Guild of Healthcare Pharmacists
Consultation on Proposals to Extend Nurse Prescribing

The Response of Council of the Guild of Healthcare Pharmacists



The Guild of Healthcare Pharmacists (GHP) welcomes this consultation process and the document produced for the consultation has been pragmatically constructed. GHP is aware of the proposal to extend of prescribing rights to other practitioners, as referred to in Queen's Speech, and many of the comments made in this response would apply equally to other groups of professional staff seeking prescribing rights. As such GHP would wish to have seen this consultation in context with the rest of the proposals that came out of the extensive review undertaken under Dr June Crown, including the new legislation covering Patient Group Directions (PGDs) and the proposals for dependent / independent prescribing.

GHP believes that it is a better understanding of the differing concepts of dependent and independent prescribing that becomes particularly important when expressing views on the five options presented, as prescribing is not necessarily the only issue, diagnosis is potentially more of an issue. GHP sees the process of patient assessment as potentially very different to diagnosis and the initiation of a long-term treatment plan.

GHP is pleased to see the statement that patient safety must remain paramount and this will be referred to on a number of occasions within this response. Our view is that proven competency is the key to ensuring patient safety and any proposals should be judged on the basis of how well the 'system' proposed assures the competency of the healthcare staff working within it. This of course is not just applicable to nurses.

Experience to date with existing limited extensions to nurse prescribing within primary care and the use of first Group Protocols and now PGDs is positive, although largely anecdotal. What has been demonstrated is the added value of nurse prescribing relating to access and timely care.

GHP would wish to register general concern that these proposals may represent undue haste. Utilising existing legislation that is now 30+ years old simply because this provides an 'easier route' to achieve a worthwhile endpoint may be fraught with risks.

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Education & Training

GHP supports the importance given to this aspect within the consultation paper but feel that the task facing the NHS to deliver on this may be underestimated. There will be considerable cost in both the delivery of the courses, in terms of those that prepare, teach and assess, as well as the time needed to allow nurses (and other professions in due course) to attend.

GHP believes that the proposed module must be at degree level as an absolute minimum. The module must be capable of being delivered as a 'stand alone' in addition to incorporation in other specialist courses. There must also be demonstrable consistency between providers if the stated goal of patient safety being paramount is to be achieved. The module should be capable of use in multi-disciplinary setting, in line with general training recommendations for NHS professional staff outlined in 'Our National Health'. The expectation is that the delivery of these training will also be multi-disciplinary and GHP is aware of the significant pharmacist input to the training for the current roll out of nurse prescribing in primary care.

The module contents should be driven by the needs of the service, with academia providing the accreditation and ensuring the rigour of assessment. As such a September 2001 deadline for such a module to be available is ambitious, perhaps too much so.

GHP is assuming that the module referred to here is a generic one covering the legal and practical aspects of prescribing. There will be a need for other modules to deal with specific needs that depend upon the medicines to be prescribed, which itself is constrained by which of the five options is taken forward.

It may seem a rather flippant statement but there is already a training program in existence that covers the very basics of diagnosis to initiate medication under Option 5, basically a medical degree! It may be worthwhile to pursue with some urgency one of the recommendations within 'Our National Health' that suggested the possibility of fast track graduate-entry medical degree courses. This is particularly the case if one of the underlying problems being tackled is the lack of access to medical practitioners.

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Prescribing Support

The points on CPD are well made but there is a significant omission with respect to the provision of regularly updated information to support quality prescribing. There have been substantial efforts made over recent years within the NHS to improve the quality of information and guidance that prescribers receive. Early consideration must be given to what extension of circulation of publications such as Drug & Therapeutics Bulletin and the support provided by the NPC south of the border might be required depending, of course, on what option for extending nurse prescribing is to be pursued.

Within the consultation paper there appears to be no recognition of the potential of the Pharmaceutical Industry for influencing these new prescribers. This should be of particular concern to the NHS if either of options 4 or 5 are adopted. GHP is assuming again that appropriate systems will be put in place to ensure nurses receive feedback on their prescribing, both simply in the form of PACT type data and in terms of peer review on trends in their prescribing compared with other nurses.

