How far can NHS go on nurse prescribing?
By Daniel Cressey
The simmering unease over non-medical prescribing began to boil over last week, as a Pulse survey revealed the true scale of concerns among doctors over patient safety.
Only one in 10 of those polled through the website
Doctors.net.uk considered the current regulations on independent prescribing adequate to protect patients.
But although the Government's decision to hand nurses and pharmacists access to every drug in the BNF is controversial, few would argue with the growing role they are playing in delivering primary care.
Without nurses in particular, GPs' sessions would be even more heavily oversubscribed than they already are – and QOF points harder to come by.
Dr Peter Fellows, chair of the GPC prescribing subcommittee, believes a more limited expansion of prescribing roles would be sensible, as long as the legal burden for mistake did not fall on GPs.
'Provided they're taking responsibility for their own actions and have adequate cover, we don't mind. We'd be happy for them to take responsibility for minor illness and to some extent to supervise chronic illness. It depends on their level of training and responsibility.'
But Dr Fellows is unconvinced by the current training programme and regulations.
He says: 'There has to be an ongoing programme for updating pharmacists and nurses. We've been very keen they only prescribe in their areas of competence. We don't think the full BNF is sensible at all.'
Experts in prescribing believe nurses can play an important role in areas they have already started to move into.
Professor Tony Avery, chair of the UK drug utilisation research group and a GP in Nottingham, says: 'It's all the areas where nurses and pharmacists are working at the moment – minor injury clinics, chronic conditions like asthma and diabetes. There are quite a lot of areas like that they can work in.'
But he cautions: 'They have got very little training and one of the key things is ongoing mentorship and support.'
Questions remain over the responsibilities GPs will hold for the competence of nurse independent prescribers who they employ. Nurse prescribers insist they will be covered by their own medical insurance and responsible for their own actions.
But GPs do retain vicarious responsibility, and could be caught out if nurse errors increase.
Dr Karen Roberts, clinical risk manager at the Medical
Defence Union, says: 'If GPs have concerns, they have a duty to make sure they can show the nurse is competent if they're delegating tasks. In theory you could be held responsible for the staff you employ.'
Alongside unease over the
legal implications are lingering concerns over training.
Although few doubt nurses are trained to provide high-quality care for their patients, there are questions over the short courses for converting them to independent prescribers and whether they provide a suitable background in pharmacology.
In the case of pharmacists the concerns are different, focusing mainly on the lack of experience in safe diagnosis, as well as worries about access to facilities and medical records while examining patients.
The current training programmes involve only a month or so of education and supervised practice, after which nurses and pharmacists have access the same palette of drugs as doctors do, bar some controlled drugs (see box, right).
But the Royal College of Nurses defends its members
vigorously. Matt Griffiths, joint prescribing and medicines management adviser at the college, says: 'We have very rigorous training, purely around prescribing. There are a lot of doctors out there who are supporting it. It's definitely here to stay and not only in the UK – other countries in the world are also considering bringing it in.'
Such enthusiasm is not shared by everyone, with the quality of clinical governance another area to have come under scrutiny.
The current regulations rely on local guidelines at trust or practice level to ensure prescribers do not work outside their areas of competence.
The regulations state: 'The employing organisation must ensure nurse and pharmacist independent prescribing is
included within their overall
clinical governance framework, to ensure nurses and pharmacists practise safely and competently.'
But Dr Brian Crichton, honorary lecturer in pharmacology and therapeutics at the University of Warwick and a GP in
Solihull, is worried by the vagueness of these arrangements. 'Clinical governance is a very
important issue and this is in-sufficiently addressed in the
status quo,' he warns.
Other experts go further. Professor Hugh McGavock,
visiting professor of prescribing science at the University of Ulster, warns that increasing problems with nurse prescribing may emerge over time.
He says: 'To begin with, nurse prescribing will be overly cautious. When they get a bit of experience they will develop a false sense of security – really
serious adverse events occur rarely. This is going to lead to major problems. It's the same as expecting senior air stewards to fly jumbo jets after a month's training. Air travel would be awful without them – but they couldn't do the job of the people on the flight deck.'