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Nurse prescribing: logical or unsafe?

The row over non-medical prescribing took a new twist recently with a warning from the Commission on Human Medicines over monitoring the safety of the new system. This follows a change in the law this year to allow suitably trained nurses to prescribe from the whole BNF except some controlled drugs.

Here, a GP who trains nurse prescribers and a GP opposed to the inexorable expansion of prescribers debate the issues by e-mail

The row over non-medical prescribing took a new twist recently with a warning from the Commission on Human Medicines over monitoring the safety of the new system. This follows a change in the law this year to allow suitably trained nurses to prescribe from the whole BNF except some controlled drugs.

Here, a GP who trains nurse prescribers and a GP opposed to the inexorable expansion of prescribers debate the issues by e-mail

Olly O'Toole is a GP in Dunstable, Bedfordshire, a former GP trainer and course organiser for GP and practice nurse training courses

Mandy Fry is a part-time salaried GP in Cirencester, Gloucestershire, and senior lecturer in primary care at Oxford Brookes University where she is part of the team leading the non-medical prescribing course

Dear Dr Fry

I, like other GPs, use my practice nurses to deal with minor illness and chronic disease. I have no problem with them prescribing within their specialised knowledge area after suitable training. I also have experience of hospital-based nurse specialists. Allowing them to prescribe in their specialised area makes sense.

What I object to is nurses being allowed to prescribe anything in the BNF (except some controlled drugs). Outside their specialised areas, the nurses I know do not feel confident about prescribing other drugs, and would never do so even if allowed. Allowing anything to be prescribed is dangerous: how can we be sure that a nurse will not exceed her limitations?

Of course there is training involved, but some reports quote as little as three months. If you add this to a nurse's three years of training and two years of work experience, it makes a maximum of six years. Compare this with the nine to 10 years' training needed to become a GP.

Also, there is more to treating illness than prescribing drugs: doctors have to examine patients and consider alternative (differential) diagnoses, and follow up their patients carefully. Nurses can be trained to do this, but not across the whole spectrum of disease areas.

We do not want to wait until any harm happens to patients: we should plan that no harm if possible can come to patients.

My real fear is that we are in danger of fragmenting our role and becoming like consultants, and thus losing the regular contact we have with our patients.

Olly O'Toole

Dear Dr O'Toole

Prior to May 2006 independent non-medical prescribing involved prescribing from a limited formulary of drugs for specific medical conditions.

It contained numerous idiosyncrasies such as being able to prescribe amoxicillin for a UTI but not for a chest infection, and ipratropium bromide inhalers for asthma but not for COPD. Opening up the formulary has removed these restrictions and enabled non-medical prescribers to use their initiative and expertise.

It has not, however, removed their professional accountability to prescribe only within areas they feel competent in and to suggest that they would do otherwise is to deny them any sense of professionalism.

I would argue that is an unfounded allegation.

It is also certainly not my experience, either in practice or as a tutor on the non-medical prescribing course at Oxford Brookes. The reality is that the training they receive, while short, makes them much more aware of the potential difficulties associated with prescribing and much more cautious about prescribing anything at all. There is also widespread recognition that prescribing involves so much more than just writing a prescription, that there is the whole area of assessment and diagnosis to consider.

To that end the Nursing and Midwifery Council (NMC) has recommended that no one should be accepted on to a prescribing course without having done some prior study in the area of assessment and diagnosis (these recommendations come into force next September). Their training also involves the submission of an extensive portfolio of evidence as to their prescribing competencies and a stringent exit exam, in the form of an OSCE.

Opening up the formulary means nurses will be able to do exactly those things that you are happy for them to be doing – dealing with minor illness and chronic disease management. Yes they could do much more but there is absolutely no evidence that they will. After all I am allowed to prescribe from the BNF in its entirety but I don't; I prescribe for those conditions I feel competent to prescribe.

Non-medical prescribing benefits patients as it enables them to get their entire treatment from one practitioner. However I believe it also benefits us as GPs. It means an end to practice nurses loitering outside surgery doors expecting us to prescribe for a patient they have assessed. It also enables us to have more time with patients to deal with the messy complexities of practice that are really at the heart of what we do.

Mandy Fry

Dear Dr Fry

I disagree strongly with your statement that lifting the restrictions allows nurses and others to use their initiative. It implies too much freedom, and could be very dangerous. Take the scenario of a patient with an exacerbation of COPD who also suffers from ischaemic heart disease and impotence. Would the non-medical prescriber prescribe something for that as well, or seek further advice from a doctor?

They should use their knowledge and expertise, always bearing in mind their own limitations as well as their areas of competence.

We have seen too many experiments in the NHS without enough research into the benefits of the proposed changes. I am not questioning the professionalism of nurses, what I object to is relying too much on their professionalism without enough knowledge or training.

