Supplementary Prescribing by Nurses within NHSScotland: A Guide for Implementation

Supplementary Prescribing by Nurses within NHSScotland: A Guide for Implementation

HOW TO USE THE GUIDE

This guide has been prepared for:

• NHS Organisations

• Personal Medical Services Pilots

• General Practitioners

• Pharmacists

• Higher Educational Institutions providing nurse education

Other groups who will be interested in the guide, and who have therefore been sent a copy, include:

• Nurse prescribing Leads

• Existing Nurse Prescribers

• Community Services Pharmacists employed by, or contracted to, NHS organisations

• Patient Groups

It will be for NHS Organisations to consider, in light of local priorities, which nurses in their area should undertake preparation for supplementary prescribing. This guide has been prepared to assist them. Copies of all or part of the Guide may be reproduced at local level as required.

It might also be of interest to the Prison Healthcare Service, the Defence Medical Services and the independent healthcare sector.

It can be found on the Scottish Executive Health Department's website: www.show.scot.nhs.uk/sehd/nurseprescribing. The website contains other detailed information on the prescribing and supply of medicines by nurses and will be kept up to date on future developments.

INTRODUCTION

1. This guide sets out the administrative and procedural steps needed to enable registered nurses and registered midwives to act as supplementary prescribers. It also provides advice on good practice for supplementary prescribers and their independent prescriber partner (doctor or dentist). [NB Where the term "nurse" is used in this document it includes Registered Midwives]

Scope of this guidance and effect of devolution

2. This guide sets out the steps required to implement supplementary prescribing in Scotland. Medicines legislation permits the introduction of supplementary prescribing across the UK, and Ministers in Scotland have decided that supplementary prescribing will be implemented. Further guidance will issue in due course for supplementary pharmacist prescribers.

BACKGROUND

General

3. Supplementary prescribing has its basis in the recommendations of the final report of the Review of Prescribing, Supply and Administration of Medicines (1999), which recommended that two types of prescriber should be recognised:

• the independent prescriber who would be responsible for the assessment of patients with undiagnosed conditions and for decisions about the clinical management required, including prescribing;

• the dependent prescriber who would be responsible for the continuing care of patients who have been clinically assessed by an independent prescriber. This continuing care might include prescribing, which would usually be informed by clinical guidelines and be consistent with individual treatment plans, or continuing established treatments by issuing repeat prescriptions, with the authority to adjust the dose or dosage form according to the patients' needs. The Review recommended that there should be provision for regular clinical review by the assessing clinician.

[Note: the previous term Dependent Prescriber is now referred to as a Supplementary Prescriber]

4. In a press release on 4 May 2001, the Minister for Health and Community Care announced the Scottish Executive's intention to allow supplementary prescribing by nurses and prescribing by other professions such as pharmacists following the enactment of the Health and Social Care Bill (see also paragraph 7 below). Ministers subsequently decided that the greatest benefit to the NHS and to patients would be the introduction of supplementary prescribing by nurses and pharmacists, following diagnosis by a doctor.

5. Between April and July 2002 the Health Department and the Medicines Control Agency (now part of the new Medicines and Healthcare products Regulatory Agency) consulted on the proposals for supplementary prescribing by nurses and pharmacists. Similar consultations took place in England, Wales and Northern Ireland. The results of the consultations were considered at meetings of the Committee on Safety of Medicines and the Medicines Commission in September 2002. Ministers considered their recommendations, and the Health Department's plans were set out in a press release issued on 21 November 2002.

What is supplementary prescribing?

6. The working definition of supplementary prescribing is "a voluntary partnership between an independent prescriber (a doctor or dentist) and a supplementary prescriber to implement an agreed patient-specific Clinical Management Plan with the patient's agreement".

Legal basis of supplementary prescribing

7. Section 63 of the Health and Social Care Act 2001 enabled the Government to extend prescribing responsibilities to other health professions. It also enabled the introduction of new types of prescriber, including the concept of supplementary prescriber, by allowing Ministers by Order to attach conditions to their prescribing. Section 42 (for England and Wales) and Section 44 (Scotland) also relate to dispensing by community pharmacists of prescriptions written by these new prescribers. Provisions in Northern Ireland are a matter for relevant NI legislation. Amendments to the Prescription Only Medicines Order and NHS regulations allow supplementary prescribing by suitably trained nurses and pharmacists.

