Health Care Managers’ Forum November 2nd 2006 “ Where is Nurse Prescribing going in 2007?”

1. Health Care Managers’ Forum November 2nd 2006“Where is Nurse Prescribing going in 2007?” Professor Matt Griffiths RGN, BA (Hons), A&E Cert, FAETC, NIP. Senior Charge Nurse – Peterborough NHS Walk in Centre. Joint National Advisor – Prescribing – Royal College of Nursing Visiting Professor – Prescribing & Medicines Management University of Northampton

2. "I hope you leave here and walk out and say, 'What did he say?" George W. Bush, Beaverton, Oregon, Aug. 13, 2004 “I hope you leave here – and have received an update on Nurse Prescribing and can see where it is “going” in 2007” Matt Griffiths

3. Outline • What type of “prescriber”? • Current situation • Different methods for the supply & Administration of medicines • Prescribing of Controlled Drugs • Education • Entrepreneurs • Areas of practice – University of Reading Research • Other developments

4. What type of “prescriber”?

5. Current Figures • DN/HV prescribers - over 29,000 • Extended prescribers – over 8500 • Supplementary prescribing nurses – over 8000 • Patient Group Directions – 670,000 Nurses of whom approx 50% use PGDs • Source NMC June 2006

6. Methods for the Supply & administering of medicines • Many methods available • Independent Prescribing • Supplementary Prescribing • DN/HV • PGDs

7. Preparing Nurses, Midwives and Health visitors to prescribe from the extended Nurse Prescribers Formulary – IP&SP • Current Extended Prescribers training (27 study days & 13 practice days over 3-6 months) • Assessments (O.S.C.E.s, Portfolio, Final Exam - Short answers & Essay question) • Calculations • Credits (20-40 credits at level III) • Distance learning • Employers to prioritise for their needs locally

8. Recent consultation – Independent Extended Nurse Prescribing • A. That there be no change - Independent Extended Nurse Prescribers continue to prescribe from a list of medical conditions and a limited formulary • B. That Independent Extended Nurse Prescribers be able to prescribe for any medical condition from a specific formulary • C. That Independent Extended Nurse Prescribers be able to prescribe for specific conditions from a full formulary • D. That Independent Extended Nurse Prescribers be able to prescribe for any medical condition from a full formulary • E. that advanced practice nurses who are Independent Extended Nurse Prescribers be able to prescribe for any medical condition from a full formulary - but all others who are Independent Extended Nurse Prescribers and not advanced practitioners be restricted to conditions and a limited formulary.

9. What has been given? • Qualified Independent Extended Nurse Prescribers will be able to prescribe any medicines for any condition within their own competence – with the exception of Controlled drugs – although certain controlled drugs have been allowed for certain conditions. • Timescale – implemented in England May 1st, Scotland 31st May, • Northern Ireland & Wales both proceeding at different times

10. Supplementary Prescribing • “Supplementary Prescribing is a voluntary prescribing partnership between an independent prescriber (Doctor or Dentist) and supplementary prescriber, to implement an agreed patient-specific clinical management plan with the patients agreement”

11. Supplementary Prescribing • Sarah Mullally Bulletin Dec 02/Jan 03 • “ There will be no legal limit on the conditions that may be included in supplementary prescribing. Supplementary prescribers will be able to prescribe all medicines currently prescribable by doctors, with the exceptions only of unlicensed medicines (except in specific circumstances) and, currently, of controlled drugs.” • Now changed – allowing both un-licenced and Controlled Drugs.

12. Independent & Supplementary prescribing – lesson learned • So what have we learned? • IP formulary – i.e. Aspirin • Southampton research • Complexities for SP • Frustrations at implementing – script pads, computer generated scripts • Training difficulties • What would we change? • Open up the formulary – now happened • Flexible training – now available – EMAP/Stirling University • Systems in place – policies to ensure roll out upon qualification

13. Private prescriptions – Non NHS • All Qualified Nurse Prescribers may prescribe their authorised medicines privately. • Supplementary nurse prescribers must still ensure that they have a valid CMP in place • Regulations and requirements are the same as for our medical colleagues • Changes for Schedule II CDs

14. DN/HV – Community Nurse Prescribers • Short training period – linked to specialist practitioner degree pathway – currently only way to access this qualification • Limited formulary – very few POMs • Able to use outside of just community care

15. Patient Group Directions • A written policy allowing certain professions to supply and /or administer a specific medicine to an unknown patient in a known situation. • Not prescribing • Authority comes from the organisation – accountability also falls with organisation • Dr, Senior Manager, Pharmacist, and Senior professional from Profession using the PGD.

16. Preparing staff to supply and/or administer under PGD • Variable training dependant on trust/employer • No statutory training • Limited by training time • No assessments • More flexibility for employers in sending staff through training • Concerns over safety – compared to prescribing • Still a valuable tool for organisations and staff

17. Recent developments in Patient Group Directions • Professionals can now administer Diamorphine for cardiac pain in CCU or A&E under PGD • They may also supply and /or administer all schedule 4 & 5 CDs (with the exception of anabolic steroids) under PGD. • Some non NHS organisations may use PGDs if registered with the Healthcare Commission

18. Patient Specific Directions • A Direction from a qualified registered prescriber • Doctor • Dentist • Nurse • Pharmacist • Physio/Radiographer/Podiatrist/Optometrist • To administer a particular dose of a particular medicine to a specific named patient.

