Unit 1 - Foundations of Prescribing Practice

History and Background to Nurse Prescribing


Overview of Legislation - The First Prescribers

Nurse prescribing first became part of the government's policy agenda following the Cumberlege Report (DHSS, 1986) (Please note: This paper is not available online), which included the following recommendation:

'The DHSS should agree a limited list of items and simple agents which may be prescribed by nurses as part of a nursing care programme, and issue guidelines to enable nurses to control drug dosage in well defined circumstances.'

Subsequently, the first Crown report (DH, 1989) recommended that suitably qualified nurses with a district nursing or health visiting qualification working in the community should be authorised to prescribe, in defined circumstances, from a limited formulary. The primary legislation that permitted initial nurse prescribing was the Medicinal Products: Prescription by Nurses Act 1992, although the necessary secondary legislation to this did not come into effect until 1994.

Although the recommendations on nurse prescribing included in the Cumberlege report were the foundation of authorised nurse prescribing, they were not the start of actual nurse prescribing. A lecturer who was a 17-year-old student orthopaedic nurse in the early 1960s recalls how, when she was left in charge of the ward on which she was gaining practical experience, she routinely prescribed and administered aperients such as Senokot, antacids such as aluminium hydroxide and cough remedies such as 'Mist Expect': ammonia and ipecacuanha mixture. The only record of such prescribing and administration was in the ward 'Aperients' and 'Patient report' books. The origins of such unofficial nurse prescribing are lost in the mists of time.

Following a successful pilot programme, the DH introduced nurse prescribing nationally for district nurses and health visitors from 1996. The Nurse Prescribers’ Formulary for Community Practitioners (until 2005 called the Nurse Prescribers’ Formulary for District nurses and Health Visitors) now enables Community Practitioner Nurse Prescribers to prescribe from a formulary of appliances, dressings and some medicines for patients in the community.

Independent Prescribing

The Department of Health (2006) working definition of independent prescribing is ‘prescribing by a practitioner responsible and accountable for the assessment of patients with undiagnosed and diagnosed conditions and for decisions about the clinical management required, including prescribing’.

In 1997 the government set up a Review of Prescribing, Supply and Administration of Medicines (under the chairmanship of Dr June Crown). In 1999 the second report of the review recognised the potential benefits to patients of extending prescribing responsibilities to healthcare professionals other than doctors and dentists and the few district nurses and health visitors who were already qualified (NMC 2006).

In 1999, the DH also published Making a Difference. The document reaffirmed the government's intention to extend the roles of nurses, midwives and health visitors to make better use of their knowledge and skills, including making it easier for them to prescribe. While the recommendations outlined in the document applied to England, other countries in the UK subsequently adopted many of the principles it contained, in particular the extensions to the role of the nurse in relation to prescribing.

In 2000, the The NHS Plan: A plan for investment, a plan for reform was published. Among other things, it made the following proposals with regard to patient care. The service was to be:

  • Designed around patient need
  • Fast and convenient care
  • Offer improved quality of care
  • Offer faster access and reduce waiting times.

To achieve this, the document proposed to:

  • Empower frontline staff and patients
  • Harness and expand the skills of all healthcare professionals
  • Break down the traditional demarcations between clinical roles
  • Increase flexibility of teamwork.

Following a consultation that began in October 2000, ministers announced in May 2001 that nurse prescribing would include more nurses and would cover a wider formulary (Nurse Prescribers’ Extended Formulary).

The necessary extended training was to be available to any first-level registered nurse or registered midwife.

What could EINPs prescribe?

Independent nurse prescribers who had completed the necessary training prescribed from the Nurse Prescribers' Extended Formulary (NPEF) list could legally prescribe all General Sales List (GSL) and Pharmacy (P) medicines prescribable by GPs, together with a list of almost 180 specified Prescription Only Medicines (POMs). Those POMs included some controlled drugs. In addition, independent prescribers could prescribe all items in the nurse prescribing list for District Nurses and Health Visitors.

Supplementary Prescribing

In April 2003, the Government enabled nurses and pharmacists to train to become supplementary prescribers. Supplementary prescribing is defined as a voluntary partnership between the independent prescriber (a doctor or a dentist) and a supplementary prescriber to implement an agreed, patient-specific Clinical Management Plan (CMP), with the patient’s agreement (NMC 2006).