Your reply contains some alarming admissions, namely that the training is short, and that applicants should demonstrate evidence of study in the area of assessment and diagnosis. From my 19 years' experience as a trainer of GPs I know it is necessary to test that the candidate has the attitudes, knowledge and skills required. This has been formally agreed in summative assessment. We need to have an equivalent for non-medical prescribers (I prefer the term nurses).

I agree there could be advantages. If it were just a matter of formalising what most of us do in our practices with minor illness and specialist nurses, then I would agree but it is opening the floodgates that I object to.

Full non-medical prescribing also demands regular audit and clinical governance meetings on the subject. Thus, it might not save as much medical time as is suggested.

Olly O'Toole

Dear Dr O'Toole

Clearly if a non-medical prescriber was faced with a complex clinical scenario, outside of their area of competence, then they would seek further advice. One of the specific competencies that we assess is their ability to recognise their own limitations. Their decision-making is based on knowledge and expertise, just as ours is.

My suggestion that they might use their initiative does not mean I would expect them to instigate new treatments or expand their role beyond either their competence or the scope of practice that had been mutually agreed with their employer (which in a practice nurse setting would be the GP partners).

Just because other experiments in the NHS have not been successful does not mean that we should halt all new developments. I find it hard to argue against a hypothetical argument which has absolutely no foundation. I can only reiterate that my experience does not fit with your concerns.

I must take issue with your comments on training. Just because a training programme is short does not mean it is not sufficient. If that were true does that mean GPs are trained less well than their consultant colleagues, as GP VTS lasts three years compared to the four or five years in hospital-based specialties?

You mention that you think we need to have an equivalent test to summative assessment for non-medical prescribers to ensure they have the appropriate attitudes, skills and knowledge required.

Summative assessment is the exit assessment of GP VTS and I consider the final assessments of the non-medical prescribing course to be comparable in many ways: there is a written component involving practice-based evidence of achievement of competencies, there is an OSCE, and there will shortly be a pure knowledge test in the form of a pharmacology MCQ.

Then they have to renegotiate the terms of their job description to incorporate (and if desired by their employers, set limits on) their prescribing role. What extra assessments would make you more confident as to their competence?

You talk about opening up of the floodgates. This is a theoretical possibility which is not borne out by experience. Developing a further limited formulary would only have created further idiosyncrasies.

Clearly ongoing professional development of non-medical prescribers is important, as is looking at the wider impact of it in terms of service provision and patient experience.

I agree that if that is done fully the actual medical time savings may be less than the Government predicts but that's not an argument for not developing non-medical prescribing. There are many other positive outcomes that could be assessed such as patient experience and recruitment and retention of practice nurses.

Mandy Fry

Dear Dr Fry

I think we are reaching a common ground in this discussion. It would appear that you train non-medical prescribers who work closely with doctors, such as our minor illness practice nurses.

I am totally in favour of this approach in primary care, which builds on the good knowledge base and relationships between practice nurses and GPs.

I, too, believe in change: but I also believe in evidence-based medical practice. Yet I have to ask, if the argument about failure to recognise boundaries of competence has no foundation, why do non-medical prescribers have access to the whole of the BNF except some controlled drugs?

It seems to me that you have accepted my argument that candidates will have to be accredited to prescribe in specific disease areas in which they work.

I am willing to accept your argument that there may need to be some common areas, such as prescribing antibiotics for skin infections. You also seem to have accepted my argument that their practice will have to be limited.

I have to take issue with your statement that opening up the floodgates is not borne out by experience. What experience? Where is the evidence? Either you set the clinical conditions or a formulary specific to the prescriber's area of working. If you can't control what you want to do, you should not do it.

I am not arguing against the development of non-medical prescribing, I am in favour of it. The main point is that there must be limitations, for the reasons outlined above. If not, then what is the point of training people to be doctors in the first place?

Olly O'Toole

Dear Dr O'Toole

I agree that if there are no concerns about nurses using their qualification beyond their clinical competence that it is illogical that controlled drugs are restricted. However, the reality is that much of the legislation and concerns surrounding the use of controlled drugs is part of the Harold Shipman effect.

I believe, and my experience suggests, that non-medical prescribers will set their own limits on what they prescribe, according to their area of specialism and therefore competence.

I also recognise, however, that many employers (including GP partners), perhaps fuelled by some of the recent allegations in both the medical and lay press, will set their own restrictions on what they are happy for their employed non-medical prescribers to prescribe.

These restrictions will be motivated by fear as to the theoretical possibility of something going wrong, not by the reality. I believe that nurses' own professionalism will 'control what (we) want to do' (as you put it).

I believe my training as a doctor, and as a GP, prepared me for so much more than a prescribing role. I would suggest that there is room for both non-medical prescribers and doctors to work together harmoniously, complementing one another's roles.

As non-medical prescribing is already here I think, as medics, we have two choices – either we campaign for it to be reversed or we get involved in maintaining standards and seeking evidence as to its effectiveness and safety.

Thank you for taking the time to debate the issue.

Mandy Fry

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