Nurse Prescribing

1. Nurse Prescribing Extended independent and supplementary prescribing

2. Session objectives • Know the requirements of NHS prescriptions • Recognise tools to monitor and improve prescribing • Identify sources of support and advice • Plan for the future

3. (1) NHS prescriptions • Prescribing decisions • Types of prescriptions • Legal requirements • Security/ safety issues

4. Prescribing decisions

5. Consider the patient

6. Consider the choice of product

7. NHS in-patient prescription requirements • Patient details First name + surname Hospital number (NHS number) Date of birth or age • Prescriber’s signature and date • Patient location (ward or department)

8. NHS out-patient & FP10 prescription requirements • Patient details First name + surname Date of birth or age • Prescriber’s signature and date • Contact telephone number

9. Prescription Details Formulary? Guidelines? • Name of item - generic for medicines - brand/trade name for appliances • Form and strength - important to avoid confusion - check sizes in Drug Tariff • Directions for use (dose & frequency)

10. Prescription Details • Duration of treatment or review date • Quantity Special containers Patient/ calendar packs Bank Holidays Reduce waste…. Reduce waste…. Reduce waste

11. Allergies & adverse reactions • Identify risk • Consider anaphylaxis • Observe • Record in patient’s records • Report – “yellow cards”

12. Disposal of unwanted medicines Pharmacy

13. Fraud/security issues • Indelible ink • Blank space • Multiple items • Record keeping • Storage

14. (2) Tools to monitor and improve prescribing • Audit • Prescribing Data e.g. PACT

15. Clinical audit Quality improvement process that seeks to improve patient care and outcomes through systematic review of care against explicit criteria and the implementation of change. Aspects of the structure, processes and outcomes of care are selected and systematically evaluated against explicit criteria. Where indicated, changes are implemented at an individual, team or service level and further monitoring is used to confirm improvement in health-care delivery.

16. The Audit Cycle Audit design (planning stage) Set design criteria and agree standards (what should be happening) Monitor progress (was the change successful) Collect data (what is actually happening) Implement changes (making the changes) Analyse audit data (compare results) Identify causes of non-achievement (decide on change)

17. Is it realistic? Is it a “real” problem? Has it a measurable activity? Can standards be set? Can a change be made? Is the effort required acceptable? Is it a controversial subject? Would changes be welcomed by everyone? AUDIT: Practical points Start small and build on success, rather than start with the hardest problem!

18. CRITERIA Simple statement Focus on key points – clinically relevant, clearly defined and measurable STANDARDS Realistic Attainable Worthwhile AUDIT: set criteria and agree standards An audit standard will focus on one aspect of patient care; guidelines cover all aspects of the patient’s management.

19. AUDIT • Audit Commission http://www.audit-commission • National Clinical Audit Support Programme http://www.doh.gov.uk/ipu/ncasp/ncaspadv1.htm • Principles for Best Practice in Clinical Audithttp://www.nelh.nhs.uk/nice_bpca.asp • Getting better with evidencehttp://www.doh.gov.uk/research/london/allappxs.pdf

20. Pharmacy Doctor, nurse or pharmacist prescribes Payments to pharmacists PACT

21. Monitoring - PACT data Prescribing analysis and cost information • Generic prescribing • Product range • Quantities • Checking formulary compliance • Peer review

22. Prescribing by: Dr CENTRE PAGES Dr No: 123456 47 BRONCHODILATOR WAY MYOCARDIAL INFARCTION REFLUXSHIRE NSA 1DS PACT Report to: STANDARD REPORT Dr CENTRE PAGES Dr No: 123456 47 BRONCHODILATOR WAY MYOCARDIAL INFARCTION REFLUXSHIRE NSA 1DS BNF Version Number 38 Q U A R T E R E N D I N G D E C 2 0 0 0 For explanatory notes and practice details, please see back page PRACTICE PRESCRIBING COSTS Change from last year (%) Your practice HA equivalent National equivalent Your own costs £149,168 £149,623 £162,101 £49,329 -1 12 11 0 October - December 2000 Your Practice costs are below the HA equivalent by < 1% Your Practice costs are below the national equivalent by 8% 1 See the coloured pages for information on Analgesics & NSAID Prescribing ®PACT is a registered trade mark of the Prescription Pricing Authority © Copyright Prescription Pricing Authority 2001

23. Standard Report: Page 1 • Shows practices prescribing costs • HA equivalent is actual figures for Wolverhampton PCT, with a practice with same demographics, so GP’s can compare with their neighbours • National equivalent is calculated in the same way • Own costs also present

