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 -Â 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 ofÂ 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 ofÂ 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.