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ANP annual conference: diversity, change and standards

November 22, 2011 by admin 

The nursing profession can congratulate itself on the way it has handled non-medical prescribing, as other professional groups now take on these responsibilities, said Dr June Crown CBE, President of the Association for Nurse Prescribing (ANP), at the start of its annual conference held in London recently. Despite the frustrations accompanying the occasionally slow progress made since the Cumberlege review 25 years ago, much has been achieved. The course is set now, even if it is slow: no more battles lie ahead.

Dr Crown added that prescribing “is of its time”: we have an ageing population whose multiple chronic diseases are increasingly being managed outside hospital by non-medical health professionals, often using prescribing to deliver the full range of care. When non-medical prescribing was first introduced, it was not defined by the setting in which it occurred: how prescient this has proved now, as different settings become intertwined and the boundaries blurred. Huge challenges lie ahead in healthcare given the financial regime, but this does provide opportunities to develop how care is delivered even further and prescribing will be central to this.

Of course, regulation and professional standards must be robust, whatever the setting, and keep pace with the changes -  this was a theme reiterated throughout the day.

Much has happened since 2006, and Fiona Culley, Professional Adviser to the Nursing and Midwifery Council (NMC), explained that work has now started on revising the NMC standards, both for prescribing and for medicines management. They will be combined, clarified and updated, with new education standards also underway. Consultation will be wide - do look out for developments and contribute. The National Prescribing Centre (NPC) is developing a single competency framework for all prescribers, with publication due in March 2012.

Most of the calls received by the NMC advice centre relate to prescribing and medicines management: remote prescribing, private prescriptions, methods of supply and administration, storage of drugs and controlled drugs are particular favourites. The bottom line is that meeting regulatory and legal requirements is not optional - whatever the setting or circumstances - and there can be no private agreements. The NMC is the regulatory body for nurses and midwives - it is irrelevant if GPs, for example, disagree with its standards. And different professional bodies adopt different lines, on self-prescribing for example. The GMC has consulted recently on medicines and prescribing standards and has asked about sports medicine in particular - the final version is due out soon.

The NMC is now hearing more fitness to practise cases than in the past, probably reflecting greater reporting because of increased media attention and public awareness. Only a handful of these have concerned prescribers, but many more relate to people who are not prescribers but think that they might be! As of September 2011, there were 57 838 nurse and midwife prescribers recorded by the NMC.

The conference included two workshop sessions with several choices for each, so delegates could follow their interests. One was a sobering but fascinating account of the state of diabetes care by Dr Rowan Hillson MBE, National Clinical Director for Diabetes, focussing particularly on the scale of the problem from a public health perspective and on some of the failures of the system when people with diabetes end up in hospital - as they so often do.

The scale of the problem is shown starkly with the Association of Public Health Observatories prevalence model: the 2010 estimate for people over 16 with diabetes is 3.1 million; by 2030 this figure is 4.6 million. Dr Hillson highlighted the importance of integrating services across settings in the NICE Quality Standards for Diabetes, stressing that for patients there should be no boundaries between care settings; and for professionals taking responsibility when they notice problems, ranging from getting specialist foot teams to see people with foot problems, to immediate referral for children with high blood glucose who may have diabetes. Dr Hillson also raised the question of why the under 55s are not doing better with their glucose control - and why they do not seem to be getting statins - are services really set up to meet the needs of the working population? Who influences your prescribing decisions and why do you make the decisions you do? All sorts of factors come into play here - local formularies, representatives of pharmaceutical companies, consultants and GPs, and NICE.

The 2010 National Diabetes Inpatient Audit captured data about the people in hospital on one day, with some exclusions. This revealed that up to a quarter of beds were occupied by people with diabetes but 31% of sites had no inpatient diabetes specialist nurses, with nearly as many having no inpatient dietetic provision for people with diabetes. The foreword pulls no punches about the report’s findings: “compared to the general inpatient population, people with diabetes in hospital are older, sicker, have more complex disease and stay longer. It also shows that they suffer frequent medication errors and not infrequently come to harm as a consequence…..many hospitals have under-staffed and under-resourced diabetes teams.”

Dr Hillson finished as she began - with the powerfully simple message that everyone with diabetes deserves the highest standards of personalised diabetes care. The discussion which followed highlighted the importance of good communication and joined-up care, and how nurse prescribers need to ensure their patients receive this, particularly with all the changes.

