Non medical prescribing in Scotland: implementation guide

Background to Independent Nurse Prescribing in Scotland

Brief history of nurse prescribing in Scotland

1. The nurse prescribing scheme for district nurses and health visitors was based on the recommendations contained in the Report of the Advisory Group on Nurse Prescribing 1989, which advised Ministers how patient care in the community might be improved by introducing nurse prescribing. The report identified a number of clear benefits that could arise from nurse prescribing:

• an improvement in patient care;
• better use of the patients', nurses' and GPs' time;
• clarification of professional responsibilities leading to improved communications between team members.

2. Implementation of DN/ HV prescribing was piloted in England in 1994 and followed by its introduction in the other UK countries. The necessary legislation to enable community nurses in Scotland with either a district nursing or health visiting recordable qualification to prescribe from a limited (Nurse Prescribers') formulary was passed in 1996. ²

3. The scheme was introduced in Scotland by a phased implementation, which commenced in 1996 and is now complete. It enabled all practising district nurses, health visitors and practice nurses with either qualification to undertake a course of preparation approved by the former National Board for Nursing, Midwifery and Health Visiting for Scotland ( NBS). Since 2001, courses for independent nurse prescribing have been approved for the Nursing and Midwifery Council ( NMC) by NHS Education for Scotland ( NES).

4. Since 1999, preparation to prescribe from the Nurse Prescribers' Formulary was included in the district nursing and health visiting/public health nursing pathways of specialist practitioner programmes. Such prescribing is now integral to the education of all district nurses, health visitors/public health nurses and the small number of practice nurses who have successfully completed the assessment requirements of either the stand alone or integrated course and whose prescribing status is noted on the Professional Register held by the NMC.

Extending nurse prescribing

5. Following a 3-month consultation with nursing, medical and pharmacy professional organisations from October 2000, Ministers announced in May 2001 that nurse prescribing would be extended to include more nurses, and to a wider range of medicines, to cover four broad areas of practice: Minor ailments, Minor injuries, Health promotion, Palliative care.

6. The extension of nurse prescribing was intended to provide patients with quicker and more efficient access to medicines, and to make the best use of nurses' skills. The key principle underlying the extension was that patient safety was paramount.

7. Following training, nurses prescribing under this extended scheme were able to prescribe all General Sale List and Pharmacy Medicines prescribable by GPs under the then NHS (General Medical Services) (Scotland) Regulations - with the exception of those products which contained controlled drugs - together with a list of Prescription Only Medicines ( POMs), listed in the Nurse Prescribers' Formulary.

8. Ministers also announced in May 2001 that steps would be taken to allow 'supplementary prescribing' by nurses and other health professionals, allowing them, after initial assessment of a patient by a doctor, to prescribe for that patient in accordance with a clinical management plan ( CMP). This form of prescribing was thought to be particularly suitable for nurses working with patients with enduring conditions such as asthma, diabetes, heart disease or mental illness. A consultation document issued in April 2002 stated that nurses and pharmacists were to be the first professionals involved in supplementary prescribing.

9. In April 2003, the Government enabled nurses and pharmacists to undertake educational preparation as supplementary prescribers. Supplementary prescribing is defined as a voluntary partnership between the independent prescriber (a doctor or dentist) and a supplementary prescriber to implement an agreed patient-specific Clinical Management Plan, with the patient's agreement.

10. The University of Southampton completed an evaluation of nurse prescribing in England for the Department of Health early in 2005. It was clear from the evaluation's conclusions that nurses and some doctors felt that the format of the Nurse Prescribers' Extended Formulary was in some cases restricting benefit to patients and efficient NHS practice. Experience had also shown that updating the Extended Formulary was a long and resource intensive process, with proposed changes taking 12 to 17 months to put into effect. Furthermore, supplementary prescribing could not be used in all settings where patients would benefit, e.g. emergency care and first contact care, because it required the development of an individual CMP agreed with a doctor/dentist.

11. A joint Department of Health / Medicines and Healthcare products Regulatory Agency consultation from February to May 2005 examined the options for the future of independent nurse prescribing. At the same time, a similar consultation examined options for the introduction of independent prescribing by pharmacists. These proposals aimed to benefit patients by providing greater access to pharmacists' knowledge and expertise, and a faster and more accessible service.