24. Page 2 YOUR PRACTICE COSTS BY BNF THERAPEUTIC GROUP 2 Comparison with HA (%) Change from Practice last year (%) HA (%) new drugs Practice costs HA equivalent -31 -4 13 16 -27 21 16 1 15 -9 6 2 -39 5 22 7 -4 -40 -4 2 30 0 13 0 32 7 10 21 £13,207 £19,054 £19,217 £26,488 £21,142 £18,354 £11,839 £19,290 £9,352 £9,742 £18,023 £13,901 £56,388 £42,794 Gastro-Intestinal System Cardiovascular System Respiratory System Central Nervous System Infections Endocrine System All other October - December 2000 THE TWENTY LEADING COST DRUGS IN YOUR PRACTICE These drugs represent 37.6% of your total practice cost. G:generic form available Drug Total cost (£) % practice total Change from last year (%) N. of items Total cost (£) % practice total Change from last year (%) No of items Drug 1: Genotropin 9,150 6.1 -3 21 2: Omeprazole 6,025 4.0 53 159 3: Havrix 5,076 3.4 55 250 4: Becotide G 2,982 2.0 -44 129 5: Augmentin 2,981 2.0 -7 356 6: Typhim Vi 2,745 1.8 -24 257 7: Becodisks 2,549 1.7 -9 53 8: Eprex 2,543 1.7 99 6 9: Beclometh Diprop (Inh) 2,498 1.7 15,057 155 10: Ranitidine HC1 2,277 1.5 170 78 11: Adalat G 2,190 1.5 17 83 12: Fluvirin 2,138 1.4 0 420 13: Proprietary Co Enternal Nutrit 1,877 1.3 -4 34 14: Influenza (Merieux) 1,867 1.3 -2 366 15: Mengivac 1,786 1.2 39 267 16: Amoxycillin 1,758 1.2 303 1,833 17: Recormon 1,580 1.1 -25 2 18: Cyclosporin (Systemic) 1,475 1.0 5 6 19: Amlodipine Besyl 1,272 0.9 869 42 20: Ins Humulin 1 (Isop) 1,248 0.8 38 24 © Copyright Prescription Pricing Authority 2001

25. Standard Report: Page 2 - cost • Practice costs for top 6 therapeutic areas are listed together with change and HA equivalent • New drugs are defined as those introduced within 3 years and are black triangle drugs. • Top 20 leading cost drugs in practice also included • Drugs that can be prescribed generically are detailed

26. THE NUMBER OF ITEMS YOUR PRACTICE PRESCRIBES Change from last year (%) Prescribed generically (%) Dispensed generically (%) 23,083 16,532 19,478 7,229 Your practice HA equivalent National equivalent Your own prescribing -4 45 43 2 58 52 3 57 52 -2 42 40 The number of items your Practice prescribed is above the HA equivalent by 40% The number of items your Practice prescribed is above the national equivalent by 19% PRESCRIBING BY BNF THERAPEUTIC GROUP IN YOUR PRACTICE Change from last year (%) Comparison with HA (%) Dispensed generically (%) No. of items prescribed HA equivalent Practice HA 1,413 1,207 1,253 2,709 4,078 1,553 3,055 2,688 3,104 2,048 996 1,067 9,184 5,260 Gastro-Intestinal System Cardiovascular System Respiratory System Central Nervous System Infections Endocrine System All other 17 15 7 25 -54 22 9 51 163 -17 -3 36 14 -6 4 55 52 -22 -11 80 -7 2 8 55 75 7 5 30 October - December 2000 3 © Copyright Prescription Pricing Authority 2001

27. Standard Report: Page 3 - volume • The amount prescribed is not taken into account – it is the number of prescriptions • If you always prescribe 28 day rather than 56 day repeats that will double your volume. • The level of generic dispensing and prescribing is also listed – some drugs will only have one brand – eg sertraline

28. 4 AVERAGE COST PER ITEM Change from last year (%) £6.46 £9.05 £8.32 £6.82 3 9 7 2 Your practice HA equivalent National equivalent Your own average cost October - December 2000 The average cost of items prescribed by your Practice is below the HA equivalent by 29% The average cost of items prescribed by your Practice is below the national equivalent by 22% THE AVERAGE COST BY BNF THERAPEUTIC GROUP IN YOUR PRACTICE Comparison With HA (%) Change from last year (%) Your practice HA equivalent Practice HA Gastro-Intestinal System Cardiovascular System Respiratory System Central Nervous System Infections Endocrine System All other £9.35 £15.79 £15.34 £9.78 £5.18 £11.82 £3.88 £7.18 £3.01 £4.76 £18.10 £13.03 £6.14 £8.14 -41 -16 6 57 -1 7 -56 10 9 -46 13 18 -37 -23 8 39 -2 5 -25 0 5 © Copyright Prescription Pricing Authority 2001

29. Standard ReportPage 4 - cost per item • Combines volume and cost information • Relies heavily on the length of repeat prescriptions • 75% of prescribing is repeat • Larger quantities = more cost = larger cost per item

30. Standard PACT Page 5 • Line graphs for six top therapeutic areas, compares cost for practice against HA equivalent Page 6 & 7 • Practice’s top 40 BNF sections, compares cost and volume against equivalent HA Page 8 • Practice details, total number of prescribing units. Nurse prescribing information.

31. Drug Tariff Online December 2003 (3) Sources of support and advice

32. Hospital Community Primary Care Pharmacy www.npc.co.uk www.ppa.nhs.uk

33. (4) Plan for the future Drug industry DRUG ALERTS Job description Medicines policy Prescription pads Competency Clinical Governance CPD Na+

34. Liability Supplementary prescribers (nurse or pharmacist) are professionally accountable for their own prescribing decisions. In addition, employers would remain vicariously liable for the actions and decisions of their staff.

35. University of Wolverhampton Extended independent and supplementary prescribing course Linda Forrester 2004