Section 63 of the Health and Social Care Act (2001) enabled the government to extend prescribing responsibilities to other health professions and to allow new types of prescribers by attaching conditions to their prescribing.

Provisions in Northern Ireland (NI) can be found on the following web site:
www.opsi.gov.uk/sr/sr2003/20030447.htm

What can Supplementary Prescribers prescribe?

Nurses, pharmacists, physiotherapists, radiographers, podiatrists and optometrists can prescribe in partnership with a doctor (or dentist). Nurse and pharmacist supplementary prescribers are able to prescribe any medicine including controlled drugs and unlicensed medicines that are listed in an agreed CMP. All supplementary prescribers may prescribe for any medical condition, provided they do so under an agreed, patient-specific CMP.

Supplementary prescribing may continue to have a role for nurse independent prescribers, particularly for newly qualified prescribers, or complex situations where there is clearly a need for a team approach to prescribing, or when a patient’s CMP includes certain controlled drugs (NMC 2006).

Link to another Unit

You will find more information on clinical management plans (CMPs) in Unit 4: Prescribing Partnerships and Unit 5: Prescribing in Practice.

Nurse Independent Prescribing

Between 2003 and 2005, work continued to expand the Nurse Prescribers Extended Formulary (NPEF) and by 2005, there were 240 Prescription Only Medicines (POMs), along with all the Pharmacy (P) and General Sales List (GSL) medicines in the formulary.

In October 2005, the Committee on Safety of Medicines (CSM) considered responses to two previous consultations which examined options for the future of nurse prescribing along with the introduction of independent prescribing for pharmacists. They recommended to Ministers that suitably trained and qualified nurses and pharmacists should be able to prescribe any licensed medicine for any medical condition within their competence. This was agreed by the ministers and announced in a press release in November 2005.

Legislation came into effect on 31st May 2006 which enables all qualified Extended Independent Nurse Prescribers (now known as Nurse Independent Prescribers) and suitably qualified pharmacists to prescribe any licensed medicine. Nurse Independent Prescribers can prescribe a range of controlled drugs for specific medical conditions but Pharmacist Independent Prescribers cannot prescribe controlled drugs, although this may change in the future (NMC 2006).

Reading

Reading

More information is available in:

Department of Health (2006) Improving Patients’ Access to Medicines: A guide to implementing nurse and pharmacist prescribing within the NHS in England.
http://www.dh.gov.uk/PublicationsAndStatistics/Publications/
PublicationsPolicyAndGuidance/PublicationsPolicyAndGuidanceArticle
/fs/en?CONTENT_ID=4133743&chk=HSzl1/

NMC Standards of Proficiency for Nurse and Midwife Prescribers (2006)
http://www.nmc-uk.org/aArticle.aspx?ArticleID=2021

further Reading

Further Reading

Crown, J. and Miller, P. (2005) Access to the whole BNF: a long-awaited triumph or the wrong decision? Nurse Prescribing 3 (6) 228-230.

 

Formularies and pharmacopoeias

Formularies and pharmacopoeias were originally introduced as reference books in an attempt to achieve uniformity of drug composition. The first formulary was produced in England by the Royal College of Physicians (RCP) in 1618. Today, formularies are more concerned with which drugs are available or approved, alongside their actions and uses.

The British National Formulary (BNF)

The BNF is jointly published by the British Medical Association and the Royal Pharmaceutical Society of Great Britain. It is published under the authority of a Joint Formulary Committee, which includes representatives from the two professional bodies and the Department of Health. The departments of health in England, Northern Ireland, Scotland and Wales receive BNFs for distribution, through local health authorities and trusts, to NHS doctors, nurse prescribers, pharmacists, wards and clinics. A small proportion of each edition is supplied for retail sales — for example, for use by private hospitals.

The BNF lists the drugs and preparations available in the UK, along with indications for their use, dosage, adverse side-effects, contraindications and costs. It is updated twice a year and is available to all registered prescribers. The BNF is not selective and carries lengthy lists of each drug. Some trusts draw up their own local formularies based on particular chapters in the BNF for reasons of efficacy, efficiency and cost (see 'Local formularies' section, below).

