Policy responses and statements

Name of organisation:

The Scottish Government: Primary and Community Care Directorate

Name of policy document:

A Safe Prescription - Developing Nurse, Midwife and Allied Health Profession (NMAHP) Prescribing in NHS Scotland

Deadline for response:

1 February 2008

Background: Legislation to introduce Nurse 1 Independent Prescribing in Scotland came into effect on 31 May 2006. It marked the culmination of a long and at times arduous process that stretched as far back as 1989, when the Report of the Advisory Group on Nurse Prescribing (The Crown Report) (DoH, 1989) claimed that nurse prescribing would lead to better patient care, better use of patients', nurses' and GPs' time, and better communications between team members.

The initiative took off properly in Scotland in 1996 with a phased introduction that is now complete. A review carried out by the University of Stirling (Watterson et al, in press) has found that many of the claims made for nurse prescribing in the Crown Report have been borne out. It found that:

• the public had considerable confidence in nurse prescribing;
• nurse prescribers believed their prescribing roles made them more effective nurses;
• GPs' workloads had been reduced as a result of nurse prescribing;
• nurses were regarded as "safe prescribers" by patients and professionals.

Legislation is now in place to allow some allied health professionals ( AHPs), such as radiographers, podiatrists and physiotherapists, to train as supplementary prescribers. 2 Joint postgraduate education courses for nurses, midwives and allied health professionals ( AHPs) from a variety of professions commenced in Scotland in autumn 2007.

The introduction of prescribing into AHP practice provides a unique opportunity to jointly consider the education, strategic and operational needs of prescribers who are nurses, midwives and AHPs ( NMAHPs).

NMAHP prescribing is now at an important point in its history. Delivering Care, Enabling Health (Scottish Executive, 2006) stated that NMAHPs should make the best use of their skills, knowledge and expertise to provide patients with quicker and more efficient access to medicines, and NMAHP prescribing clearly has a big role in enabling this aspiration to happen in practice.

At around the same time as Delivering Care, Enabling Health was published (December 2006), the Guidance for Nurse Independent Prescribers document was produced (Scottish Executive, 2006a). It sets out the parameters and standards for prescribing practice - the "nuts and bolts", day-by-day operational issues that will ensure safe and effective practice.

What is needed now is a strategic vision to drive NMAHP prescribing over the next decade, a vision that will enable NMAHP prescribing to support and complement national policy imperatives and help NHS boards to meet their responsibilities to patients and the public across a wide range of clinical and health areas.

This document provides that strategic vision. It sets out the infrastructure that will be needed to drive NMAHP prescribing forward in relation to three key areas:

• culture
• capability
• capacity

The main driver for the strategy is a recognition that while nurse prescribing is bedding down well in certain parts of Scotland, 3 with safe, effective nurse prescribers providing valuable services to patients and the NHS, the overall picture in Scotland is patchy.

There are significant differences between regions and boards on how many nurse prescribers are in place, how they operate, how they are managed and how they are resourced. The University of Stirling research referred to above found "a lack of coherent, integrated and stable board-level infrastructure for prescribers and, in some instances, there have been slow responses of boards to the prescribing agenda."

Models of excellence in developing nurse prescribing services are emerging, and some of these are referenced in the document. But the main aim of the strategy is to provide NHS boards with a framework from which they can develop NMAHP prescribing services that are right for patients and the public, right for NMAHPs, and right for fellow health professionals.

While local differences in emphasis will always exist, the strategy also puts in place a set of recommendations on developing and managing an NMAHP prescribing service that will help to create consistency in quality throughout Scotland. In addition, a self-assessment tool designed to facilitate implementation of the strategy recommendations at local level is presented at the end of the document.

COMMENTS ON
THE SCOTTISH GOVERNMENT
A SAFE PRESCRIPTION - DEVELOPING NURSE, MIDWIFE AND ALLIED HEALTH PROFESSION (NMAHP) PRESCRIBING IN NHS SCOTLAND

The Royal College of Physicians of Edinburgh is pleased to respond to the Scottish Government on its consultation A Safe Prescription - Developing Nurse, Midwife and Allied Health Profession (NMAHP) Prescribing in NHS Scotland.