Another hot topic at the moment is prescribing and medicines management in aesthetic medicine, where the workshop was led by Karen Ford, Senior Lecturer and Non-Medical Prescribing Lead at De Montfort University.

Some aesthetic nurses work in large organisations and some on their own but whatever the setting, practice should be professional and the laws and regulations on prescribing and medicines management followed to the letter. Nurses are professionally accountable to the NMC for their practice - what the GMC says is irrelevant - they have to follow their own standards and regulations. Professional accountability and reporting concerns are professional duties.

The workshop looked at some of the issues around stock management, stressing that stock becomes the patient’s property when a prescription is issued, the use of patient specific directions and patient group directions, where there has been confusion, and the use of the same drug under different names because of licensing. The whole remote prescribing issue again brings out the importance of professional standards: nurses must follow the NMC advice whatever other professionals may say.

How can non-medical prescribing in mental health be developed and sustained? What actions are needed to deliver safe, high quality prescribing within an organisation? Steve Turner, a nurse prescriber, director of  a social enterprise company and Associate Lecturer at the University of Plymouth, led a workshop looking at these issues.

He started by looking at three key documents (see here and here) and discussing how a model of successful change can be applied to the situations faced by delegates. With this as a basis, the discussion then turned to the remaining difficulties and obstacles in the implementation of non-medical prescribing in mental health, and what is needed to make it successful. A common quality assurance framework incorporating best practice from all service areas is needed, and it is important at a time of change to demonstrate the value of non-medical prescribing including involving patients and public in service developments, perhaps using audits and national and local patient and staff satisfaction surveys. It is also important to educate staff, patients and the public about non-medical prescribing.

The workshop discussion produced a checklist of items vital for adequate planning and for support for newly qualified non-medical prescribers, which delegates felt should all be included in local policies. Items included dedicated medical supervision and consultant/medical support; peer support (including within specialties); regular non-medical prescribing meetings; induction packs and preceptorship; access to continuing professional development (CPD); the issue of  CPD portfolios which can be used in review sessions; involvement in audit and service evaluation; mentoring and buddying; development of career pathways; and education about the benefits of non-medical prescribing for the entire workforce.

Another workshop that highlighted the importance of CPD and education for professionals, and also good education and resources for patients, was on breakthrough cancer pain (BTcP). It was facilitated by Ray Bunn, Community & Palliative Care Pharmacist, Kamsons Pharmacy and St Catherine’s Hospice, Crawley, West Sussex.

After a presentation on the definition, assessment, diagnosis and management options for BTcP, participants discussed and identified key issues that should be addressed to improve the management of BTcP in secondary, hospice and primary care settings.

For healthcare professionals, one issue was inconsistent understanding of the terms ‘breakthrough cancer pain’ and ‘end of dose’ pain. Other issues and barriers included: inadequate understanding of the role of opioids in BTcP, including which options are appropriate; the indications, prescribing and baseline opioid dosing if a ‘rapid release fentanyl’ is considered; the fact that primary care has not really embraced the increased profile of rapid release fentanyls with, perhaps, the exception of Actiq; concerns about their use and the potential for tolerance and addiction; and potential side effects and how to manage them.

For patients, better understanding of dose titration for the various opioids used for BTcP and the relative complexity of titration would be helpful. There are also some availability issues for some preparations from pharmacies, especially rapid release fentanyls.

All this led to the conclusion that more education and educational resources are needed: for professionals, including more accredited CPD; more verbal patient education including one to one patient and carer education by healthcare professionals; and more patient education resources, for example Patient UK information leaflets, which are used extensively in general practice and community pharmacies.

Dr David Edwards is a GP with an interest in sexual medicine - he is president elect of the British Society of Sexual Medicine and has a post-graduate degree in medical anthropology. He led workshops on sexual health that followed the interests of the participants using case studies as a starting point for discussion.

Something that emerged as a common issue was getting the patient comfortable in talking about sexual matters and the discussion also touched upon the difficulties that the healthcare professional might have in asking about such matters. Many aspects of female sexual problems were covered, particularly vaginismus, which many delegates had encountered.

The importance of erectile dysfunction and testosterone deficiency syndrome were discussed, along with the lifestyle issues that are often found and the importance of encouraging patients to help themselves, using a COSH (contract of sexual health). This metaphorical tool enables the patient to help himself whilst the healthcare professional encourages him on lifestyle issues and adjusts factors such as glucose and blood pressure monitoring for example. The clinician, in return, helps the patient deal with the medical treatment aspect of the sexual dysfunction.

