

Conference announcement: A practical guide to nurse prescribing

This one-day conference will be held at the Royal College of Nursing on 8 July and includes sessions on prescribing in practice, legal issues and patient group directions (see here for further details).
 

Latest figures on numbers of nurse prescribers

More than 25,500 District Nurses and Health Visitors (DNs and HVs) are trained to prescribe from the DN/HV formulary; more than 2000 nurses are now qualified to prescribe from the Nurse Prescribers Extended Formulary; and more than 1400 of these nurses and nearly 100 pharmacists are trained as supplementary prescribers.
These figures are contained in a government progress report on primary care (‘A responsive and high-quality local NHS’). It looks at how primary care has developed over the last four years and what will happen in future years.
 

New prescribing publications from the NPC

The National Prescribing Centre (NPC) has published a glossary of prescribing terms (download here) and a practical guide and competencies framework for patient group directions (download here).
 

MeReC publishes hay fever bulletin

Hay fever is the subject of the March bulletin from the MeReC (download bulletin here). It describes the classification of hay fever symptoms and how to manage them, management in pregnant women, choice of antihistamines and corticosteroids, evidence for alternative therapies, and the role of immunotherapy. At present, there is not enough evidence to favour the use of third-generation over second-generation anti-histamines and their use should be reserved for patients that do not respond to other therapies or are intolerant of them.
 

Emergency medicines to be included in NPEF?

Plans to add emergency and ‘first contact’ medicines to the Nurse Prescribers’ Extended Formulary (NPEF) have been announced by Health Minister John Hutton. The government says that these proposals will help improve emergency care for patients and help relieve the burden on staff working in Accident and Emergency departments.

The consultation proposes adding more than 60 medicines to treat 30 new conditions and has been launched by the Department of Health (DH) and the Medicines and Healthcare products Regulatory Agency (MHRA; download consultation here). It is being circulated throughout the UK and consequent changes to the POM Order would apply in England, Scotland, Wales and Northern Ireland. The consultation period closes on 13 July.

Proposed additions to the list of conditions:

The consultation proposes that the following conditions be added to the list of treatable conditions:

Central nervous system:

• acute dystonias
• acute severe pain after trauma
• changing painful dressings
• emergency treatment of meningitis
• nausea and vomiting (outside palliative care)
• prophylaxis and treatment of nausea and vomiting in the postoperative period
• generalised tonic-clonic seizures

Circulatory:

• acute pulmonary oedema associated with cardiac failure
• angina pectoris
• fluid replacement and potassium replacement (hypovolaemia and dehydration)
• plasma substitutes for patients with a low blood volume
• “Thromboprophylaxis” (defined as deep vein thrombosis; acute coronary syndrome; congestive heart failure in bed-bound patients and perioperatively)
• ventricular fibrillation or pulseless ventricular tachycardia

Eye:

• Ophthalmic conditions (diagnostic use in ophthalmology, tear deficiency, inflammation following ophthalmic surgery, and corneal trauma)

Gastrointestinal conditions:

• prophylaxis of acid aspiration during surgery

Infections:

• cellulitis (defined as treatment for ascending cellulitis of the leg, to be distinguished from inflammation associated with varicose ulcers).
• tetanus treatment

Musculoskeletal:

• pain and inflammation/soft tissue injury

Oral conditions:

• dental infections

Poisoning:

• poisoning

Respiratory:

• acute exacerbation of chronic bronchitis
• acute reversible airways obstruction (acute severe asthma or acute exacerbation of chronic obstructive pulmonary disease)
• anaphylaxis
• conditions requiring oxygen supplementation (e.g. hypoxaemia)
• croup

Skin:

• psoriasis
• molluscum contagiosum

Substance dependence:

• acute alcohol withdrawal

Proposed changes to the POM Order:

The consultation sets out the list of additional medicines, and the thinking behind their inclusion, together with their linked conditions. As at present, the conditions will be the subject of guidance, whereas the substances will form part of the POM Order.

