Nurse and other non-medical prescribers are not mini-doctors or doctors on the cheap. However, as more nurses adopt levels of autonomy in advanced practice akin to those of their medical colleagues, the profession does need to consider aligning arrangements for such matters as training, management, assessment and governance with those of doctors.
This was one of the themes that cropped up throughout the recent one-day ANP annual conference, held in London in November, and chaired by ANP President Dr June Crown CBE.
After her many years with the NHS, Dr Crown thought she knew about uncertainty – untilÂ now. She stressed the need to hold on to standards and principles of quality and safety, while systems evolve. Practice will have to change under the new English NHS systems, as well as with financial pressures. Services will be redesigned and care will be delivered in different ways. Clinicians need to be involved in this process, and nurses should be engaging with it, and leading it. There is an important part for non-medical prescribers to play, said Dr Crown, as the NHS faces its greatest challenges yet, particularly in integrating care and caring for often elderly people with multiple chronic conditions. These ideas also formed a common thread between the variety of speaker sessions on the day, as did the need to operate within clear legal and professional boundaries at all times, within and outside the NHS, but to find time and space to learn, drive change, reflect upon practice, and stay up to date.
There is now a golden opportunity to develop non-medical prescribing, as it fits perfectly with the demands being made on the service, said Dr Mike James, a consultant urologist from Chesterfield Royal Hospital – although some barriers remain. He feels that many of these could be addressed by the development of clear, robust role definitions for nurses working in advanced roles, and defined competencies, training and assessments, as there are for doctors. He described the nurse-led prostate cancer clinic in his hospital, how it works, how it developed, and the training and practice arrangements. The nurse consultant has a high degree of autonomy and has developed great expertise: leave is covered by a medical consultant.
Succession planning is a concern for successful clinics such as this, where a nurse is running a clinic and prescribing but is also undertaking other aspects of an advanced role. For non-medical prescribing, there are agreed standards, a competency framework and nationally agreed training and assessment, but this is not the case for other constituents of this sort of practice. In contrast, doctors have training and qualifications that cover the whole of their practice; and job descriptions are more generic and less likely to have evolved in response to local need or around a particular individual. This highlights the need for standards for all of independent practice – if there are not national ones then local ones should be agreed – with associated arrangements likely to follow the medical model. As well as making staff potentially vulnerable, the current situation means that these clinics or services can fold if someone leaves. Dr James also emphasised the importance of audit and said that non-medical prescribers should be managed as doctors are, on the basis of overall performance and not a single episode.
The inevitability of change in the ways services are delivered was clear from the session by Scott McKenzie, a management consultant who works with many different NHS organisations and is currently working to implement the government NHS reforms programme. The financial challenge is here to stay, regardless of any change in government, and clinical practice has to change – but this process can be led by clinicians to deliver high quality, consistent, safe care. The mantra must be, ‘more with the same, not more of the same’, and clinicians do now have a genuine opportunity, he feels, to lead the way and drive the significant changes that lie ahead. The focus must shift to prevention from low-volume high-cost specialist care: he envisages a seamless system of integrated care that is prevention-led, not the different sectors working in silos; and hopes that clinicians can work together to redesign care pathways, with change enabled by management. Partnership working will be crucial in ensuring greater quality and consistency.
Everyone is involved in regulation, said Fiona Culley, who is now working as an independent consultant and Care Quality Commission bank inspector and bank specialist advisor after her two stints at the Nursing and Midwifery Council (NMC). Self-regulation should be part of the daily routine, and audit and review should be ongoing, not just before an inspection: practitioners were urged to think broadly about what regulation is. At the end of 2013, patient safety trumps all.
The regulatory landscape itself is changing, as the NMC refocusses its efforts, following the July 2012 CHRE review (the CHRE is now the Professional Standards Authority) of the NMC, which defined tightly the role of the regulator as setting the baseline. Ms Culley highlighted some of the salient points in the Berwick review into patient safety, whichÂ puts learning at the heart of NHS culture and improvement, the review of the NHS hospital complaints system by Ann Clwyd MP and Professor Tricia Hart, and the new General Medical CouncilÂ (GMC)’s ‘Good practice in prescribing and managing medicines and devices (2013)’, which reiterates the July 2012 ban on remote prescribing of cosmetic injectables. In his letter to clinicians, managers and NHS staff, Don Berwick said, “..as you probably also know, real, sustainable, active improvement depends far more on learning and growth than on rules and regulations. And that is the balance we are suggesting that the NHS seek to strike – between the hard guardrails that keep things in proper order and the culture of continual learning that helps everyone to grow….measurement is not a threat.”
Since October, European legislation means every nurse and midwife must have ‘an appropriate indemnity arrangement’ in place for registration with the NMC, which has consulted the profession about the information it will provide on this; the final document should be published soon. The legislation is likely to come into effect in the UK early in 2014 and will make professional indemnity insurance mandatory for all healthcare professionals. This follows the change in the RCN’s stance on indemnity insurance late in 2011. Many practitioners will be covered by their employer’s vicarious liability and Royal College of Nursing (RCN) or other cover, but Ms Culley said thatÂ some practise nurses have gone down the MDU route, for example. Nurses in some extended roles, for example endoscopists, have also taken out separate cover. This is not required by the regulator but nurses and midwives do have to demonstrate that they have appropriate cover for the risks involved in their their practice; if they cannot, they will be removed from the register. So here too, nurses need to check their individual practice and situation carefully and may need indemnity arrangements more analogous to those of doctors. (NB, this session presented information for England, Scotland and Wales: there may be some variations in Northern Ireland).
