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Daniel Cressey looks at the implications of giving nurses and pharmacists virtually full prescribing powers

The Government blurred the traditional boundaries between NHS staff as never before last week, as it handed nurses and pharmacists virtually full prescribing powers.

It was the latest in a series of initiatives that have chipped away at doctors' monopoly on prescribing and diagnosis, coming less than a month after the announcement of the curriculum for the new medical care practitioners.

But while some GPs hope providing pharmacists and nurses with access to the whole formulary ­ bar controlled drugs ­ will relieve the workload burden, prescribing experts have serious reservations over patient safety.

Professor Hugh McGavock, visiting professor of prescribing science at the University of Ulster, warned: 'Nurses' knowledge of diagnosis and therapeutics will be very inadequate, resulting in a high level of risk to their patients.'

Professor Tony Avery, professor of primary health care at the University of Nottingham and a GP in the city, called the proposal 'one of the most far-reaching extensions of prescribing by nurses and pharmacists anywhere in the world'.

But he added: 'I wasn't keen on things going as far as they have. Our concerns were this is a relatively new thing ­ it hasn't been evaluated. It certainly would have been worth waiting a couple of years.'

Training is a key area where doctors have concerns.

Dr Peter Elliott, prescribing lead for Redbridge PCT and a GP in east London, said: 'The question is: are people going to have had enough training to fit the extended role?'

Dr Brian Crichton, honorary teaching therapeutics and pharmacology lecturer at the University of Warwick and RCGP prescribing adviser, said nurses were well-equipped to take histories of acute conditions such as sore throats or coughs, but needed training on chronic conditions.

'If this is going to occur very significant nurse training will need to support it.'

At present, nurses undergo 38 days' training to become extended formulary nurse prescribers. The Department of Health is still finalising details of the proposals and it is unclear whether nurses will require additional training, or how much training pharmacist independent prescribers will undergo.

But Professor McGavock, a former member of the Committee on Safety of Medicines, believes the training will be nowhere near sufficient.

He said: 'The CSM in 2000/1 recommended senior nurses must undergo one year's full-time academic training covering both diagnosis and the vast science of medication. At the end of that, they might prescribe a limited range of drugs. That advice was largely ignored by the department.'

The BMA has demanded an urgent meeting with Health Secretary Patricia Hewitt to discuss the Government's plans.

Dr Hamish Meldrum, GPC chair, said: 'We did support some extension to nurse prescribing and limited roll-out of pharmacist prescribing.

'The distinction we're trying to draw is that the training of all three professions is different. It's only our training that's comprehensive on the pharmacology and diagnostic side that would allow us to prescribe the whole pharmacy.'

But prescribing experts stress that while nurses and pharmacists will have access to the whole formulary, in practice they will only prescribe in their areas of specialism. Professor Avery said: 'Particularly in things like asthma and diabetes and travel you can see nurses having an important and appropriate role.

'When we're talking about complex care that clearly seems to be most appropriate for [doctors] to deal with.'

Professor Claire Anderson, director of the University of Nottingham's Centre for Pharmacy, Health and Society, said: 'The patient safety issues are important. What is important is that nurses are prescribing only in their areas of competency.'

But Dr George Rae, member of the GPC prescribing subcommittee, said there were concerns that prescribers might start to move outside their specialties as things got 'hazy' in the future.

'That is a concern within the medical profession. We have all the greatest rules, regulations and criteria but it tends to get a bit fuzzy round the edges as things move on,' he added.

The BMA wants limits written into regulations on the specialist areas pharmacists and nurses can prescribe in.

But many specialists from a pharmacist and nursing background insist opening up prescribing powers will improve patient care.

Dr Sue Latter, reader at the University of Southampton School of Nursing and Midwifery, said her evaluation for the department had found nurses, patients and doctors viewed independent nurse prescribing positively.

Dr Latter told Pulse: 'Our evidence indicated patients were very happy with the current form of nurse prescribing. I don't see any reason why that pattern wouldn't continue [with new proposals].'

Professor Anderson added: 'It's going to facilitate better patient care. People will be able to have consultations outside the eight-minute GP consultations.'

If concerns over training and patient safety can be met many GPs could be in favour ­ workload issues may be key to winning them over.

How the shape of prescribing

will be changed by proposals

NOW

Extended formulary nurse prescribers

· Around 6,000 currently, two-thirds in primary care

· 30 days' training

· Prescribe and manage 110 conditions with a formulary of 240 prescription-only medicines

Supplementary prescribers

· Around 450 pharmacists and 5,700 nurses

· Prescribe medicines specified in clinical management plans

FUTURE

Extended formulary nurse prescribers

· Will have access to full BNF, apart from controlled drugs

· Extra training may or may not be required

Pharmacist independent prescribers

· New category of pharmacists to have access to the full BNF

· Training to be determined

Supplementary prescribers

· Role to continue

Medical care practitioners

· New category of health care professional; range of medicines available to MCPs is currently out to consultation

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