Some controlled drugs are included, such as morphine for acute severe pain after trauma and diazepam, lorazepam and midazolam for generalised tonic-clonic seizures. Their addition to the NPEF would require a change in Home Office regulations.

The list also includes some substances such as oxytetracycline dihydrate which are already in the NPEF but which are proposed for a new condition (acute exacerbation of chronic bronchitis in this case).

Some of the proposals involve a further extension of ‘off-label’ prescribing. The paediatric working group involved in drawing up the proposals supported the need for adequate pain relief for children, even though it could involve ‘off-label’ prescribing. Apart from major trauma, however, it considered that the NPEF should not cover the prescribing of intravenous opiates to a neonate or young child without a definitive diagnosis.

The consultation also proposes some additions to the list of antimicrobials, on the basis of the assumption that extended formulary nurse prescribing will not lead to an overall increase in antimicrobial prescribing. These include: parenteral benzylpenicillin sodium for cellulitis and the emergency treatment of meningitis; erythromycin, erythromycin stearate and erythromycin ethyl succinate for the treatment of dental infections, acute exacerbation of chronic bronchitis, and cellulitis; oral and parenteral flucloxacillin for cellulitis; and amoxicillin trihydrate for dental infections and acute exacerbation of chronic bronchitis.

Substances which were considered for inclusion but rejected, often on the grounds that they were inappropriate for first contact or emergency care, are also listed.

Reactions to the consultation:

The proposals seem to have been largely welcomed by professionals, although both the RCN and the NMC favour opening up the entire British National Formulary to nurses. Stuart Skyte of the NMC is reported to have told the website ePolitix.com that, “This is a good step in the development of nurse prescribing. It will bring benefits to patients and the health services”. Matt Griffiths, joint prescribing advisor to the RCN, told the BBC that, “We welcome the proposed additions, but we would like to see the entire BNF…opened up to nurses”, adding that the RCN would want to ensure that safety was paramount.

Let us know your views on the proposed extension to the formulary by visiting the forum.
 

ANP Conference highlights

Extended nurse prescribing is improving patient care, according to the first results from a Department of Health study described at the recent Association for Nurse Prescribing (ANP) annual conference (see here for the ANP newsletter containing conference highlights and news).

Of the 215 extended nurse prescribers in the study, 97% said prescribing was allowing them to improve patient care. The general picture was positive, with 66% saying they were confident in their prescribing practice, 88% saying they had the support of medical colleagues, and 87% saying they had received more than 12 days’ medical mentoring while training. The limitations of the formulary were seen as unhelpful by 92%, however, and some nurses had had problems obtaining prescription pads or access to drugs budgets. Respondents also wanted to be able to generate computer prescriptions (see here for news item).
 

Pharmacist supplementary prescribers qualify in England 02/04/04

The first batch of pharmacist supplementary prescribers in England has now qualified. Rosie Winterton, the health minister, said that she was “delighted” at this development. According to the DH, about 30 have now qualified, with around 100 more in training, and it expects this figure to increase substantially later in the year as the number of training courses increases. The Department of Health (DH) said that supplementary prescribing was the first step towards independent prescribing (see here).

Peter Wilson, consultant to the Royal Pharmaceutical Society and its lead on supplementary prescribing has commented that there is “still some way to go” if the government target of 1000 pharmacist supplementary prescribers by the end of the year is to be met (‘The Pharmaceutical Journal’, 20 March, p340). According to this article, there are now 18 postgraduate supplementary prescribing courses in England, Wales and Scotland, with more on the way.
 

Nurses can generate computer scripts 02/04/04

An authorized system for nurses to generate computer scripts has been released by The Phoenix Partnership (see here for details of the software). This means that nurse prescribers using the Phoenix system can generate their own computer scripts automatically by clicking on a special nurse prescribing icon next to a drug. Tests on other systems are due to follow.

Matt Griffiths, RCN Joint Prescribing Advisor, commented that, “this is a long awaited development. It will aid nurses in their safe prescribing practice, reduce the duplication that is required by handwriting scripts and will make supplementary nurse prescribing a viable service which benefits patients. It is fantastic for prescribers that this service has now become a reality.”
 