General Comments

The College recognises the important contributions of specialist nurses and AHPs to clinical teams and has welcomed the addition of supplementary prescribing in restricted areas and within limited formularies. However, many of our Fellows continue to have significant concerns over unrestricted, independent prescribing by NMAHPs, particularly for undiagnosed or newly diagnosed patients. The College believes that responsibility for these patients should remain under the supervision of medical staff, who have the benefit of a broader understanding of the pharmacological, pharmokinetic and pharmodynamic principals and the medical principles that underlie diagnosis. These concerns have been voiced previously in other consultation responses, the most recent of which were compiled for the MHRA on independent prescribing by nurses and pharmacists and for the Home Office on controlled drugs (attached as appendices).

The benefits cited in support of expansion in this strategic framework may be appropriate to supplementary prescribing and prescribing within agreed protocols and formularies. They include timeliness of medication, improved understanding via longer nurse consultations and patient expressed confidence. However, the College is unaware of evidence focusing on the higher risk aspects of independent NMAHP prescribing. It is important that patients and all health care professionals appreciate the difference between independent and supplementary prescribing – Box 1 on page 6 underplays these important differences.

The following comments on the proposed recommendations must be read in the context of medical concerns about the risks of unrestricted prescribing rights after limited relevant training.

Governance

The College agrees that all Health Boards must have robust systems in place to monitor the safety and effectiveness of all prescribing. To encourage further expansion of NMAHP prescribing before such systems are established nationally could compromise patient safety. In particular, the freedom available to independent prescribers must have robust accreditation and revalidation procedures to ensure all prescribers operate only “within their area of expertise and level of competence”.

Policy

NMAHP prescribing policies must be integral to all medicines management policies at Health Board level. The College believes that national standards are essential to monitor the quality of NMAHP prescribing – this is too important to be left to local discretion.

Monitoring

Lines of responsibility for assessing the continuing competence of independent prescribers must be clear, particularly where patients may not have a firm diagnosis. Monitoring should include analysis of iatrogenic disease and adverse drug reactions. Clear evidence is required of the effectiveness of education initiatives and the safety of independent prescribing in Scotland. Such monitoring should include analyses of iatrogenic disease and adverse drug reactions.

Much of the current evidence cited in the consultation in favour of expansion of NMAHP prescribing is within a review undertaken by the University of Stirling and not yet in press or available for independent scrutiny. This does little to increase the confidence of doctors at this time, many of whom share the College’s concerns about independent prescribing but are being asked to train and supervise nurse and AHP prescribers.

Resources

The College considers it is essential that all Health Boards review the evidence for the effectiveness and safety of independent prescribing before taking strategic decisions to encourage and fund its expansion. This must be recognised in consultant job plans if doctors are required to supervise trainee prescribers in addition to training and assessment responsibilities for junior medical staff.

Informing

The College agrees that it is essential that the evidence on effectiveness of NMAHP is available to patients and health care professionals. The College cautions that apparent operational efficiency benefits must be balanced against clinical risk in all circumstances and supported with published cost effectiveness and patient safety data.

IT

Many of the anticipated benefits of expanding prescribing rights beyond doctors rest on access to the (as yet aspirational) electronic patient’s record. The consultation document itself accepts that “Many of the clinical governance concerns around NMAHP prescribing will be resolved when these [EPR and electronic prescribing] systems are in place”. The College again cautions about the risks in prescribing for undiagnosed patients by health care professionals with limited training and before the NHS can facilitate access to patient records.

Education

The College calls for a review of the educational courses offered in HEIs for NMAHP prescribing, and the outcomes in terms of competences. A 26 day course (much of which is theoretical learning) cannot provide the same level of understanding as a 5 year undergraduate degree comprising physiology, pharmacology, and therapeutics and further postgraduate training, particularly for acutely ill and/or undiagnosed patients.

Equally important is the continuing professional development of non-medical prescribers to cope with the increasing complexity of prescribing with new drugs, drug interactions and a broader evidence base.

11 February 2008