Extending Prescribing Responsibilities from Policy to Implementation

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Extending Prescribing Responsibilities- from
Policy to Implementation

• Paul Robinson
• Policy Lead, Extending Prescribing
  Responsibilities
• Department of Health

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Aim

• To maximise benefit to patients and the NHS,
  through increased flexible use of workforce skills

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Mechanisms

• Patient Specific Directions
• Patient Group Directions August 2000
• Exemptions under Medicines legislation
• Extended Formulary Nurse Prescribing April 2002
• Supplementary Prescribing (nurses and
  pharmacists) April 2003

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Extending Prescribing - DH Core Delivery Team

• Administrators - Paul Robinson
• Doctor - Peter Clappison
• Nurse - Maureen Morgan
• Pharmacist - Gul Root
• AHP - Kay East
• Modernisation Agency - Jackie Younger

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Review of Prescribing, Supply and Administration
of Medicines

• Dr June Crown CBE - March 1999
• made recommendations and helped inform DH policy

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Patient Group Directions (PGD)

• Definition
• A written instruction for the supply or
  administration of medicines to groups of patients
  who may not be individually identified before
  presentation for treatment

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Patient Group Directions (PGD)
Who can currently use a PGD?

• Registered Health Professionals Nurses
• Midwives
• Health Visitors
• Ambulance Paramedics
• Optometrists
• Chiropodists
• Radiographers
• Orthoptists
• Physiotherapists
• Pharmacists
• NB As named individuals

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Patient Group Directions (PGD)

• Intention to expand this list by April 2004
• MHRA proposes to add four more AHPs -
• Dietitians
• Occupational therapists
• Prosthetists and orthotists
• Speech and language therapists

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Patient Group Directions (PGD)

• The majority of clinical care should be on an
  individual, patient-specific basis
• Signed by a senior doctor (or dentist) and a
  senior pharmacist
• NB - No discretion.
• plus Exemptions under Medicines legislation -
  e.g. for Paramedics, Midwives, Optometrists

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Independent Prescribing by Nurses

• District Nurses and Health Visitors - limited
  formulary, over 25,500 nurses
• Nurse Prescribers Formulary for District
  Nurses and Health Visitors
• - mainly appliances, dressings and a few
  medicines (13 POMs)
• Extended Formulary Nurse Prescribers

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Nurse Prescribers Extended Formulary

• Range of medical conditions
• broadly covering minor ailments, minor injury,
  health promotion and palliative care
• Potential for emergency care

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Nurse Prescribers Extended Formulary

• all Pharmacy (P) and GSL medicines for these
  conditions
• 140 POMs
• 170 POMs from Feb 2004

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Numbers

• Over 1,800 Extended Formulary Nurse Prescribers
• - qualified and registered with NMC
• several hundred more in training - examples
• Nurse Practitioners in primary care
• Practice Nurses
• AE / Minor Injuries Unit nurses
• Walk-In-Centre nurses

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Training

• Outline Curriculum agreed in 2001
• Prescribing Training course 26 days, plus 12 days
  with supervising medical practitioner
• Face-to-face contact, but provision now also for
  some open and distance learning

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Funding for Training

• DH funds direct training costs, via SHA Workforce
  Directorates
• More flexible use of funding, from April 2003

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Expanding the Nurse Prescribers Extended
Formulary

• Consultation by MHRA and DH April 2003
• Announcement by SofS - November 2003
• 10 new medical conditions
• 30 additional medicines added to Extended
  Formulary - from 1st February 04

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Next Steps

• CSM considering proposals to fill other gaps in
  Extended Formulary - particularly for Emergency
  care
• Further consultation early in 2004
• Website www.doh.gov.uk/nurseprescribing

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Supplementary Prescribing

• introduced through POM Order amendment and NHS
  regs in April 2003
• nurses and pharmacists
• will assist continuing care, rather than one-off
  episode of care e.g. asthma, diabetes, other
  chronic disease, mental health

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Definition

• Supplementary Prescribing
• A voluntary prescribing partnership between
  the independent prescriber and a supplementary
  prescriber, to implement an agreed
  patient-specific Clinical Management Plan with
  the patients agreement.