Letter about medicinal name changes issued 02/04/04

On 17 March, the Chief Medical Officer, Chief Nursing Officer and Chief Pharmaceutical Officer issued a joint letter providing further information about the 1 December switch from British Approved Names (BANs) to recommended International Non-Proprietary Names (rINNs; see here for news item). The letter lists the key actions needed to implement this change.

The exceptions to the switch are adrenaline and noradrenaline, where manufacturers will be encouraged to use both names on product packaging and literature.

The letter, together with a list of affected substances in common use, can be downloaded here.
 

Paramedics to be allowed to administer amiodarone? 02/04/04

The Medicines and Healthcare products Regulatory Agency (MHRA) has proposed adding amiodarone to the list of prescription-only medicines that paramedics can administer on their own initiative (see here for consultation letter ).
 

Prescribing for children conference 02/04/04

‘Good medicine for children: BNF prescribing excellence conference 2004’ will be held on 18 May in London. It will examine prescribing and practice issues in children, with the aim of promoting the provision of reliable information on the use of medicines. The conference is organized by the BMA and the Royal Pharmaceutical Society, in collaboration with the Royal College of Paediatrics and Child Health. Further information can be found here.
 

Conference announcement: Mental Health Nurse Prescribing Conference 22/03/04

The Doncaster & South Humber Healthcare NHS Trust have announced the programme for their forthcoming conference on Nurse Prescribing within a Mental Health context. The conference will take place in Doncaster on June 11th, 2004 and will include presentations and workshops on a variety of subjects. The conference will offer a vital chance to discuss Nurse Prescribing and the specific concerns of the Mental Health Nurse.

Download the programme by clicking on the file format required: or  
 

Growth in nurse prescribing in England

Over 30,000 items were prescribed by extended formulary and supplementary nurse prescribers in December 2003, compared with over 5000 in December 2002, according to the March report from the Prescription Pricing Authority on Prescription Volume and Growth. The growth reflects the increasing number of nurses who are qualified to prescribe. Practice nurses are prescribing more items from the extended formulary than Primary Care Trust nurses.

There has also been a growth in the volume of nurse prescribing overall, with prescribing from extended formulary/supplementary nurse prescribers representing a small proportion of the total. Prescribing by nurses increased by 12.8% in the year to December 2003 compared with the previous year.
 

Zinc paste bandages removed from DN/HV list
 
Some zinc paste bandages, for example Calaband, have been removed from the list of items prescribable by District Nurse/Health Visitor (DN/HV) prescribers (they are no longer in Part IXA of the Drug Tariff). As they are P or GSL medicines, they are, however, prescribable by extended formulary nurse prescribers or by supplementary prescribers.
 

Additions to formulary will benefit emergency care nurses

The next batch of additions to the Nurse Prescribers’ Extended Formulary will be of particular value to nurses who work in first contact and emergency community and acute care settings, according to the Department of Health (DH; see here for March ‘Emergency Care Bulletin’).

A three-month consultation will begin soon, and the DH suggests that advanced nurse practitioners and consultant nurses working in these areas explore the benefits that prescribing could bring to their practice once the formulary is extended.
 

Range of emergency POM exemptions may be extended

A consultation on proposals to add nerve agent antidotes to the list of prescription-only medicines that can be injected by anyone in any emergency has been issued by the Medicines and Healthcare products Regulatory Agency (MHRA) and the Department of Health (see here for consultation).
 
Article 7 of the POM Order allows the parenteral administration of certain medicines for the purpose of saving lives in an emergency. The proposal is to add pralidoxime chloride and obidoxime chloride to the list of medicines covered by the exemption. In combination with atropine sulphate, which is already listed, these are recognized antidotes to poisoning by organophosphate pesticides and nerve agents.

The legislation allows administration of the listed agents by anyone in an emergency, but in practice it would be by ambulance paramedics and other trained staff (not doctors).

