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Doctors split over nurse script rise

It is nine o’clock on Monday morning and Sheila Smith is looking down a patient’s throat. She sees just a slight redness and patiently explains why there is no need of a prescription. A standard general practice consultation.

It is nine o'clock on Monday morning and Sheila Smith is looking down a patient's throat. She sees just a slight redness and patiently explains why there is no need of a prescription. A standard general practice consultation.

But Sheila Smith is not a GP. She is one of the new breed of independent nurse prescribers whose introduction has alarmed many GPs.

The Government extended nurse and pharmacist prescribing powers last year to cover almost the entire formulary, in the face of opposition from all 16 medical bodies they consulted.

There are now 10,000 independent or supplementary nurse prescribers in the UK, three-quarters of them in primary care.

The move is part of a broader Government drive to relax prescribing restrictions, which last week saw the announcement of plans to give optometrists prescribing powers.

But figures obtained by Pulse and reported last month bear out the fears of many GPs over nurse prescribing, after finding many nurses appear to have taken on the management of complex conditions.

Use of some medicines – including new drugs such as rosiglitazone – has leapt by more than 200% in a year.

Professor Dennis Johnston, professor of clinical pharmacology at Queen's College, Belfast, is worried by the figures. He warns: ‘The prescribing of glitazones is quite concerning because these are drugs of questionable use and toxicity. If nurses are giving these drugs in a non-structured environment that would be worrying.'

Dr George Rae, former chair of the GPC prescribing subcommittee and a GP in Whitley Bay, Tyneside, has particular concerns over nurses' ability to diagnose. He says: ‘There are substantive clinical skills you need to give out antibiotics that fall within a doctor's domain.'

But defenders of nurse prescribing insist that the most complex drugs would only be prescribed by specialist nurses, who would consult a doctor with any doubts.

Mrs Smith, a respiratory nurse specialist in Leatherhead, Surrey, says: ‘I have done exams to say I am competent in asthma and COPD prescribing and I have done a degree to become a nurse practitioner.

‘I would not prescribe diabetes drugs, for example, because it would be stupid to prescribe outside of my competencies.'

Yet concerns remain. ‘There needs to be greater scrutiny and greater external regulation,' says Dr Chaand Nagpaul, a GPC negotiator and a GP in Stanmore, Middlesex. ‘The Government is rushing through its agenda before it has put the necessary monitoring in place.'

He is one of a number of

GPs who are concerned the Government sees nurse prescribers as a way of providing primary care on the cheap.

Dr Nagpaul adds: ‘I suspect that part of the Government's agenda is its belief that GPs can be replaced by less costly health professionals.'

Dr James Kingsland, a nurse prescriber trainer and chair of the National Association of Primary Care, warns some nurse prescribers are being used ‘for the wrong reasons', such as ‘capacity issues'.

Professor Tony Avery, professor of primary care at the University of Nottingham and a GP in the city, who is currently conducting a review of nurse and pharmacist prescribing for the Department of Health, says the key issue is training. ‘Nurse prescribing has been brought in as a stand-alone model rather than as a much wider approach to advanced nursing practice,' he says.

But Dr Brian Crichton, a GP in Solihull and prescribing adviser to the RCGP, reckons the problem is not so much with the initial training, which consists of 26 days of theory and 12 days of mentored practice, as with nurse prescribers' continuing educational needs.

‘The prescribing training course is an adequate starting point but not a finishing point. It gives a kind of benchmark of adequacy, but the onus is on the prescribers to access continuing education,' he says.

To prevent doctors' worst fears being realised, GPs should ensure they have a good working relationship with their nurse prescriber who should be an integrated part of the practice team, rather than an isolated individual, prescribing specialists advise.

‘With nurse prescribers you need to work in teams, not independently,' says Dr Kingsland. ‘They have a lot of knowledge and are good at following protocols, but they shouldn't necessarily initiate care.'

Professor Avery adds: ‘It might be hard work for supervising doctors in the early stages but the queries will get less as nurse prescribers build up their competencies.'

But many GPs remain unhappy that nurse prescribers are responsible for defining and policing their own competencies.

Sheila Smith is an example of a nurse prescriber who knows exactly where the boundaries of her competencies lie. But will all her colleagues be as self-aware?

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