Nurse prescribing chimes with economic and political realities

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