The issue of vicarious liability and where it stops, so important as nurses extend their practice, can be a confusing one but Graham Brack, a pharmacist prescriber and associate lecturer at Plymouth University, made sense of it by explaining the sometimes colourful historical cases that contributed to the current situation. In essence, the “master” is liable if the “servant” is acting in the course of employment, even if they are not following instructions. If the servant is on a “frolic of his own”, the master will not be liable. Some useful guidelines include: if the purpose of the act is approved by the employer, then the employer is liable whether the method is approved or not; if the purpose is unapproved then if the method is also not approved, the employee is liable. However, if the employee is carrying out an act whose purpose is unapproved but using an approved method, the situation is a little more tricky: does it look to someone else, perhaps a patient as if the practitioner was authorised? If so, the employer may be liable if they did not stop the activity. For the employer to have vicarious liability, more is needed than simple opportunity through the nature of the job.
Checking individual arrangements is vital: for example, community nurses helping out at a GP practice where they spend a lot of time may not be covered by vicarious liability: not by that of the Trust, which had no part in this arrangement; nor by that of the practice, which is not the employer. So, the nurses should not have agreed to help. As teams form and re-form for particular services or projects, it is important to check that every aspect of the role is covered, and the initial agreement should set out where liability falls.
Vicarious liability is an entirely civil concept and would not apply to illegal actions (which usually involve criminal negligence). Turning to the criminal law and its implications, Mr Brack looked at the two types of involuntary manslaughter – that caused by gross negligence and that caused by an unlawful or dangerous act. Gross negligence is difficult to define and is decided by juries: it relies upon the existence of duty of care (usually easy to demonstrate for healthcare professionals); a breach of that duty of care that causes or significantly contributes to death; and that the breach should be characterised as gross negligence and therefore a crime.
Earlier this year, the Chief Medical Officer’s annual report said that there are few new antibiotics in the pipeline and that “our armoury” is “nearly empty”. In September, the Department of Health published the ‘UK Five Year Antimicrobial Resistance Strategy 2013 to 2018‘. It raised the prospect of being unable to prevent or treat everyday infections or diseases in the near future – and sets out action for all sectors. Jerome Durodie, a clinical microbiologist turned pharmacist and clinical lecturer at Medway School of Pharmacy, addressed the thorny topic of antibiotic resistance, stressing that it is not about never prescribing but it is about appropriate prescribing. To put things in context, 90% of cells on or in the human body are not human cells, but only 10% of micro-organisms are harmful and many are beneficial. By the 1970s, the majority of known antibiotic classes had been discovered or developed; no new classes were licensed in the 70s, 80s or 90s, and only four since 2000 (three modes of action). Lots of useful information, and much to think about.
Andrew Rankin, a nurse independent prescriber who is a board member of the British Association of Cosmetic Nurses (BACN), which is working with the ANP to change legislation about stock medicines for nurse prescribers, talked about the issue of prescribing for people who are non-prescribers. He set out what factors should be considered, and once again highlighted the importance of considering each situation carefully and not making assumptions. The relevant standards are the NMC standards for medicines management (section 5) and the NMC Standards of proficiency for nurse and midwife prescribers (standard 14, which is very clear that the person a prescriber delegates to must be competent and trained). Mr Rankin then outlined the difficulties presented by the restriction on nurses working independently not being able to hold stock, which is an issue in his clinical area for injectable products, pain relief and any emergency medicines needed, for example adrenaline. Anticipating all the drugs that might be needed for a particular patient could mean ending up with large amounts of drugs that cannot be used, as they have been prescribed for an individual. Another method is to employ a doctor or dentist who can prescribe which does protect the practice and patients. Dr Crown and ANP Chair Dr Barbara Stuttle CBE pointed out that this may be more of an issue for nurses working in other clinical areas in future.
Medicines not being taken as prescribed is a major issue, and one that can appear intractable. Dr Austyn Snowden, who is professor in mental health at the University of the West of Scotland, and an independent prescriber, described an intriguing pilot study designed to measure the impact of concordance on psychiatry. His findings suggest that without defining what concordance is exactly – notoriously difficult – we may be able to measure whether or not it improves quality of life. What is concordance, and does the concept differ between professions? What would a study look like that, rather than trying to change behaviour, attempted to understand it better? One of the assumptions behind the research is that it is easier to understand and work with people’s (possibly irrational) beliefs, which are broadly coherent with their actions, than try to change them – but most interventions do not start from this perspective.
Professor Snowden described a concept analysis of concordance in different health professions, which revealed some fascinating variations. It suggested that each discipline – nursing, psychiatry, general medicine and pharmacy – practised a “different conceptualisation of concordance”, and that any concordance research needs to factor in these points of agreement and disagreement. The study design the group has now piloted captured the correlation between the patient’s attitude to concordance in a medicines management consultation, and what the prescriber thought the patient’s attitude was. These correlation scores were then plotted against a measure of the impact of medication management (using Bech’s pharmacopsychometric triangle). The pilot results suggested a correlation between concordance and wellbeing, without anyone having to agree on what concordance is. This research, considered in the context of trying to care for people with a complex mix of physical and mental health conditions, seemed very pertinent at the end of the conference.