There is also a proposal to allow the administration of smallpox vaccine in an emergency involving a confirmed or suspected case of smallpox under certain circumstances. Administration would, in practice, be restricted to healthcare professionals.

There is a shorter consultation period than normal, and it closes on 26 March, 2004.
 

List of reclassified medicines

The Medicines and Healthcare products Regulatory Agency (MHRA) has issued a list of those products that have been reclassified (POM to P or P to GSL) since April 2002 (and ones reclassified before then with product information requirements over and above the conditions for supply). The list can be found here and information about reclassification of medicines and lists of conditions for POM, P or GSL supply of medicines here.
 

Research into pharmacists as supplementary prescribers invited

Research proposals examining the role of pharmacists as supplementary prescribers are being invited by the Pharmacy Practice Research Trust, an independent research charity. The grant will cover a maximum budget of £50,000 including overheads and VAT, and is sponsored by Boots the Chemists.

See here for further information.
 

New PRODIGY guidance issued 10/03/04

PRODIGY has recently issued new full-text guidance on the following topics: balanitis; boils, carbuncles and paronychia; oral candida; insect bites and stings; nappy rash; and palliative care – cough, dysnopea and respiratory secretions. It has also updated topics on: emergency contraception; glue ear; headlice; heart failure; pubic lice; roundworm; scabies; threadworm; and transient ischaemic attack. Quick Reference Guides have been issued on: emergency contraception; headlice; headlice – treatment failure; molluscum; nappy rash; pubic lice; scabies; scabies – treatment failure; threadworm; and warts.
 

Welsh supplementary prescribing courses to start in April? 10/03/04

The first supplementary prescribing courses in Wales will start soon, probably in April, according to the Task & Finish Group on Supplementary Prescribing. Five higher education institutes are expected to run the courses, which require 15 days of face to face teaching, significant private study and 12 days ‘learning in practice’ with a designated supervising medical practitioner.
 

Outline curriculum underway for AHP supplementary prescribers 10/03/04

The professional bodies for physiotherapists, podiatrists and radiographers, together with higher education institutes and other stakeholders, including the National Prescribing Centre, have been working to develop an outline curriculum framework for supplementary prescribing for these groups, according to Kay East, Chief Health Professions Officer (see bulletin). Public consultation will follow in the Spring.
 

First pharmacist prescribers registered 10/03/04

Fourteen pharmacists were registered as supplementary prescribers by the Royal Pharmaceutical Society in February, according to an article in ‘The Pharmaceutical Journal’ (28 February, p235). All practise in Scotland. Another group are expected to register in England in April.
 

Conference announcement: Nursing in Practice 2004 02/03/04

The Nursing in Practice 2004 conference for primary care nurses will be held in Edinburgh on 1 April. Further information can be found here.
 

DH updates guide for extending independent nurse prescribing 02/03/04

The Department of Health has published the 2nd edition of ‘Extending independent nurse prescribing within the NHS in England – A guide for implementation’ (February 2004). It can be downloaded here.

The guide has been prepared to assist organizations to decide which nurses should undertake extended prescribing training. It includes information about training, good practice, funding, the formulary, liability, safety, dispensing, record keeping and NMC requirements.
 

Conference announcement: National Practice Nurse Conference 02/03/04

The 21st National Practice Nurse conference will take place on 30 June to 2 July in Winchester. See here for further details.
 

Distance learning course approved 02/03/04

An e-learning nurse prescribing course has received Department of Health approval and the first intake is expected in September, according to an article in ‘Nursing Times’ (3 February, p47). The course has been developed by Emap Healthcare Open Learning in conjunction with the University of Stirling.
 

BPC 2004 programme announced 02/03/04

Prescribing will be one of the many subjects discussed at the British Pharmaceutical Conference 2004, the annual conference of the Royal Pharmaceutical Society of Great Britain. It will be held in Manchester on 27-29 September. See here for further information.
 