The need to demonstrate the impact of non-medical prescribing on patient care, and examine how it works, was raised several times at the conference so the presentation towards the end of the day by Non-Medical Prescribing Lead Sam Sherrington about the audit of non-medical prescribing in NHS North West was very timely. The results demonstrate reductions in GP appointments, consultant appointments, unscheduled care episodes, length of hospital stays, and medicines-related admissions. Clinicians really were prepared to participate and the results demonstrated how non-medical prescribing can support the QIPP agenda.

As other sessions had highlighted, the legal aspects of prescribing can be a complex area and clarity is vital. Emma Galland, a solicitor-advocate at Weightmans LLP who trained at a hospital trust, provided a robust and clear outline of the current situation.

She highlighted those parts of legislation and of the NMC Code and standards that are particularly relevant to prescribers working in different settings. For example, colleagues must be informed when care is shared; this is especially relevant if prescribing is in the community but the patient may need admission. Professional judgement must not be influenced by any commercial considerations. The 2010 Bribery Act is relevant here and prescribers should always be clear that there is a clinical basis for decisions.

The NMC also recommends that nurses have professional indemnity insurance, and this is even more important if extra responsibilities such as prescribing are involved. In her view, having indemnity cover is part and parcel of being a professional. There was a lot of discussion about the change announced recently by the RCN (see here for further information on this). ,

Using abbreviations is one example of the risks involved in writing prescriptions: one example was someone moving from intensive care to the ward coming off a sliding scale who was prescribed 6U of insulin, despite the BNF specifying that U should not be used for units. He was given 60 units and subsequently died. Another example is the security of prescription pads - best practice is to return pads at the end of the day or session so that they can be stored securely.

Another tricky area is that of consent and capacity to consent. Capacity involves the ability to understand the information provided, to retain it, to weigh it up in making a decision, and to communicate the decision by any means. Consent is needed specifically for supplementary prescribing, which must be explained to the patient preferably by the independent prescriber. The patient’s agreement needs to be documented. Consent is also needed for any treatment. If treatment is given without consent, it is an assault.

If an adult is assessed as not having consent, their best interests must be assessed holistically, taking a range of factors including social, religious and cultural, into account. To a limited extent, it is possible in these circumstances to talk to family and friends, but as little confidential information as possible should be disclosed. She also discussed the issue of children consenting or refusing to consent, and what Gillick competence means. This can depend on the consent required and the consequences of the decision.

ANP urges Prime Minister to act on controlled drugs legislation

April 28, 2011 by admin 

“We can therefore see no reason for continuing delay” in making the necessary changes to controlled drugs legislation (see here), writes ANP Chair Barbara Stuttle recently in a letter to the Prime Minister, David Cameron. She points out that all political parties and all professional groups support the changes and that, until they are implemented, very seriously ill people are facing delays in getting adequate pain relief. One consequence can be unnecessary hospital admission.

ANP endorses Therapeutics Plus

April 28, 2011 by admin 

The Association for Nurse Prescribing (ANP) has endorsed a free, online, continuing professional development resource, Therapeutics Plus, aimed primarily at non-medical prescribers. It has been developed by Prescriber, NPC Plus and Keele University and is funded by Pfizer. There are modules available now on the management of chronic asthma, neuropathic pain, smoking cessation and chronic obstructive pulmonary disease (COPD) and more will follow.

December updates from CKS

December 16, 2010 by admin 

More new topics have been added to the Clinical Knowledge Summaries (CKS) website in December: cervical cancer and HPV; diabetes type 1; diarrhoea - adult assessment; pancreatitis - acute and chronic; and pityriasis rosea.

Nurse prescribing chimes with economic and political realities

December 8, 2010 by admin 

The enormous changes coming to the NHS and the harsh economic climate present real opportunities for the development of nurse prescribing: this was the message that emerged throughout the day at the recent ANP annual conference held in London.

A time of “great turmoil” in the NHS provides “great opportunities through greater diversity of healthcare delivery” said Dr June Crown CBE, President of the ANP, in a rallying cry for nurse prescribers to take the chance to be innovative while celebrating the progress made - and building on it. The provision of better services, more coordinated care, reaching hard to reach or vulnerable groups, the list goes on.