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Quote

• I am enthusiastically in favour of this
  development. With the right safeguards in place,
  this will be of benefit to nurses, doctors, and
  particularly patients - saving everyone time, and
  increasing teamwork, skillmix, and efficiency
• Prof David Haslam, Chairman of Royal College of
  General Practitioners

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Principles

• Patient safety paramount
• Benefit to patients and the NHS
• Patient agreement
• Communication between all prescribers and Access
  to the Patient Record

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Principles (Continued)

• Voluntary Partnership
• Separation of Prescribing and Dispensing
  responsibilities where possible

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Criteria

• Independent Prescriber must be a doctor (or
  dentist) - who makes Diagnosis
• Supplementary Prescriber must be a Registered
  Nurse, Registered Midwife or registered
  Pharmacist
• Written Clinical Management Plan specific to a
  named patient and the patients condition

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Medical conditions

• Clinical Management Plan agreed with the doctor -
  sets out how much (or how little) responsibility
  is delegated

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Medicines

• No legal restriction, except
• Controlled Drugs (for the present) - Home Office
  consultation ended in September
• Unlicensed medicines MHRA/DH consultation began
  late December 2003
• BUT off- label prescribing is permissible

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Clinical Management Plan - Templates

• Two blank draft Templates on the DH website
  www.doh.gov.uk/supplementaryprescribing
• Clinical Management Plan needs to be simple -
  otherwise, it wont happen!

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Training

• Outline Curriculum agreed in 2001 by former ENB.
  NMC endorsed in 2002 and 2003
• Prescribing Training course 26 days, plus 12 days
  with supervising medical practitioner
• Face-to-face contact, but provision now also for
  some open and distance learning

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Supplementary Prescribing

• work has started on extending Supplementary
  Prescribing to some AHPs
• physiotherapists
• podiatrists
• radiographers
• and Optometrists

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Current Position

• Nurses in training since January 2003
• Nearly 1,100 nurse supplementary prescribers
  qualified already
• Pharmacists in training, qualifying from February
  2004

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Quote

• Before Kathy qualified, she like the other
  nurses, would see patients but have to get doctor
  approval for prescriptions. Now she can deal
  with that herself, saving GP time to concentrate
  on complex cases. Supplementary prescribing has
  valuable long term benefits, but this is a fairly
  major change to the way practice works and so we
  have to take it slowly to get it right.
• - Dr Vish Kini, GP in Chester

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Conclusions

• Mechanisms that will assist emergency care and
  one-off episodes of care
• PGDs for supply and administration of medicines
• Exemptions for sale and supply, under the
  Medicines Act
• Nurse Prescribers Extended Formulary
• Continuing care and chronic disease -
  Supplementary Prescribing (and PGD)

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Nurse Prescribers Extended Formulary

• More medical conditions and medicines from
  February 2004
• Further discussions with CSM about needs of
  emergency care nurses
• Consultation on more medical conditions and
  medicines from Spring 04

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Supplementary Prescribing

• Controlled Drugs likely to be made available
• Consultation on three AHPs and optometrists
  Spring 2004

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The Future

• Non-Medical Prescribing Programme -
• taking work on nurses, pharmacists, optometrists
  and AHPs under one umbrella Programme
• Commitment to work on a Framework for Pharmacist
  Independent Prescribing - from early 2004

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The future - continued

• Is it making a difference to patients?
• Its beginning to!
• Have we reached critical mass yet?
• Perhaps not quite, but were well on the way

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Extending Prescribing Responsibilities- from
Policy to Implementation

• Paul Robinson
• Policy Lead, Extending Prescribing
  Responsibilities
• Department of Health