Article 12 of POM Order extended 02/03/04

Article 12 of the Prescription Only Medicines Order has been amended to include written instructions by an appropriate practitioner and to specify that where conditions apply to prescriptions by an extended formulary nurse prescriber or a supplementary prescriber, those conditions also apply in relation to their written directions. There has been confusion about whether non-medical prescribers can prescribe using hospital drug charts. The Statutory Instrument containing these changes can be found here.

 

Conference announcement: Preparing for prescriptive practice - What do nurses need to know?

A conference titled 'Preparing for prescriptive practice - What do nurses need to know?' will be held at the University of Sheffield School of Nursing and Midwifery on Tuesday 27th April, 2004. Speakers will include Katherine Bailey, formerly of Yale University School of Nursing, and Steve Hemingway, of the University of Sheffield. Further details are available from Steve Hemingway or you can download the flyer here.
 

DH removes broad categories from NPEF (10/02/2004)

The Department of Health has published an updated version of the Nurse Prescribers’ Extended Formulary (NPEF) that includes the new medicines added after the consultation last year (see here for the updated list and allowed conditions and here for news item about the additions).

Until now, all the conditions listed in the NPEF have been grouped into categories (Minor Injuries, Minor Ailments, Palliative Care and Health Promotion), and two more were due to be added to encompass some of the new conditions.

Nurses should only prescribe for the conditions listed in the NPEF, which are now divided into narrower treatment areas, as well as the palliative care area.
 

NICE issues guidance on foot care in Type 2 diabetes (10/02/2004)

The National Institute for Clinical Excellence (NICE) has issued a clinical guideline on foot care for people with Type 2 diabetes within the NHS in England, covering the prevention and management of foot problems (see here for the full document and quick reference guide).


Pharmacists’ advice criticized in Which? report (10/02/2004)

More than 40% of pharmacies gave unsatisfactory advice in a Which? undercover investigation. The report points out that pharmacists are assuming greater responsibility for prescribing and supplying medicines and giving health advice.

Twelve researchers visited 84 pharmacies (major chains, smaller chains, supermarket-based pharmacies and small independents) and asked for advice on four different situations. A panel of three professional pharmacists rated the advice received in 35 out of the 84 visits as unsatisfactory.

As well as unsatisfactory advice, with staff not asking enough questions to ensure that the medicines would be safe and appropriate, the report also identified a lack of privacy, poor or non-existent health promotion advice, limited access to the pharmacist, and little difference in the quality of advice provided by pharmacists and their assistants.

David Pruce, Director of Practice and Quality Improvement at the Royal Pharmaceutical Society of Great Britain, responded by saying that the Society would welcome the opportunity to investigate these incidents and that the results are disappointing, with some of the pharmacies letting down the vast majority. John D’Arcy, Chief Executive of the National Pharmaceutical Association (NPA), said that the NPA “is disappointed and concerned with the findings of this ‘research’”, and commented on what needs to be done in the future.
 

Conference announcement: Prescribing in a Changing Landscape (10/02/2004)

A conference on ‘Prescribing in a Changing Landscape’ will be held on 26 February in London. It includes talks on nurse prescribing and extending the role of pharmacists and is aimed at people from the pharmaceutical industry and others who need to understand current prescribing issues (see here for further details).
 

NPC develops support packages (10/02/2004)

The National Prescribing Centre (NPC) has developed a range of support packages, NPC Plus, which can be commissioned by healthcare organizations. They include therapeutic workshops for nurses based on the Nurse Prescribers’ Extended Formulary and guidance and training on Patient Group Directions (see here for further information).
 

Nurse prescribers need to get budget access (10/02/2004)

Nurse prescribers need to fight for better access to prescribing budgets according to a report of Barbara Stuttle’s speech to the ‘Nurse Led Care’ conference in Manchester in January (‘Nursing Standard’, January 21, p7). The chair of the Association for Nurse Prescribing said that nurses should ‘wise up’ to make sure they can access the budget, despite opposition from GPs.
 

Checks needed in all medication systems (10/02/2004)

Checks and error traps should be built into all medication processes, including prescribing, dispensing and drug administration. This is among the conclusions of a report on medication safety by the Chief Pharmaceutical Officer, launched in January by the health minister Lord Norman Warner (“Building a safer NHS for patients: improving medication safety”).