Pharmacy as a profession has provided significant support to prescribing doctors over many years and it will need to prepare itself to support this new group of prescribers. Given that this is a new group of prescribers there could be significant impact upon resources at a time when there are already significant workforce difficulties.

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Legal & Practical Issues

GHP is convinced that the legal issues need to be thought through in greater detail before selecting any of the options put forward as all have their difficulties. GHP was particularly concerned that it could not find reference anywhere in the consultation proposals on accountability for the overall care that a patient is to receive as a result of the options. The Crown Review was very strong on there being a need to ensure there was a focus for such care. For most patients this is naturally their General Practitioner and GHP would favour this arrangement continuing. The difficulty with the consultation proposals, particularly 4 and 5, is that new and fully independent prescribers will be created. There is plenty of evidence currently that this situation causes difficulties now, the best example is communication difficulties between primary, secondary and tertiary care.

The manner of the change to be made to existing legislation could well lead to potential problems as there appears no way to prevent an eligible nurse prescriber from writing private prescriptions. There are a number of possible scenarios, including private clinics offering 'lifestyle' medicines that may not be in the best interests of the public. There may also need to be consideration given to private nursing homes. GHP wishes to stress that this does not mean that it believes nurses, or others, are more likely to act improperly but simply to reflect that there are already identifiable problems within groups of professionals who can prescribe. Our view is that this represents an added risk to the public which will require active management.

Likewise, self-prescribing or prescribing for friends and relatives would be poor practice offering absolutely no benefit to the public or patients. While the BMA does issue guidance to doctors on this it is guidance that cannot be enforced in law.

On some very practical issues the identification of who can prescribe and what can be prescribed (dependent on option chosen) may well be a significant issue for those that have to dispense prescriptions or utilise information to deliver patient care, particularly where that care is shared across boundaries.

Devolution in the UK may lead to differing practices. While this may be beneficial in meeting defined needs of a local population it should not form a barrier to free movement of nurses nor restrictions on where patients may get their prescriptions dispensed.

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The Options Proposed in the Consultation Paper

Option 1

This has served a purpose in terms of the introduction of nurse prescribing within certain limited areas. It is, however, unlikely to meet the broad objectives stated within 'Our National Health' nor is it consistent with many of the statements made within the consultation paper itself.

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Option 2

Similar comments apply as in the comments on Option 1. It is not believed that all P or GSL medicines are in the BNF now, which does raise the additional question of what might be actually prescribable by a nurse and what may be prescribable under the NHS. There is a distinct lack of clarity on this in the consultation paper. If the goal is to ensure easier access to medicines to enable patients to self-manage minor ailments then this is probably better addressed by better utilisation of community pharmacists, where there is generally very easy access. Additionally, if the intent is to allow such GSL and P medicines to be prescribable under the NHS then presumably normal exemption conditions will apply, which would certainly be of benefit in a number of circumstances. Once again the same result could potentially be achieved for most of the medicines under consideration by better use of community pharmacists, who have already been trained.

Overall GHP believes that, like Option 1, this is not going to meet the needs of a modernising NHS.

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Option 3

Has worked for the existing nurse prescribers but this is a well defined relatively homogenous group of practitioners. There may be benefits for some other well defined groups to have a specific section of the formulary dedicated to them, such as Midwives, but overall the concept of many different sections or many different Formularies is likely to be totally unworkable in practice.

However, it is imperative that the concept of 'patient safety must remain paramount' must be kept in clear focus. Adding new POMs to this Formulary may be time consuming but taking the necessary time, if it is dealing with patient safety, may be the price that has to be paid.

If the consultation proposals had considered the future impact of dependent prescribing then Option 3 would have a number of attractions. It could provide a balance between an extension of the nurse formulary, allowing nurses to work independently within a scope of knowledge that the NHS might well have the resources to deliver on, and the greater use of protocols to manage chronic conditions where the diagnosis and outline treatment plan are decided on by a doctor and the nurse, or other suitable healthcare practitioner, assesses, monitors and then changes treatment in accordance with agreed protocols.

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Option 4

The consultation paper describes this option as 'quite radical' and GHP would agree with this assessment.