What are the distinctive features of nurse prescribing - is it ‘doctor prescribing on the cheap’ or does it offer something truly different? Molly Courtenay (professor of clinical practice: prescribing and medicines management, University of Surrey) and colleagues have done a lot of work on how nurse prescribing is perceived by different groups, most recently looking at patients’ views of nurse prescribing, and how they see their relationships with the nurse prescriber (results published here and here). After more than 80 interviews with patients with diabetes or dermatological conditions being cared for by a nurse prescriber, common patient views included: nurses are more knowledgeable than GPs for specialist areas; nurses have more time for discussion; and nurses are more caring, relaxed, approachable and easy to talk to than doctors. Clearly, there is indeed something distinctive going on here, with positive implications for concordance, continuity and efficiency.

Patients were confident about nurse prescribers - one reason for this was the high level of specialist knowledge and experience: in diabetes prescribing in particular, appropriate training and experience were seen as very important. Future research plans from this group include measuring outcomes - not always easy as the prescribing qualification can often change people’s practice over and above the actual prescriptions they write.

A sense of proportion is vital in balancing complacency and fear, according to Fiona Culley (Professional advisor: non-medical prescribing and medicines management at the NMC). She pointed out that there have only been two fitness to practice allegations involving nurse prescribers (both were fairly extreme examples) and that standards and documentation can help nurse prescribers strike the right balance. She urged the audience to engage with the development of the profession, respond to consultations, and keep up-to-date with current standards, guidance and advice, pointing them to useful resources such as the updated advice sheet on the NMC website (see Links ) about mixing medicines. Figures from the NMC for November show that there are now more than 58 000 nurse and midwife prescribers in total, with about 21 000 recorded against the V300, extremely encouraging statistics.

Changes in doctors’ attitudes to, and support for, non-medical prescribing were highlighted by a speaker from the BMA speaking in a personal capacity. Dr Bill Beeby (GP and Chairman of the BMA General Practitioners’ Committee’s Clinical and Prescribing subcommittee) used a splendid wizarding (you had to be there!) metaphor to remind the audience of the initially vigorous opposition to non-medical prescribing in certain medical circles. This was another salutary reminder of those first, tiny steps…..and of the distance travelled since then.

Current attitudes are, of course, much more positive and recent research and the experience in his practice have confirmed the benefits of non-medical prescribing. He urged caution and care in some particular areas. One was the importance and challenge of training and support, and how mentoring can improve mentors’ skills - as long as they understand the process; ensuring the independence of training courses is also vital. Another was supervision, where his practice uses random case analysis, and a third the increased marketing and promotion aimed at nurses. Dr Beeby also advocated resisting pressure to prescribe unlicensed medicines. One suggestion for improving accountability is improving the quality of information, by giving all prescribers a unique number so they are accountable for all their prescriptions, wherever they are written.

Efficiency without quality is unthinkable and quality without efficiency is unsustainable, said Chief Nursing Officer Dame Christine Beasley, as she examined how nurse prescribing supports the current priorities of improving health and wellbeing, QIPP (Quality, Innovation, Productivity and Prevention), personalised care and patient choice. Examples include nurse prescribers taking nicotine replacement therapies and smoking cessation services to mosques and football matches, providing whole episodes of care in A and E departments, particularly for minor injuries and ailments and pain relief, running specialist clinics in secondary care, and improving concordance, access to medicines and clinical outcomes in mental health services. All these illustrate how clinical quality and efficiency now go hand-in-hand.

Looking forward, the controlled drugs legislation has been agreed by ministers and is now awaiting implementation by the Home Office (see here). Even more opportunities for innovation and development in nurse prescribing include more prescribing for patients with co-morbidities, enabling service re-design, and adopting a more strategic approach now that nurse prescribing is well established and integrated in the management of patients’ conditions. The national evaluation commissioned by the Department of Health is about to be published and will provide more evidence about patient satisfaction.

A vision of the future for information prescribing and prescribing was presented by Coleen Milligan and Kathy Drayton from the Department of Health: “paper is no longer fit for purpose”. They stressed the many benefits of electronic prescribing and the use of mobile technologies, commenting that in a time of limited resources, it will be very important for early implementers to help build the evidence base about the savings achieved through, for example, the reduction in adverse drug reactions. This will start to show how the benefits can replay the investment.

