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Nurse independent prescriber qualification has had little overall impact on prescribing

The proportion of primary care prescribing undertaken by nurses rose just 0.4% in the first five years after the introduction of nurse independent prescribing, researchers have reported.

The team from University of London looked at how nurse prescribing in primary care changed after the introduction of the nurse independent prescriber qualification in 2006, which enables qualified nurses to prescribe any licensed drug – including some controlled drugs – for any medical condition within their clinical competence.

The community practitioner nurse prescriber qualification, first introduced in 1992, enables nurses to prescribe only from a more limited list of medicines.

As reported in the journal BMC Health Services Research, the researchers found the proportion of items prescribed by nurses in primary care has risen only slightly since nurse independent prescribing came in, from 1.1% of all items in 2006 to 1.5% in 2010.

Overall, the number of nurses registered to prescribe rose by 18%, from 30,753 to 36,281.

In line with this, the number or nurses issuing prescriptions increased from 13,391 in 2006 to 15,841 in 2010.

However, this still meant the number as a proportion of all those qualified and authorised to prescribe remained static over the five-year period, at 43%.

It found that while nurse independent prescribers contributed most towards prescribing of emergency contraception, community practitioner nurse prescribers mainly contributed to prescriptions of dressings, stockings and incontinence appliances.

The team concluded: ‘The percentage of prescriptions written by nurses in primary care in England is very small in comparison to GPs and there has been little change in that over five years.’

‘Our findings suggest that nurse prescribing is used where it is seen to have relative advantage by all stakeholders, in particular where it supports efficiency in nursing practice and also health promotion activities by nurses in general practice. It is in these areas that there appears to be flexibility in the prescribing role between nurses and general practitioners.’

BMC Health Services Research 2014

Readers' comments (19)

  • Have recently undertaken, I found the course extremely challenging in terms of pharmacology/ exams etc. One of our GP's said he did not think he could answer the exam questions!!! In my area most nurses use IP, out of interest how many nurses and GP's work within a supplementary prescribing context within general practice?

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  • Is supplementary prescribing underused in general practice? Long term conditions? Tripartite agreement patient .GP. and nurse.

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  • After working in GP for over 10 years, I think the biggest issue causing nurses not to take up IP is due to lack of practice recognition of this qualification which is not reflected in their pay!

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  • I think the biggest issue causing nurses not to take up IP is due to lack of practice recognition of this qualification which is not reflected in their pay!
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    For many practices it doesn't really decrease workload for the GP employers and they become vicariously liable for a very exposed area of medicine. We wouldn't want one of our nurses to undertake this because we're not convinced that the courses and training cover prescribing in anywhere near the depth required for safe prescribing.

    I know that this will generate howls of protest from the nurse prescribers (who may well be very safe) but, in our opinion, it still falls far short of the level of pharmacology and prescribing experience that a new GP registrar would have and the risks don't outweigh the benefits. Finally, I suspect a very large proportion of the nursing population wouldn't want the additional responsibility that goes with this role anyway.

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  • GP employers are vicariously liable for actions/ommissions of nurse employees regardless whether they prescribe or not. As none of your nurses have undertaken course, can assure you that there is plenty 'depth' complexitiy in terms of pharmacology/pharmacokinetics/safe prescribing. There is a body of evidence to suggest that NMP's are extremley safe/ competenent people and maintain exellent prescribing partnerships with their patients. - this is perhaps the most important point- and also how is nurse prescribing used in general practice - my point above - what about supplementary partnerships - PT/ GP/ Nurse would this facilitate better prescribing outcomes? in terms of PT ed/ concordance etc? GP/s PT/Nurses working together!!!

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  • Research consistently shows no difference in outcomes between Medical and non medical prescribing - whatever the anxieties are about training models.
    The funding for training of non medical prescribers has been affected by health economics so there has been a slow down in the number completing training which will influence these figures.

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  • "As none of your nurses have undertaken course, can assure you that there is plenty 'depth' complexitiy in terms of pharmacology/pharmacokinetics/safe prescribing"
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    That may be your assessment, but it isn't ours. We are well aware that we are variously responsible for all actions - what I am suggesting is that we, as employers, as not willing to be liable for this. That, as partner's is our decision. Equally, we can't see a large business benefit to this - other employers may take a different view.

