Lessons we've learned in moving to new premises
Dr Peter Stott outlines the benefits for practices in the development of the role of the nurse practitioner
Until recently, one of the major stumbling blocks to the development of the role of the nurse practitioner (NP) was that NPs could not issue or sign prescriptions. Extended independent nurse prescribing, which began in 2002, was widely hailed as heralding a sea change in patients' access to medicines; but initially this only enabled suitably qualified nurses who had been district nurses or health visitors to prescribe a handful of products, most of which could already be obtained without a prescription.
That situation has changed with the publication of a new and quite comprehensive nurse prescribers' extended formulary (NPEF) see back pages of the BNF. This includes such potent medicines as antibiotics, HRT, NSAIDs, H2 blockers, prednisolone, norethisterone and most vaccines.
Independent nurse prescribing
Nurses able to prescribe from the NPEF must have received training as 'independent prescribers'. Initially, this was a separate qualification and indeed any degree-level nurse may still obtain it after a short course. Since 2004, however, independent prescribing has been included in the training for supplementary nurse prescribing.
Nurse practitioners trained as supplementary prescribers are automatically independent prescribers too, able to prescribe from the NPEF.
With their training in acute minor illnesses, this means they can see patients with everyday illnesses in their own clinics, diagnose them, treat them without recourse to a doctor,
prescribe from the NPEF and sign their own prescriptions from their individual pad.
It is important to realise though that there are major differences in the legislation which covers extended nurse prescribing (when nurses act as independent prescribers from the NPEF) and supplementary prescribing (when they prescribe in partnership with a doctor).
When acting as supplementary prescribers, nurses can prescribe from the whole of the BNF, except for some scheduled drugs.
Independent prescribing is not the same as supplementary prescribing (SP). The current supplementary nurse prescriber training is a university course that involves a 25-day course delivered over a period of three-six months with 12 days of supervised prescribing after the initial course.
It began for nurses in 2002 and for pharmacists in 2003. Originally it was seen as a way to move these professionals into higher roles within specialist therapy areas. It was thought that most supplementary prescribers (SPs) would restrict their work to specific therapy areas like hypertension, hypercholesterolaemia, lithium or anticoagulation clinics. In reality, however, one of the biggest groups of applicants has been nurse practitioners from primary care.
The original Crown Report1, Section 63 of the Health and Social Care Act 2001 and the Department of Health document MLX 284 dictate that SPs must work in close collaboration with the two groups of existing prescribers, ie doctors and dentists, who somewhat confusingly were also to be known as independent prescribers (IPs).
IPs remain responsible for diagnosis and clinical management decisions while SPs take responsibility for the continuing care of patients.
Individual clinical management plan (ICMP)
The Act (Section 63 of the Health and Social Care Act 2001) enables SPs to prescribe within limitations set out in a signed individual clinical management plan (ICMP). The legislation dictates that this should be a written plan, specific for each patient and designed in consultation with them, and that it
will be signed by both IPs and SPs to confirm mutual ownership and responsibility.
It will contain details of the patient's history and future management and will define the limits of the supplementary prescriber's power and responsibility.
SP and long-term care
SP is intended for long-term conditions like hypertension and asthma. To use hypertension as an example, the ICMP might define the range of target blood pressure to be achieved, the drugs and range of doses that could be used.
It will specifically mention drugs that are contraindicated and situations in which the supplementary prescriber should refer the patient back to the independent prescriber.
The legislation expects that SPs will be professionally responsible for monitoring and assessing patients' progress and that if they develop new problems while under the care of a SP, patients should be referred back to the IP. When patients are admitted to hospital, the ICMP will be suspended.
When patients are discharged it will be reinstated, or a new ICMP will be initiated. If the ICMP is faulty then the IR will retain vicarious liability even though the prescription may have been issued by the SP.
So supplementary prescribing is useful in primary care when nurses work in chronic care clinics. It enables them
to change therapy and to issue prescriptions for any drug mentioned in the ICMP.
Problems with ICMPs
Creating, debating and signing ICMPs for individual patients is time-consuming and impractical in a busy surgery. As a result, to date there is little experience of it in general practice.
However, creation of the ICMP could be linked to a formal medicines management review as required by the new GP contract. At Tadworth Medical Centre we are debating how this might be managed by a pharmacist and the benefits it might bring.
Prescribing by nurses is advancing rapidly and there are now more than 4,000 nurse prescribers in the UK. The relative inexperience of nurses when they begin prescribing has lead some to criticise this rapid growth and to suggest that it may result in an increased number of adverse reactions and inappropriate prescribing. In defence, one might point to the similar difficulties experienced by young doctors when they qualify.
Becoming an effective prescriber obviously does not end with the completion of a short course. The nurse prescribing qualification should not be seen as an end in itself, but rather the beginning of a supervised period of continuing experience which will
benefit the nurse, the mentor and the patients.
1 Crown J. Review of prescribing, supply and administration of medicines: final report (the Crown report). London: Department of Health, 1999
2 Medicines Control Agency. MLX 284: proposals for supplementary prescribing by nurses and pharmacists and proposed amendments to the prescription-only medicines (human use) order 1997. London: MCA, April 16, 2002
3 Royal Pharmaceutical Society of Great Britain. RPSGB Task Group Report. London: RPSGB, September 2002
4 Jackson C. Prescribing from policy into practice. Medicines Management 2002 (September/October); 1(5): 14
Peter Stott is a GP in Tadworth, Surrey