12. The responses to both consultations were considered by the Committee on Safety of Medicines who recommended to Ministers that suitably trained and qualified nurses should be able to prescribe any licensed medicine for any medical condition within their competence. These recommendations were agreed by Ministers and announced in a press release on 10 November 2005.

13. Changes to regulations in May 2006 enable nurses who train and qualify as 'nurse independent prescribers', to be able to prescribe any licensed medicine (i.e. products with a UK marketing authorisation) for any medical condition they are competent to treat.

14. Nurse independent prescribers can prescribe a limited range of Controlled Drugs for specific medical conditions. [N.B. - See also para 90 on Controlled Drugs and Appendix 9.]

15. Within the Scottish context, the University of Dundee was commissioned by the Scottish Executive to undertake a 'Research Literature Review on Prescribing'. Jane Harris et al (2004) examined research studies for the period 2000 - 2003. Two key findings from this review were firstly, that further research was needed to evaluate the impact of different models of prescribing on patient care and the effectiveness of educational preparation for the prescribing role. Secondly, a more judicious approach to the use of patient group directions ( PGDs - see Appendix 13) was needed.

16. Further research by Stirling University is in progress to undertake an 'evaluation of the extension of independent nurse prescribing in Scotland'. The final report of this staged study will be in 2007. The quantitative assessment from the survey data on individual nurse prescribers in Scotland captures information on: professional biographical information, age, gender, qualifications, how long each has qualified and worked as a nurse prescriber, and information on workloads, job satisfaction, and impact on patients. Further evaluation work is planned and will involve interviews with nurse prescribers, patients, carers and relatives, GPs, pharmacists and managers. This work will influence the implementation and delivery of nurse prescribing in Scotland.

Current nurse prescribers

17. District Nurses and Health Visitor/Public Health Nurse prescribers ( NMC V100) will continue to be entitled to prescribe from the current Nurse Prescribers' Formulary for community practitioners in the British National Formulary ( BNF). The formulary will be regularly reviewed, kept up to date and in line with practice requirements. These professionals will in future be called 'community practitioner nurse prescribers' (see paragraph 28).

18. There are a small number of nurses who under the old system qualified as 'extended formulary' nurse prescribers ( NMC V200), who have not undertaken the top-up training which allows them, additionally, to act as supplementary prescribers. They will however be entitled to act as 'nurse independent prescribers' in the new system (see paragraph 29).

19. The nurses who have qualified as 'extended formulary' nurse prescribers and as 'supplementary prescribers' ( NMC V300) will be entitled to act as 'nurse independent prescribers' or as 'supplementary prescribers', as appropriate (see paragraphs 29 - 31).

Definition of independent prescribing

20. A working definition of independent prescribing is prescribing by a practitioner (e.g. doctor, dentist, nurse, pharmacist) responsible and accountable for the assessment of patients with undiagnosed or diagnosed conditions and for decisions about the clinical management required, including prescribing. Within medicines legislation the term used is 'appropriate practitioner'.

21. In partnership with the patient, independent prescribing is one element of the clinical management of a patient. It requires an initial patient assessment, interpretation of that assessment, a decision on safe and appropriate therapy, and a process for ongoing monitoring. The independent prescriber is responsible and accountable for at least this element of a patient's care. Normally prescribing would be carried out in the context of practice within a multidisciplinary healthcare team, either in a hospital or in a community setting, and within a single, accessible healthcare record.

Legal basis of independent prescribing by nurses

Nurse Prescribing, in Scotland, has progressed, since 1996 as shown in the chart entitled 'History of nurse prescribing' (see Appendix 14).

22. The initial legal basis for the introduction of nurse prescribing was provided for in reserved legislation and in NHS regulations. See paragraph 2. In Scotland, the Scottish NHS regulations underpinning the subsequent introduction of nurse supplementary prescribers and nurse independent prescribers are set out below:

Supplementary Prescribing (2003):

• The National Health Service (Pharmaceutical Services) (Scotland) Amendment Regulations 2003. SSI No. 296
• The National Health Service (Charges for Drugs and Appliances) (Scotland) Amendment (No. 2) Regulations 2003. SSI No. 295
• The National Health Service (General Medical Services) (Scotland) Amendment (No. 3) Regulations 2003. SSI No. 443

Nurse Independent Prescribing (2006):

• The National Health Service (Pharmaceutical Services) (Scotland) Amendment (No. 2) Regulations 2006. SSI No. 245
• The National Health Service (Charges for Drugs and Appliances) (Scotland) Amendment (No. 2) Regulations 2006. SSI No. 246
• The National Health Service (General Medical Services) (Scotland) Amendment Regulations 2006. SSI No. 337

23. Section 63 of the Health and Social Care Act (2001) enabled the Government to extend prescribing responsibilities, including supplementary prescribing, to other health professions.