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  • Nurses led long term condition management ?
    Advanced nurse practitioners managing on the day requests and minor ailments ?

    Both need prescribing skills to complete episodes of care and both are cost effective

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  • Nurse led LTC management doesn't need the ability to prescribe (it has worked for years and still does in most areas without this).

    Many practices are moving away from ANPs for untriaged care because it's often cost-equivalent to hire a salaried doctor (when adjusted for number of patients seen and the expanded role-set).

    Of course, different practices may take a different view but in business terms, the benefits to the practice are not necessarily well defined.

    Of course, in terms of professional development etc for the nurses concerned there may be other benefits - but I'm talking from an employer's perspective.

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  • There can be benefits for patients- still the most important point!
    For some, LTC clinics are mainly been driven by QoF, financial incentives templates and tick boxes, none of which requires a registered nurse! let alone a nurse prescriber. In my area, the patient is at the heart of everything we do.

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  • Dissociating the prescriber from the patient consultation is a high risk IMO . Just last week I had to correct a prescription added to records by the GP in response to elevated BP and cholesterol as the patient was breast feeding and keen to fall pregnant quickly again
    Safer for considered holistic assessments not 'tick box' 'task focused' care
    Which is where right person right time approach saves lives as well as pennies
    Just saying ....

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  • " In my area, the patient is at the heart of everything we do."

    As it is in ours - we have taken the view that our patients benefit more from seeing a general practitioner with a broader skillset, the ability to deal with anything that walks through the door (both therapeutically and diagnostically) and experience of prescribing rather than someone who is limited to a disease area or minor illness.

    If your system works for you that's great - we're happy with ours.

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  • Always interested to hear how others manage their skill mix ... But if your GPs see all the chronic disease and all the walk ins and minor illness what do the nurses do ?
    I agree , if just smears, ears and imms not much need for nurse prescribing skills and status quo - but as this doesn't work for so many partnerships what's special about how you work together ... something's got to give on this model surely or do you practice in Heartbeat land ?

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  • The ability to deal with anything that walks through the door (both therapeutically and diagnostically) and experience of prescribing is also my domain as an advanced clinician in general practice for the past 10 years. I've also got expertise in commonly presenting mental health presentations and prescribe when required compared to a lot of my GP colleagues. Research completed in 2011, showed there had been no change since 1975 in their ability to recognise patients with depression and GPs lacked knowledge on mental ill health. Not all ANP just deal with triage and minor-illness!

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  • 'anything that walks through the door' !! are you talking about patients? 'disease area' = Patients who have to life with impact of a long term condition or chronic health need.
    Prescribing either GP or nurse is the endpoint.

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  • The research team may have overlooked the fact that the prescriptions issued by an IP nurse or, as in my case, a pharmacist, may apply only to initiating treatment. Repeat prescriptions will be generated on the Practice computer on a GP prescription, and invariably signed by the GP whose name is printed on the prescription. Many thousands of repeat prescriptions that may have been originally initiated by an IP are therefore not attributable to that IP.

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  • That's a very good point , re repeat scripts! In addition, its worth remembering that the current NMP (non medical prescribing) qualification covers several disciplines. Pharmacists/Podiatrists/ Physios/nurses, all undertake take the same course at University, and are required to demonstrate the same level of knowledge and skills in terms of pharmacology and its application into clinical practice. WE all take the same pharmacology exams/ maths tests/ OSCE's/assignments. The course is designed to be complex and there is a approx 30% pass rate. Working and studying together across disciplines helps foster a better working relationship which each other, and I feel this will be beneficial to patients. upon completion we are IP's ( independent prescribers) + Supplementary prescribers. both models of prescribing can be adopted and used to benefit patients.

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  • correction above 30% failure rate! its early

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  • It is common for medical professionals to try and lessen the value of the nurse prescribing course. In my opinion, it is about a misconception that NMPs are going to replace doctors and hence understandably they feel threatened. Who wouldn't? NMPs are an invaluable resource that has proven can reduce medical pressures in a lot of specialisms. It is out of ignorance for any medical doctor to underestimate the ability of an NMP, especially in my area of specialism: substance misuse. If you are a medical doctor who intends to prescribe in this area but are unsure, please seek support before you kill someone, remember to swallow that pride coz NMPs can help !

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