19. Prescribing of Controlled Drugs • Supplementary Prescribing of ALL CDs allowed • Currently certain CDs on Independent Extended Nurse Prescribers Formulary ( pain relief & Palliative Care) Diamorphine and Morphine for Trauma, Cardiac pain, Post – operative pain • - Several others have been added for palliative care • CD Legislation is UK wide • We must remember that these changes have taken place during ……….

20. The Shipman Inquiry • “I arrive at a total of about 250 deaths. My overall conclusion is that Shipman killed about 250 patients between 1971 and 1998, of whom I have been able to positively identify 218” • Dame Janet Smith DBE, Q.C.– Author of the Shipman Inquiry- The 6th Report

21. HM Government “Safer management of Controlled Drugs” – The Government’s response to the Fourth Report of the Shipman Inquiry (3.20)- December 2004 • “The Government agrees with the consensus view and proposes to amend the Misuse of Drugs Regulations and the GMS contract regulations to allow the prescribing of controlled drugs by Supplementary Prescribers, and in due course to extend the range of controlled drugs which Independent Prescribers may prescribe”

22. You teach a child to read, and he or her will be able to pass a literacy test. George Bush “Education surrounding prescribing needs to be continual – CPD is necessary.” Matt Griffiths

24. Training & Education • In agreeing to the proposals to allow the Supplementary Prescribing of CDs, the Advisory Council on the Misuse of Drugs (ACMD) has stressed the importance of adequate training for new prescribers • HM Government “Safer management of Controlled Drugs” – The Government’s response to the Fourth Report of the Shipman Inquiry (3.21)- December 2004

25. IMPORTANT • Only work within their area of competence • ***Patient safety is paramount*** • Not happy to prescribe or supply and/or administer - then don’t

26. Training & Education • Undergraduate training • Postgraduate Education • Continuing Professional Development

27. Education resources • OK a bit of a plug!!! • Cambridge University Press • £19.99 • ISBN Number • 1-84110-196-6

28. The French don’t have a word for Entrepreneur George Bush

29. Entrepreneur • John Reid – had a vision of Nurse Entrepreneurs • Employing Doctors • Becoming partners in practices • Setting up Ltd companies and subcontracting services to the NHS • Non-medical prescribing in Community Pharmacies • Offering choice to patients • Freeing up talents • Redesigning the Health Service • Nurses do need to be included in practice based commissioning

30. Independent Extended and Supplementary Nurse Prescribing: A National Questionnaire Survey • Courtesy of Professor Molly Courtenay • School of Health and Social Care • University of Reading

31. Patient benefits • Patients generally positive • Time savings • Convenience • Continuity of care • More detailed information about medicines

32. Nurse benefits • Increased satisfaction • Increased status and autonomy • A belief that patients receive better information about their medicines • Time savings • Improved communication • Increased patient confidence • Able to deliver complete episodes of care

33. Nurse concerns • Some nurses have concerns about making a diagnosis • Some nurses have concerns about their pharmacological knowledge • A move towards a medical model of care

34. Aim To provide an overview of the prescribing practices of independent extended/supplementary nurse prescribers and the factors that facilitate or inhibit prescribing

35. Research Design • National postal questionnaire survey • In-depth case studies of practice settings

36. Questionnaire No sent out No returned Response rate Main study total 1,187 863 73% Mode of Prescriber Percentage prescribing Extended 756 (87%) Supplementary 304 (35%)

37. Job titles

38. Primary or Secondary Care

39. Qualifications

40. Years of post-reg experience prior to course

41. Barriers to prescribing

42. Areas in which SP is used

43. Have you undertaken any CPD since qualifying as a prescriber?

44. Needs of nurse prescribers

45. Looking Ahead

46. The future of Nurse Prescribing Independent Extended Nurse Prescribers – Can prescribe from the entire formulary and with the exception of some controlled drugs Supplementary Prescribing may remain for more complicated patients or for staff training to prescribe for new conditions. Nurses can Supplementary Prescribe all controlled drugs and un-licenced medicines – provided that they have an individualised Clinical management Plan. More Nurses will now train as prescribers as the formulary matches their practice. Accessible Continuing professional Development is required to ensure we are all up to date with best practice and ensuring patient safety. Nurses MUST treat this responsibility with respect. We are now able to prescribe nearly ALL medicines that Drs are able to prescribe. With this extra responsibility comes extra accountability to ensure our patients safety.

47. How can pharmaceutical companies help? • Speak to Nurse prescribers • Find out their needs • Get involved in education/CPD and get it validated • Be transparent • Support Non medical prescribing events

48. So which method is best? • Dependent on: • Clinicians/patients needs • Clinicians competencies • Their employment status • The organisation that they work with or for

49. I have opinions of my own – strong opinions – but I don’t always agree with them George Bush “I do however believe in my opinion that Independent Prescribing from the entire formulary, limited only by the practitioners own competencies, will revolutionise the Nursing profession, and the care that we can deliver” Matt Griffiths

50. Useful websites • www.dh.gov.uk – search for cno/nurse prescribing/supplementary prescribing • www.npc.co.uk • www.nurse-prescriber.co.uk • www.rcn.org.uk • www.rpsgb.org.uk • www.hpc-uk.org • www.homeoffice.gov.uk