The reports says: “Attention is usually focussed on the actions of individuals who are considered to be the cause of error. But latent conditions within an organisation and triggering factors in clinical practice are important causes of error”.

The report examines the causes and frequency of medication errors and identifies models of good practice to improve safety, pointing out the importance of system weaknesses that predispose to human error. Other recommendations include: the implementation of modern IT systems; improving education about medication safety for health professionals; and Primary Care Trusts giving direct responsibility for medication safety to a named individual, and ensuring that both primary and secondary care have medicine safety policies in place.
 

Conference announcement: Developing Nurses’ Roles in Emergency Care (10/02/2004)

This conference will be held on 24 February in London and includes presentations on Patient Group Directives and the Nurse Prescribing Extended Formulary (further information).
 

CNO promotes benefits of nurse prescribing (10/02/2004)

The Chief Nursing Officer (CNO) has outlined the benefits of nurse prescribing, saying that, “it is now taking centre stage as a mechanism for enabling nurses to better meet the needs of their patients”, in her January/December bulletin. Sarah Mullally also confirms that there will soon be a consultation about extending supplementary prescribing to optometrists and some allied health professions (see January 2004 newsletter and news item ).

The statement includes figures for nurse prescribers in England:

• More than 25 000 nurses are now trained to prescribe from the District Nurse/Health Visitor (DN/HV) formulary.
• More than 1800 nurses are qualified and registered to prescribe independently from the Nurse Prescribers Extended Formulary (NPEF), of whom almost 1100 are also trained as supplementary prescribers.

A supplement about nurse prescribing is attached to the bulletin (download here). It includes case studies which demonstrate how nurse prescribing can enhance nurses’ practice and benefit the patient by speeding up treatment and improving continuity of care, commenting that an NHS well-equipped with “a range of nurse prescribers making the health service more patient-centred”. It also describes the different forms of prescribing, as well as Patient Group Directions and Patient-Specific Directions.

The latest figures on funding of prescribing training included in the supplement show that it is expected to rise to about £7m in 2004-2005 and to around £10m in 2005-2006.

The bulletin also comments that nurse prescribing is expected to champion a shift in thinking towards concordance. It explains this approach, and includes information about clinical governance, accountability and corporate responsibility.

 

Extending prescribing/PGDs to further allied health professionals? 20/01/2004

Plans for the future of prescribing for allied health professionals were set out by the Department of Health towards the end of 2003 (see here - scroll down to “The Future”).

The Department of Health is talking to allied health professionals about which of the professions could be candidates for supplementary prescribing and under what circumstances. After this, a 12-week consultation period on the ensuing proposals will follow before recommendations are put to Ministers by the Committee on Safety of Medicines (CSM).

The DH also said that some allied health professionals who often work independently from doctors may be candidates for independent prescribing for some medical conditions. The next step is for the DH and the Medicines and Healthcare products Regulatory Agency (MHRA) to discuss with these groups the conditions and medicines which it would be appropriate to include in plans for independent prescribing, before another period of public consultation.

CSM was due to consider the comments received on the consultation about proposals to extend the use of patient group directions (PGDs) in December. The proposal was that dieticians, occupational therapists, speech and language therapists, and prosthetists and orthotists should be added to the list of professions authorised to supply and administer medicines under PGDs (see news item 1  and news item 2). Changes to regulations may follow by April this year.

 

RPS briefing paper on supplementary prescribing 20/01/2004

The Royal Pharmaceutical Society of Great Britain (RPSGB) has issued a briefing paper about supplementary prescribing, highlighting the impact pharmacists can make and outlining practical first steps for Primary Care Trusts. It also discusses how independent prescribing by pharmacists could affect hospital and community practice. See here for the briefing paper.

