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GPs go forth

How nurse prescribers will help practices gain quality points

Delegation and good diversity of skills will be a key to success under the new contract – Dr Helen Crawley explains how nurse prescribing, including extended and supplementary prescribing, can all help

Increasingly nurse prescribers are writing and signing their own prescriptions, improving the advanced access and chronic disease management provided by their practices – and saving GPs' time.

Suitably trained district nurses and health visitors have been able to prescribe from a limited list of mainly over-the-counter medication since 1994, but their activities had little practical impact on the working lives of GPs.

However, from 2001 training has been available for all nurses, including practice nurses, to become extended formulary nurse prescribers (EFNPs), able to sign prescriptions from a much wider formulary.

And last year supplementary prescribing was introduced, allowing EFNPs to sign prescriptions for anything – except controlled drugs – in co-operation with a doctor.

Extended nurse prescribing was set up to enable nurses to complete episodes of care by writing prescriptions. Nurses are allowed to treat conditions listed by the Department of Health by prescribing either over-the-counter medications or from their extended formulary.

EFNPs can prescribe in four categories:

•Minor ailments including conjunctivitis, otitis externa, dermatitis, constipation, acne, urinary tract infections, dysmenorrhoea, thrush and bacterial vaginosis

•Minor injury – this helps practices offer minor injury care as an enhanced service; it includes prescribing for soft tissue injuries and bites

•Health promotion including preconceptual advice, family planning and smoking cessation

•Palliative care, including prescribing for nausea, vomiting and pain control.

A full list of conditions treatable by EFNPs can be found at


The extended formulary is frustratingly small at present and contains only a few antibiotics for a very limited range of circumstances. However, it seems likely that it will gradually be expanded. This year's additions include HRT, emergency treatment for asthma attacks and hypoglycaemia, antibiotics for animal bites, trichomonas

vaginalis and chlamydia, and lignocaine for suturing.

Supplementary prescribing is an ideal mechanism for nurse prescribing in chronic disease management.

Under this system an 'independent prescriber' – for example a GP – makes a diagnosis. The EFNP or doctor then writes a clinical management plan listing the medications or classes of medication which could be used, and the circumstances under which doses should be changed or new prescriptions introduced. The clinical management plan can make reference to local or national guidelines. It must be agreed by the doctor and EFNP.

This is an excellent way to gain quality points. By setting up clinical management plans for new hypertensives, for example, practice nurses can increase dosages and introduce new medication to gain and maintain adequate blood pressure control.

Other quality areas that are ideal for supplementary prescribing include:


lcoronary heart disease


The nurse can review, renew and sign prescriptions, altering doses or introducing new medication in accordance with the clinical management plan. Warfarin monitoring could be offered as an enhanced service.

There are some administrative niggles with supplementary prescribing. The GP must review the patient and agree to the clinical management plan at least once a year.

Supplementary prescribing ceases if the GP who agreed the clinical management plan is no longer responsible for the patient, for example because they have left the practice.

But there are ways around these problems such as getting more than one doctor in the practice to sign every clinical management plan.

In order to qualify as an EFNP and supplementary prescriber, nurses need to attend a course comprising 26 taught days and pass an exam.

They must also undertake 13 days of practical experience mentored by a medical supervisor (doctor) who is able to assess their competencies in a list of defined areas.

Supervising nurse prescribers while on their courses is not a core service under the new contract but most practices find that the time saved in signing prescriptions eventually makes up for the effort of supervising a nurse.

Nurses accepted for training as EFNPs will generally be well paid as they should have the skills to complete episodes of care – except for prescribing rights – before they start the course.

Many nurses studying to become EFNPs qualify for backfill money, so a locum nurse can be employed to cover their study leave and this will not cost the practice anything.

Helen Crawley is a GP in Twyford, Berkshire, and visiting lecturer at the University of Reading School of Health and Social Care

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