Non-medical prescribing has yet to achieve its potential, despite its successes and the growing evidence base. Could the NHS reforms in England, and the tight budgets everywhere, provide the necessary stimulus, as commissioners look for cost savings in the delivery of high quality, joined-up care?
In this light, the recent ANP annual conference was very topical, with a range of speakers highlighting the importance of audit and evidence, and pointing to the growing recognition that the fundamentals of good prescribing practice look the same, whatever the clinical setting or professional background of the prescriber.The ANP annual conference 2013 will be on 14 November in London, come and join us!
Non-medical prescribing: audit, evidence, care in the future
In some organisations, non-medical prescribing is embedded, with good support and infrastructure. Consultant pharmacist Pieter Shaw, who runs a viral hepatology service, described how the difference non-medical prescribers are making in primary care is now apparent to those working in his hospital, as patients come through the system. Non-medical prescribers have also been responsible for bring new drugs into local formularies. Knowledge, competence and skills should provide the boundaries for prescribing, not the profession of the prescriber, he said, a theme that was touched on throughout the conference.
Clinical audit is a powerful tool that can be quick and simple to complete, was the rallying cry from Sam Sherrington (Strategic NMP Lead NHS Northwest, ANP Vice Chair, and the board nurse for three clinical commissioning groups). SheÂ described an annual audit tool for non-medical prescribing that involves clinicians filling in online answers to a few questions (for example, was a prescription required?) after each consultation, whether it involved a prescription or not: on average, an audit took 3 minutes. The audit has grown dramatically, from 209 responses in 2009 to over 19,000 this September. This provides a mass of useful information to demonstrate the impact of non-medical prescribing and the possibility of large cost savings – nearly 5000 GP appointments were reported as prevented, and over 1200 subtherapeutic doses identified, in September in this one region, for example.
Another useful tool, often used to look at prescribing, is the Medication Appropriateness Index (MAI). Melanie Hart, a community matron who is the non-medical prescribing and governance lead for a community trust, outlined some fascinating research she has completed that used the MAI to look at how safely and effectively community matrons are prescribing independent prescribers. A small percentage (under 4%) of prescribing of the community matron prescribing was identified as not appropriate; although direct comparison is difficult, a 2003 study using GP records found just over 4% was inappropriate. Two interesting aspects of the research were the use of both qualitative and quantitative methods as a way of capturing events, and the way that the pilot study was use to resolve differences between raters. The prescribers here are part of a rapid response team, working short term with very complex cases, so establishing an understanding of the way they prescribe is important. Given that, the MAI could be used in any setting.
ANP President Dr June Crown CBE pointed out that despite the huge organisational upheavals in the NHS in England, which may mean nurses and other healthcare professionals working for new organisations or for ones outside the NHS, demographic and medical changes mean the focus will remain on older people with a range of co-morbidities. And non-medical prescribing can help deliver good care. ANP Chair Dr Barbara Stuttle CBE also stressed the extent of the changes in England, and how care is getting more complex. Along with policies and procedures, there is a role for common sense and taking individual responsibility for spotting gaps and doing something about them, she argued.
An example of the benefits of nurse prescribing was provided by Helen Ward (Principal Lecturer on the non-medical prescribing programme at London South Bank University), as she went step by step through the process of a structured medication review with a 75-year-old. This led to new diagnoses and a much fuller understanding of what was really going on. Looking to the bigger nursing picture, Barbara Stuttle and Sam Sherrington gave a sneak preview of the Chief Nursing Officer’s ‘Six C’s': care, compassion, courage, communication, competence and commitment, Compassion in Practice.
Non-medical prescribing: regulation, frameworks and legislation
Right touch regulation is the name of the game now in healthcare regulation. Fiona Culley, who was prescribing and medicines management advisor at the Nursing and Midwifery Council (NMC) and is now an independent consultant, mapped out the changes to the system and the way the NMC’s role has changed. This follows the ‘Strategic Review of the NMC’, conducted earlier this year by the Council for Healthcare Regulatory Excellence (CHRE) which identified problems ‘at every level’ and said there had been confusion over its purpose: ‘the role of the regulator is to set the ‘baseline’, the standard below which professional practice must not fall. It is the role of professional bodies to seek to raise the bar and to encourage nurses and midwives to achieve excellence in practice.’ And employers have a role, in performance management, training, support, and workplace systems. All the healthcare regulatory bodies will now be working towards right touch regulation, the use of minimum regulatory force to achieve the desired result.
Another area where professional boundaries are no longer relevant is the new single competency framework for prescribers. The National Prescribing Centre (NPC, now part of NICE) was asked in 2009 to look at competency frameworks for physiotherapists and podiatrists, as they started to move towards independent prescribing. It became clear, explained Jane Brown, who led the NPC project, that there was a core set of prescribing competencies, regardless of profession. And the General Medical Council’s work on prescribing errors by doctors showed that this should be something for all professionals. So instead, the NPC took existing frameworks, updated and consolidated them, and developed these using wide consultation into a single framework, published in May this year. She highlighted the different ways in which it can be used, as did the audience discussion.
Finally, it looks like junior doctors will be undergoing prescribing assessments in future. The British Pharmacological Society and the Medical Schools Council, which are developing it together, say that the results of the two-hour pilot tests in 2013 will inform the next stage of implementation.
What happens when things go wrong, which they can do? Solicitor John Glendening swept though recent legislative changes – particularly the controlled drugs amendments and the Human Medicines Regulations 2012 – and then looked at the procedures that may kick in after something goes wrong. Nurses are now much more likely to be called to appear as witnesses in inquests, so it is vital to keep real-time accurate records, and to be certain that any informationÂ supplied to an employer or the regulator is accurate after an incident – it may end up in court, months down the line. Absolutely essential, in his view, is professional indemnity insurance for anyone undertaking any kind of extended nursing role.