 

Many medicinal substance names changing 20/01/2004

The Medicines and Healthcare products Regulatory Agency (MHRA) has announced that the names for virtually all medicinal substances currently using the British Approved Name (BAN) are to change to the international name (rINN), with the exception of adrenaline and noradrenaline, which will continue to be dual-named. Further details can be found here, together with a list of the substances affected.

 

Consultation on supplementary prescribers to prescribe unlicensed medicines

The Medicines and Healthcare products Regulatory Agency (MHRA) has issued a consultation on proposals that supplementary prescribers could prescribe unlicensed medicines in England (download the consultation letter). Comments should be received by 31 March 2004.

These changes would require changes to several items of legislation, set out in detail in the consultation, and to NHS Regulations. Similar consultations are being circulated in Wales, Scotland and Northern Ireland and similar changes to NHS Regulations are also proposed in those countries.

The consultation proposes that, within the terms of a Clinical Management Plan as agreed with the independent prescriber, supplementary prescribers would be able to prescribe and order: unlicensed medicines manufactured in the UK and supplied as ‘specials’; unlicensed medicines imported into the UK; and unlicensed medicines prepared by pharmacists from active pharmaceutical ingredients and inactive pharmaceutical ingredients.

Following the consultation about supplementary prescribing, the Committee on Safety of Medicines (CSM) recommended that supplementary prescribing cover reformulation of a licensed product for the purposes of administration. An example would be crushing tablets to make a liquid suspension. The advice was that unlicensed products should be excluded from the supplementary prescribing arrangements with the exception of those which were part of a clinical trial.

When CSM further considered the prescribing of unlicensed medicines, it considered the fact that liquid oral formulations are sometimes prepared by a pharmacist from active pharmaceutical ingredients. To meet the clinical needs of patients, there may be situations where it is more appropriate to use starting materials rather than reformulate a licensed product. CSM therefore agreed, in principle, that the exclusion of all unlicensed medicines from the supplementary prescribing arrangements would not work to best effects in areas such as paediatrics or the provision of total parenteral nutrition.

CSM comments that the proposals do not envisage that supplementary prescribing of unlicensed medicines will be widespread. It is most likely to happen in specialist areas where both independent and supplementary prescribers have specialist knowledge. Various aspects of the arrangements will provide safeguards against the inappropriate use of ‘specials’ and extemporaneously prepared medicines. A further safeguard is that pharmacists would usually be involved in the formulation, preparation and supply of unlicensed medicines prescribed by a supplementary prescriber, and the consultation explains why this should be so. CSM does not consider that there is a need for the wholesale supply of unlicensed medicines direct to a supplementary prescriber.

Examples of situations where the prescribing of unlicensed medicines by supplementary prescribers could have benefits include:

• Paediatrics and neo-natology: Paediatric pharmacists provide advice to medical staff on most appropriate doses and formulations for children and this often involves unlicensed medicines. If these can be included in CMPs, supplementary prescribing by these hospital pharmacists would be much more practical than if they have to refer patients back to independent prescribers for unlicensed medicines, despite the fact that they are able to prescribe many complex licensed medicines as agreed in the CMPs.
• Dermatology: Many dermatological preparations have to be prepared extemporaneously.
• Oncology: For example, without these changes, oncology pharmacists and nurses would be able to prescribe medicines to control some symptoms but not lemon mucilage, manufactured by hospitals as a ‘special’ for the relief of sore throats.
• Palliative care: For example, ready-diluted analgesic injections prepared as ‘specials’.
• Total parenteral nutrition: Often requires the addition of unlicensed medicines by pharmacists.

Some examples of unlicensed medicines that could be prescribed by supplementary prescribers include: clobazam suspension for epileptic fits; clonidine suspension for pain and sedation, routinely used in paediatric intensive care units; and peppermint water as a carminative. Let us know your views on these proposals in the forum.
 

MHRA publishes views on extending the formulary 08/01/04

The Medicines and Healthcare products Regulatory Agency (MHRA) has published a summary of the responses to received to consultation MLX 293 about the extension of the Nurse Prescribers’ Extended Formulary (see here for summary). Plans to extend the formulary following this consultation were announced later last year (see news article).


 

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