While both options 4 and 5 are radical approaches it would appear on closer examination that these two are not that different. In fact 4 is potentially 5 if there are no medicines identified as restricted! Given the comments earlier on some of the legal issues the adoption of 4 might be a more pragmatic approach as it provides the opportunity to restrict in the public interest. The onus would be on the Government to identify such medicines.

In the 'dependent prescribing' model, outlined by the Crown Report, GHP would see many of the aspirations encompassed by option 4, and indeed option 5, being attained but with much greater control that should lead to assurance of patient safety. As an 'independent prescribing' model there must be real doubts as to whether the NHS has the resource to deliver the training and education required to achieve the number of nurse prescribers to 'make a difference'. Additionally the clinical governance implication for individual organisations needs to be considered in some depth.

There are also potential issues around private practice, outside of the direct control of the NHS, that must be addressed.

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Option 5

The comments on Option 4 apply equally to Option 5.

The consultation paper describes this option as 'very radical' and GHP would agree with this assessment. Given this assessment it is of some concern that the consultation paper did not include a critique of what were seen as the key risks/benefits of this particular approach.

The reference to Dentists is not particularly helpful as GHP believes they cannot prescribe any drug under the terms of the NHS pharmaceutical service, even though they can theoretically prescribe anything on private prescription. This option, as currently proposed, is therefore a significant departure from current practice or experience. GHP was also uncertain as to what was meant by the term '…dispensable as part of NHS pharmaceutical services, by suitably trained nurses..'. The Crown Review was quite clear that 'best practice' was still the separation of prescribing and dispensing where that was possible as this provided an extra element in assuring patient safety.

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Controlled Drugs

This requires closer examination as there is clearly a good case to be made for including Controlled Drugs in the prescribing list for some specialist nurses and they are, of course, already there for Midwives. GHP is assuming that such proposals would also have to be considered by the Advisory Council on Misuse of Drugs. It may be better to await the results of the enquiry in to the 'Shipman Case' as potential recommendations around extra record keeping might provide the right environment for extension of prescribing rights here. For palliative care nurses this can probably equally be achieved under a 'dependent prescribing' model.

GHP also has concerns around private clinics again and while the numbers of such 'rogue' practitioners would always be very small they would be a real risk to the public.

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Unlicensed Medicines

There is relatively poor understanding of this issue among existing prescribers. GHP believes that there is no place currently to extend prescribing rights for this group of drugs unless local Formularies include them. In these instances GHP is of the view that effective clinical governance arrangements would be in place through the Drug & Therapeutics Committee. In such cases it would be far preferable to use the PGD approach than allow independent prescribing. GHP is also of the view that the same restrictions should apply to the use of licensed medicines being used for an unlicensed indication.

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Black Triangle Medicines

GHP is of the view that, given the relatively limited experience in use and evidence available at launch, there is no place currently to increase the number of practitioners with prescribing privileges. GHP believes, as with unlicensed medicines, that the use of PGDs provides a more appropriate approach. This has certainly worked with Levonelle-2, with individual organisations providing the necessary clinical governance overview. While it is not mentioned within the consultation paper there will be a need for the Committee on Safety of Medicines to look again at reporting arrangements for Adverse Drug Reactions. This is, of course, particularly relevant to this category of medicines.

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In the introduction to this response the Guild of Healthcare Pharmacists (GHP) welcomed the consultation process and commended the fact that the consultation document had been pragmatically constructed. GHP is still very supportive of extending nurse prescribing and it hopes that the comments made above are taken as constructive offerings to inform the debate.

There is a clear need to strike some form of balance between the need to address the current limitations of patient care and the need to assure that medicines are used appropriately and safely. As a consequence GHP cannot recommend the adoption of any of the options without significant qualification, especially given our concerns over the legal route being used.

In reality GHP believes that a mix of options 3 for independent prescribing and 4/5 for dependent prescribing is likely to be in the best interests of both patients and the NHS. The key will be ensuring that those practitioners who have prescribing rights extended to them are trained and assessed as competent to undertake the task and, for the future, have clinical governance systems in place to ensure they maintain that competence.

Naturally GHP would be more than willing to expand on any of the points made in this document.

Guild of Healthcare Pharmacists
January 2001

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