Four workshops - from which those attending could choose two - looked at specific areas in more detail, with lots of opportunity for discussion and questions. Dr Clive Grundy, Consultant Microbiologist, Ashford and St Peter’s Hospitals NHS Trust) provided a public health perspective on antibiotic use, including some fascinating examples of the effects of health tourism and travel on bacterial resistance and up-to-date information on patterns of resistance, with case studies and advice about what to prescribe when. He stressed that any antibiotic use selects for bacteria resistant to that antibiotic.

Alison Dugdale (Senior Nurse Practitioner, Minor Injury/Walk-in Centre Service, Eastern and Coastal Kent NHS Community Services) looked at prescribing for soft tissue injuries and sports injuries, with a reminder about non-pharmacological management and that pain is what the patient says it is. Dr David Edwards, in an interesting whistle-stop tour of sexual dysfunction looked at erectile dysfunction, stressing the implications of its link with diabetes, female sexual dysfunction, treatment of sexual trauma, and how to raise the subject and what patients expect. Claire Westwood (Director of happynurses) talked about “the 9Cs of inspired leadership” in nursing.

Throughout the day, speakers highlighted the progress made since district nurses and health visitors took the first tentative steps towards full independent prescribing. Nurse prescribing can drive or facilitate innovative service redesign, more personalised care, better concordance and co-ordinated care, efficient and safe access to medicines, increased patient choice and, of course, better use of nurses’ skills and resources.

So, what can we say about the future of nurse prescribing? As the number of non-medical prescribers and the volume of their prescribing increases, with nurses now running their own clinics and providing complete services, it is important to make the case for the contribution non-medical prescribing can make in the future - and make sure the case is heard. The current imperative to maintain or improve quality of care with reduced resources chimes with the now well-established benefits of nurse prescribing, both for patients and for the system.

Lowri Daniels

CDs: nurse prescribers urged to write to MPs

December 7, 2010 by admin 

Nurse prescribers should make their views on the delays to controlled drugs legislation known, according to nursing leaders. Frustration at the speed - or lack of it - with which the Home Office is introducing the long-promised changes to the law needed to allow nurse and pharmacist prescribers to prescribe all controlled drugs (see here) was apparent at the Association for Nurse Prescribing (ANP)’s annual conference in London last week.

Matt Griffiths, ANP committee member and visiting professor of prescribing and medicines management at the University of the West of England, has been campaigning on this issue for some time and is now urging nurse prescribers to write to their MPs asking them to press ministers to make this happen. The Chief Nursing Officer, Christine Beasley, agreed that nurse prescribers should make their views known to their MPs - she said she knows how important this issue is to nurses and their patients and that the changes will happen, despite the long delay so far.

If you would like to write to your MP, you can do so quickly and easily through this website.  Alternatively, Professor Griffiths suggests that a handwrittten letter to your local MP can be a more effective way of getting their attention; and that if practitioners have case studies (anonymised of course) which would demonstrate the cost to services, waste of resources or compromises to the quality of patient care, then this will strength your case. He commented, ‘We have been waiting for this legislation for over two and a half years, and patients really are suffering as a result’. Do let others know through the forum on the community login side of the site.

Advanced level nursing: position statement sets benchmark

November 24, 2010 by admin 

The Department of Health (DH) has now published a position statement on advanced level nursing, which highlights the role of prescribing at this level.

In the past, this term has been used inconsistently, leading to confusion. In her foreword, the Chief Nursing Officer Christine Beasley says that the statement defines, “the nature of advanced practice, what it encompasses and how it is different from the level of practice at registration”, and applies to all nurses involved in direct care delivery working at an advanced level.

The statement groups different elements into four themes: clinical/direct care practice; leadership and collaborative practice; improving quality and developing practice; and developing self and others. The first theme will usually include prescribing medication.

Course for NMPs and their teams

November 24, 2010 by admin 

A half-day interdisciplinary course for non-medical prescribers (NMPs) and their clinical colleagues including GPs, to prepare for the roll-out or implementation of non-medical prescribing is now available, and has been accredited by the Association for Nurse Prescribing (ANP). The course is delivered locally, can be tailored to meet local needs, and has been developed in association with the Cornwall Partnership NHS Foundation Trust.

The course can cover topics such as: the competencies needed by NMPs, accountability, regulatory body requirements and legal issues, governance compliance, clinical management plans, continuing professional development requirements, and developing prescribing. It is aimed at assisting teams to prepare for change and takes a whole systems approach.