Drug Tariff and Scottish Drug Tariff

This is a tariff produced monthly by the Pharmaceutical Directorate of the Prescription Pricing Authority (PPA) for the secretary of state for health, and is supplied primarily to pharmacists, doctors' surgeries and — twice a year — to nurse prescribers. In short, it tells you the rules you should follow when dispensing, the fees and the allowance you will be paid, the drug and appliance prices you will be paid, as well as what is allowed and what is not.

England

Wales

In England and Wales, the Drug Tariff was distributed to nurses in printed format for the final time in May/June 2004. Since then, nurses have been able to access the Drug Tariff via the PPA web site:
www.ppa.org.uk/edt/June_2005/mindex.htm

Use this link for more information on the Drug Tariff:
www.ppa.org.uk/a/drug_tariff_guidance.htm#link1

Scotland
To date, the Scottish Drug Tariff will continue to be supplied every six months in printed format.
Northern Ireland

Northern Ireland Drug Tariff:
http://www.dhsspsni.gov.uk/pas-tariff

Local formularies

These are developed using evidence-based theory and consider the issue of cost-effectiveness. Local formularies offer prescribers a smaller range of products to prescribe from, reducing the need to trawl through a huge number of products, many of which may have similar properties.

Formularies are often made up for managing conditions such as chronic wounds — for which there is an extensive range of products to choose from. One or two products from each dressing type may be selected for the formulary, and when a decision is made to use a specific dressing type the prescription should adhere to those listed in the local formulary.

There are two schools of thought on this. Narrowing the choice for the prescriber may be more cost-effective and may help to maintain standards of treatment, however, some prescribers may feel that their choices are being restricted and their autonomy curtailed.

Reading

Reading

Furniss, L. (2001) Formularies in primary care. Pharmaceutical Journal 1: 2, 37-39.
www.pharmj.com/PrimaryCarePharmacy/200003
/medicines/formularies.html

Reflection

Access your local formulary: if you don't know how to do this, contact your clinical supervisor or local pharmacist.

Consider the advantages and disadvantages of having local formularies.

In what way are these evidence based?

Prescribing from patient group directions

These are written instructions for the supply or administration of medicines for groups of patients who have not previously been individually identified and should not be confused with prescribing. The medicines must be named and must be given in an identified clinical situation only.

It is a requirement of the legislation that the PGD is signed by a doctor or dentist, as appropriate, and by a senior pharmacist. The PGD must also designate — in writing — the individual(s) who may supply any of the medicines from the PGD.

Qualified persons who are eligible to supply or administer medicines under a PGD:

  • Nurses
  • Midwives
  • Health visitors
  • Optometrists
  • Pharmacists
  • Podiatrists
  • Physiotherapists
  • Ambulance paramedics

Details required for a valid PGD

The PGD must contain the following information:

  • The period during which the PGD shall have effect
  • The description or class of PoM to which the PGD relates
  • Any restrictions on the quantity supplied , and what these restrictions are
  • The clinical situations in which the medication can be used to treat a patient
  • The clinical criteria for eligibility
  • Exclusions to treatment
  • Circumstances for seeking further advice
  • Strength
  • Dosage
  • Route(s) of administration
  • Frequency of administration
  • Minimum or maximum periods of administration
  • Relevant warnings
  • Follow-up action
  • Arrangements for referral for medical advice.

The DH has made it clear that the majority of clinical care must be provided on an individual patient-specific basis and that the use of PGDs should be reserved for limited situations where they offer an advantage for patient care without compromising patient safety.

The link below provides a useful flow chart to assist practitioners to decide when the use of PGDs is appropriate:
www.npc.co.uk/publications/pgd_updated_oct2002.pdf

You will find examples of approved PGDs using the following link:
http://www.portal.nelm.nhs.uk/pgd/default.aspx

Reflection

You may be able to obtain a local PGD from your area of practice: if you do not know how to do this, ask your clinical supervisor. Try to identify the above elements of information within your PGD.

Link to another Unit

You will find more information on the subject of consultation and decision-making and developing a clinical management plan in the 'Documentation' section of Unit 4. Prescribing Partnerships.

Make Notes

Make notes about how you think Supplementary nurse prescribing might affect the use of PGDs in future.


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