The Response of Council of the Guild of Healthcare Pharmacists
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.
Education & Training
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.
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.
Legal & Practical Issues
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.
The Options Proposed in the Consultation Paper
Overall GHP believes that, like Option 1, this is not going to meet the needs of a modernising NHS.
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.
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.
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.
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.
Black Triangle Medicines
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