For further information or an informal discussion, please contact: Steve Turner; email: steve@stnov8.co.uk; website: http://www.stnov8.co.uk/; tel: 01726 842583.

New post for ANP committee member

December 13, 2009 by admin 

Matt Griffiths has just been appointed Visiting Professor of Prescribing and Medicines Management at the University of the West of England, a position which he says will allow him to continue the work he has been doing at the University of Northampton in bridging practice, policy and education.

Safe prescribing - ANP conference

December 4, 2009 by admin 

How can we work together to ensure that we maintain competency, access continuing professional development (CPD) and make sure patients get good care, in what is likely to be an increasingly difficult financial situation? asked Barbara Stuttle, ANP Chair, at the end of the ANP’s lively regional conference on ‘Ensuring Safe Prescribing Practice’, held in London on 26 November.

She urged her audience to start preparing to persuade managers that CPD is a right, not a luxury, as budgets tighten: CPD is essential to ensure continuing safe practice. Several nurse prescribers in the audience had funded their attendance and taken annual leave to attend. She also stressed the importance of making notes, recording incidents and - sometimes - challenging colleagues and changing practice.

The conference was chaired by Baroness Cumberlege, Patron of the ANP, who highlighted the tremendous progress made in the last 20 years, from a situation in which no nurses prescribed and queues formed outside doctors’ doors for them to sign prescriptions for unseen patients. The BMA’s fears that opening the formulary was dangerous have proved unfounded and soon, it is hoped, controlled drugs will be available too (see here).

Baroness Cumberlege stressed the importance of trust, a theme that cropped up throughout the day, and looked to the day when multiprofessional education becomes the norm.

Trust and confidence take years to build up but can be destroyed in an instant, pointed out Mark Gagan (senior lecturer, Bournemouth University) in his talk on legal developments in nurse independent prescribing. Following a series of scandals, the professions now need to restore public trust, and nurse prescribers must be able to justify what they do, both to build and maintain trust and confidence and for legal reasons. The work of the Nursing and Midwifery Council (NMC), Health Professions Council and the Council for Healthcare Regulatory Excellence highlights the increasing importance of regulation. Accountability is key: to the patient, criminal law, civil law and employer and, some say, to oneself.

For negligence claims, the claimant must prove that: a duty of care existed, the defendant breached the duty of care and was careless, and that carelessness caused harm to the claimant. Mark highlighted the importance of:

• Not giving casual advice to friends and neighbours.
• Checking adequate cover for damages is in place especially for those nurse prescribers working in GP surgeries or independently.
• Good record-keeping.
• Evidence-based practice (actions must have sound logical basis).

Turning to recent legislative developments, Mark examined the workings of the Mental Capacity Act and how competence is defined, the use of advanced directives, lasting power of attorney, and the current situation about mixing medicines and controlled drugs (see here and here).

A rich picture of the impact of the impact of nurse prescribing on service delivery is emerging, said Molly Courtenay (professor of clinical practice: prescribing and medicines management, University of Surrey), from her research in different therapy areas since 2004. Molly and her colleagues have looked at pain, dermatology, children and diabetes care, and have used a variety of methods to try to establish how the rollout of nurse prescribing is working in practice in different areas.

The data have provided evidence about how nurse prescribing is working from the following standpoints: efficiency and access; quality of care; safety; the impact on the team and changing models of care; and the support needed.

Less time being spent in waiting for doctors’ signatures, increased capacity partly through better use of skills in teams (for example in diabetes where nurses, nurse practitioners and doctors are seeing different groups of patients) and partly through enabling nurse-led services (for example, in dermatology), and improved access to medicines, have all boosted efficiency and access. The impact on the quality of care has also been positive, as nurse prescribers can complete episodes of care, and provide continuity of care and a holistic assessment: adherence to medicines and better prescribing decisions may both result from these changes.

Safety concerns have been much discussed since nurse prescribing was introduced but the evidence here, too, is reassuring: nurses are picking up errors, are prescribing safely, and have a tendency to stick to guidance, leaving more complex cases where this may not be appropriate to medical colleagues.

Professional roles have shifted, with doctors no longer signing prescriptions for patients they have not seen, and having time to concentrate on the more complicated cases. For diabetes specialist nurses, the prescribing qualification is becoming essential for career progression but in other areas, non-nurse prescribers are happy not to prescribe. In an interesting development, medical students from Cambridge University are attending a non-medical prescribing programme.