24. Amendments to the Prescription Only Medicines (Human Use) Order 1977 (the POM Order) and associated medicines regulations enable nurses against whose names in the Nursing and Midwifery Council Register is an annotation to act as nurse independent prescribers or nurse independent/supplementary prescribers. These nurses may prescribe any licensed medicine, (i.e. products with a UK marketing authorisation) including some Controlled Drugs, for any medical condition within their clinical competence (see paragraphs 29 - 31).

Aims of independent prescribing by nurses

25. Government policy is to extend prescribing responsibilities to non-medical professions to:

• improve the quality of service to patients without compromising patient safety;
• make it easier for patients to get the medicines they need;
• increase patient choice in accessing medicines;
• make better use of the skills of health professionals;
• contribute to the introduction of more flexible team working across the NHS.

26. Independent prescribing by nurses aims to provide patients with quicker and more efficient access to medicines, and to make the best use of their skills, knowledge and expertise. Independent prescribing by nurses will also allow doctors to make better use of their expertise.

27. NHS Boards should develop their strategic plan for non-medical prescribing to include independent prescribing by nurses and pharmacists. Typically this would involve senior managers and clinicians (doctors, nurses, pharmacists) and the drug and therapeutics committee (or equivalent). The plan should be approved at Board level and would, for example:

• recognise the benefits to patients of non-medical prescribing;
• identify an initial range of clinical areas where patients could benefit;
• identify a way to support and sustain the transition of staff to extended roles and the services they currently provide;
• develop a communications plan aimed at informing both patients and all clinical and managerial staff;
• include timescales for implementation;
• identify a lead director to be responsible for implementation.

Different categories of nurse prescriber

'Community Practitioner Nurse Prescribers'³

28. On successful completion of a community specialist practitioner programme which incorporates 'community practitioner nurse prescribing' ⁴ such nurses can prescribe from the Nurse Prescribers' Formulary for Community Practitioners. ⁵ This Formulary includes dressings, appliances and a limited list of medicines relevant to community nursing and health visiting/public health nursing practice. Applicants for the preparation programme (Specialist Practitioner Qualification/ Specialist Community Public Health Nurse Qualification) for community practitioner prescribing from the Nurse Prescribers Formulary for Community Practitioners must provide evidence of meeting the NMC criteria for eligibility to undertake an integrated prescribing programme as part of the Specialist Practitioner/Specialist Community Public Health Nursing Award. The criteria are that:

• nurses must be registered as a nurse and/or midwife;
• applicants intend to practise in an area of clinical need for which prescribing from the Community Practitioner Formulary will improve patient/client care and service delivery.

'Nurse Independent Prescribers'

29. Nurse independent prescribers will be able to prescribe any licensed medicine (i.e. products with a UK marketing authorisation) for any medical condition, including some controlled drugs. Nurse independent prescribers must only ever prescribe within their own level of experience and competence, acting in accordance with Clause 6 of the NMC (2002) Code of Professional Conduct. ⁶

30. Supplementary prescribers ⁷ can prescribe in partnership with a doctor or dentist. Nurse 'supplementary prescribers' are able to prescribe any medicine, including a limited range of Controlled Drugs and unlicensed medicines ⁸ that are listed in an agreed CMP. All supplementary prescribers may prescribe for any medical condition, provided that they do so under the terms of a patient-specific CMP which will be drawn up, with the patient's agreement, following diagnosis of the patient, and following consultation and agreement between the doctor and the supplementary prescriber.

31. Supplementary prescribing may still be the most appropriate mechanism for prescribing in some instances, e.g. where a nurse is newly qualified as a prescriber or where a team approach to prescribing is clearly appropriate, or where a patient's CMP includes certain controlled drugs or unlicensed medicines. The NMC (2006) ⁹ Practice Standard 8 should be followed by nurse prescribers in such situations. See also paragraph 94 and Appendix 11.

In future, nurses will be prepared as both 'nurse independent prescribers' and 'supplementary prescribers' (described by the NMC¹⁰ as nurse independent/supplementary prescribers) in the new arrangements. This document refers to this group of practitioners as 'nurse independent prescribers'.