There has been an issue with trained nurse prescribers in mental health either not prescribing or only prescribing as supplementary prescribers.  One mental health trust has now tried using individual and team formularies to provide support for existing prescribers and for those who have qualified but are yet to make the step to independent prescribing, and the results are encouraging, with the formularies being seen as helpful by those new to this role, as they can ‘clarify and formalize each prescriber’s area of competence, thus setting clear boundaries’. This is useful in increasing confidence and reducing uncertainty, and has other benefits, but it is important that the formularies are kept up to date and in line with local practice.

Dobel-Ober D, Bradley E and Brimblecombe N. An evaluation of team and individual formularies to support independent prescribing in mental health care. J Psychiatr Mental Health Nursing 2012; published online ahead of print 5 March.

http://dx.doi.org/10.1111/j.1365-2850.2012.01885.x

The PRACtICe Study sampled records from 15 GP practices and found that nearly one-third of errors involved “incomplete information on the prescription” and that children and people of 75 or over were nearly twice as likely to have an error on their prescriptions as those aged 15-64 years. Underlying causes included factors related to the prescriber (including undergraduate therapeutic training), to the patient, to the team (poor communication was one), to the working environment (time and workload pressures), to the task, to computer systems (generally seen as positive in preventing error but in some cases causing problems) and the interface between primary and secondary care (variation in quality of hospital communication, willingness of GPs to prescribe medicines recommended by specialists). Interestingly, GPs did express concern about what one called the ‘quasi-autonomous role’ of nurses, with GPs being asked to sign prescriptions for patients they had not assessed. The study authors say that this was not one of the highest risks, but they did pick up a small number of errors associated with this practice, and they comment that, “if nurses are to issue prescriptions based on their own clinical assessment practices it would seem most sensible (and in line with current legislation) for them to be qualified as non-medical prescribers”. Training more non-medical prescribers, particularly pharmacists who might be in a good position to manage complicated regimens, is also suggested as a possible way of adjusting GP workload levels.

And were these all ‘GP prescriptions’? Well, of the 6048 prescriptions included in the study, most were issued by GP partners, with a mere 60 being attributed to non-medical prescribers.

In England, the factsheet notes that 20% of independent nurse prescribers are actually using supplementary prescribing, that a few NHS hospitals insist that independent nurse prescribers practise as supplementary prescribers for six months after qualifying, that some NHS Trusts place restrictions by setting or formulary, and that training and professional development are still issues.

In Scotland, a 2010 progress review demonstrated the benefits and positive perceptions of nurse prescribing, which is in place across most of the country, with policies to underpin it; in Wales, however, although legislation was passed in 2007, there has not been a focus on developing it in key areas, and uptake is largely dependent on individuals. Legislation was also passed in Northern Ireland in 2007 but the report does not discuss uptake or implementation of nurse prescribing there.

The evidence base - or lack of it - for nurse prescribing, especially on outcomes, has been highlighted recently (see here and here). The RCN factsheet looks at the work that has been done, and the evidence that is accumulating for the safety and advantages of nurse prescribing mainly from qualitative and anecdotal surveys and questionnaires, concluding that empirical evidence of positive clinical and economic outcomes of nurse prescribing is still lacking.

The Home Office has issued a circular, setting out the background and explaining the amendments, and the NPC has also issued a Controlled Drugs Alert (dated April 2012) and will be updating its FAQs soon. Briefly, they cover:

• new regulations that allow nurse and pharmacist independent prescribers to prescribe schedule 2-5 controlled drugs for any medical condition (but not to prescribe cocaine, diamorphine and dipipanone for the treatment of addiction), provided they prescribe within their clinical competence. This is the key change that nurse prescribers have been waiting for. Some of the other changes relate to this, for example about, requisitioning, possession and directing others to administer controlled drugs.
• nurse independent prescribers who work in substance misuse can now supply articles for administering or preparing controlled drugs.
• nurses and pharmacists may now supply, or offer to supply, diamorphine and morphine under a patient group direction (PGD) for, “the immediate, necessary treatment of sick or injured persons (excluding the treatment of addiction)”.
• mixing medicines: nurse and pharmacist independent prescribers can mix schedule 2-5 controlled drugs for administering to a patient and provide written directions for others to do so; supplementary prescribers may also do this under the terms of a clinical management plan.

The NPC stresses that nurse and pharmacist independent prescribers should ensure that they always prescribe only within their clinical competence, and “that they have up to date knowledge of the doses, side-effects, interactions, cautions and contraindications of the controlled drugs they intend to prescribe”, and says that organisational governance arrangements should be followed. This, of course, also applies to supplying and administering any medicine under PGDs, where nurses and pharmacists must also work within their clinical competence, ensure their knowledge is up to date and follow organisational and governance arrangements.

The NMC says that, “Nurses and midwives should in the first instance refer to local organisational governance arrangements, and standard operating procedures” and reminds nurses and midwives of the importance of practitioners working “within their own competence, in line with robust education, training and governance arrangements.” It also points out that Northern Ireland has yet to make these changes. The NMC has recently said that, in future, its primary focus will be core regulatory activities.

ANP Chair Dr Barbara Stuttle said, “At last, we have some excellent news. Patients will benefit as independent nurse prescribers will be able to provide the right care at the right time. Our thanks go to Baroness Cumberlege, Chris Beasley, Matt Griffiths and others, who have lobbied tirelessly over many years. At the ANP, we have also been lobbying, and are delighted that the frustrating wait to put in place something that will benefit patients, and which all parties agreed to years ago”.

The NMC said before the SI was passed that it would provide information about the changes once it had heard from the Department of Health. The situation is complex and advice from the regulators will be needed.

• Tuesday 4 September at the University of Surrey in Guildford
• Thursday 22 November at the Wellcome Collection Conference Centre in London.

Given the changes underway in the NHS, and the pace of clinical developments, it is more important than ever for nurse prescribers to stay up to date with what is happening in their area. So do consider joining us at one of these events, which will have a range of speakers and plenty of opportunity for discussion.

The full programme details will be announced soon - so watch this space.

It proposes significant changes to the legal framework for bodies such as the Nursing and Midwifery Council (NMC), with the many different pieces of legislation being repealed and replaced with a single Act. The idea here is that this will impose consistency across regulators where necessary but at the same time give them greater autonomy. The aim to make the regulatory system more transparent and responsive, and to simplify and modernise a set of rules that have evolved in a piecemeal fashion. Role changes such as nurse prescribing are cited as one of the drivers for change. The consultation covers education, training and professional conduct and practice.

The changes are expected to allow nurse and pharmacist non-medical prescribers to prescribe controlled drugs within their competence, and to regularise the practice of mixing medicines that include controlled drugs. Again…watch this space!