Support, as ever, is necessary but is still lacking in some areas. As well as CPD, supervision, and peer support, organizations need to make sure that policies and clinical governance are in place as non-medical prescribers come through the prescribing programme and that workforce planning considers the use of their skills. There is some evidence that pharmacist prescribers are not prescribing once they have qualified as their role, and the services they could deliver, have not been defined in advance.

Accountability, the evidence base, and good record-keeping were again highlighted by Fiona Culley (professional advisor, NMC), as she talked about developments in nurse prescribing from the perspective of the NMC. There is no room for “confusion and creativity” in prescribing and complacency and fear need to be balanced. Prescribers should review their prescribing practice in the light of the Code of Conduct and consider the various standards taken together. Interestingly, although prescribers now form nearly 10% of the register, and the NMC has 6-8 fitness to practice hearings a day, nurse prescribing has not been an issue.

Next year, nurse prescribers should look out for several developments on the NMC website: the next stage of consultation on pre-registration education; revised standards of proficiency for nurse and midwife prescribers; and progress on revalidation.

What is polypharmacy, how much of a problem is it for older people and how should it be tackled, were among the important questions addressed by Lelly Oboh (consultant pharmacist for older people, Lambeth PCT) in a fascinating talk that set out clearly exactly how older people in particular end up taking so many medicines, and the consequences it can have for them.

Polypharmacy can be defined as being on many drugs at the same time (usually four or five) but can also be seen as people being on any medicines they should not be on. To put the issue in context, 15% of over-75s in the community take five or more medicines, and nursing home residents take an average of six to eight and sometimes up to 20 medicines. In some cases, these may all be needed and valid but polypharmacy does have all sorts of negative consequences including more and longer hospital stays and poorer quality of life. Regular, thorough, medication reviews, good communication and record-keeping, alongside a wealth of other strategies, were set out by Lelly as ways of reducing polypharmacy.

There are lots of reasons why polypharmacy arises, particularly in older people, including multiple clinicians prescribing for the same patient, drugs becoming more available without prescription, multiple pathologies, and the impact of targets. It can be important to resist the temptation to prescribe and sometimes it is necessary to make difficult decisions about risks and benefits (which, again, should be carefully documented). Prescribers should think holistically, balancing efficacy of treatment with quality of life.

Older people have increased sensitivity to some drugs and can have impaired pharmacokinetics so, for example, the effects of sedatives can last longer, causing drowsiness and making falls more likely. For these and other reasons, they are often at increased risk from the effects of polypharmacy.

Medication errors are everyone’s concern, said Matt Griffiths (senior nurse, medicines management, University Hospitals of Leicester, and visiting professor, prescribing and medicines management, University of Northampton) in his session on medication errors and safety. He discussed the ‘Safety in Doses’ reports (one covering 2005 and half of 2006 and one covering all of 2007) from the National Patient Safety Agency, which make sobering (and worthwhile) reading but do contain some good news. Reporting of medication incidents has increased, and after earlier guidance on the safe use of potassium chloride injection and oral methotrexate, the report covering 2007 contained no incidents of death or serious harm involving these medicines.

The earlier report highlighted the fact that two groups of patients are associated with medication errors. One is people with allergies receiving a medicine to which they are known to be allergic (these accounted for only 3.2% of all hospital incidents but one-third of these caused harm). The other is children - children up to four years were involved in 10.1% of incidents where age was stated.

Matt looked at the different types of medication incidents - using examples that provoked gasps from the audience - and then at the key actions for improving medication safety. For example, one action is minimising dosing errors - but how is this actually done? Yes, use information, training and tools, direct efforts at high-risk patients (such as children) and high-risk drugs; but what about double checking - is it really independent or do we tend to assume that someone senior is better at the maths? What if it is simply impractical to double check every time because the regimen is so involved? Another action is ensuring medicines are not omitted and Matt explained how his Trust has introduced a system for patients self-medicating while waiting on admission, if the admission is nothing to do with medication and the patients are capable.

The tremendous progress made in nurse prescribing as well as the importance of good record-keeping, communication, evidence-based practice, and updating, were highlighted again and again during the day, which concluded with a choice of workshops on CPD using disease-specific case studies and decision-making processes. Look out on the website for news of the 2010 events - and come and see for yourself. Lowri Daniels

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