Aims of supplementary prescribing

8. Supplementary prescribing is intended to provide patients with quicker and more efficient access to medicines, and to make the best use of the skills of trained nurses and pharmacists. Over time, supplementary prescribing is also likely to reduce doctors' workloads, freeing up their time to concentrate on patients with more complicated conditions and more complex treatments. Time spent initially developing a simple Clinical Management Plan, should be time saved when the patient returns for review to the supplementary prescriber rather than the doctor.

Comparison with independent nurse prescribing and with Patient Group Directions

9. Following training incorporated into their specialist practitioner programmes, District Nurse and Health Visitor independent prescribers can prescribe from the Nurse Prescribers' Formulary for District Nurses and Health Visitors: this comprises a limited list of medicines and a large number of dressings and appliances relevant to community nursing and health visiting practice.

10. "Extended Formulary" independent nurse prescribers undertake a longer specific programme of preparation and can prescribe from the Nurse Prescribers' Extended Formulary. This includes all Pharmacy and General Sales List medicines prescribable by GPs on the NHS, together with a list of specified Prescription Only Medicines to treat conditions in four broad therapeutic areas - minor illness, minor injury, health promotion and palliative care.

11. Patient Group Directions are written instructions for the supply or administration of medicines to groups of patients who may not be individually identified before presentation for treatment. The Department has always made it clear that the majority of clinical care should be provided on an individual, patient-specific basis. Consequently the supply and administration of medicines under Patient Group Directions should be reserved for those situations where this offers an advantage for patient care (without compromising patient safety), and where it is consistent with appropriate professional relationships and accountability. Further detail is set out in NHS HDL (2001) 7.

12. Supplementary prescribers prescribe in partnership with a doctor or dentist (the independent prescriber). They are able to prescribe all medicines (with the current exceptions of Controlled Drugs, unlicensed drugs, unless they are part of a clinical trial which has a clinical trial certificate or exemption, and any restrictions set by Schedules 10 and 11 of the NHS (General Medical Services) Regulations). They may prescribe for the full range of medical conditions, provided that they do so under the terms of a patient-specific Clinical Management Plan (CMP). The Plan will be drawn up, with the patient's agreement, following diagnosis of the patient by the independent prescriber, and following consultation and agreement between the independent and supplementary prescribers.

HOW SUPPLEMENTARY PRESCRIBING WILL WORK

General principles

13. The independent prescriber must be a doctor or dentist. It is for the independent prescriber to determine which patients may benefit from supplementary prescribing and the medicines that may be prescribed by the supplementary prescriber under the CMP. S/he will clearly need to take account of the professional relationship between the independent and supplementary prescriber as well as the experience and areas and degree of expertise of the supplementary prescriber when coming to a decision.

14. Supplementary prescribing is a partnership between the independent and the supplementary prescriber who, between them, should draw up and agree an individual CMP for the patient's condition before supplementary prescribing begins. Sample draft templates are available on the Scottish Executive Health Department's prescribing website: www.show.scot.nhs.uk/sehd/nurseprescribing and also attached as Annexes B and C to this Guide, should help with this. The templates have been produced to help the NHS to develop CMPs more easily. The use of these templates is not mandatory. They can also be adapted/amended to suit local needs, or in some cases, it may be appropriate to develop CMPs from scratch. But there must be an individual CMP. Detailed information on what should be included in the CMP is set out in paragraph 43.

15. In each case the independent and/or supplementary prescriber should obtain the patient's agreement to supplementary prescribing taking place and then discuss and agree the CMP for that particular patient. The independent and supplementary prescribers must agree how to maintain communication, and that communication must be maintained, while the supplementary prescriber is reviewing and prescribing for the patient They should ideally jointly carry out the formal clinical review at the agreed time - normally within a maximum of 12 months of the start of the CMP. (Periods longer than 12 months between joint clinical reviews or reviews by the independent prescriber may occasionally be acceptable in the CMP where the patient's condition has been shown to be stable and deterioration of the condition is not to be expected during a period longer than 12 months. The appropriateness of such a longer period between joint or independent prescriber clinical reviews is the responsibility of the independent prescriber though it must be agreed with the supplementary prescriber). If a joint clinical review is not possible, the outcome of the clinical review by the independent prescriber needs to be discussed with the supplementary prescriber, who must agree continuation of, or changes to, the CMP.

16. The independent prescriber should be the clinician responsible for the individual's care at the time that supplementary prescribing is to start. If this responsibility moves from one independent prescriber to another (for example from the patient's GP to a hospital consultant, or from one GP to another), the supplementary prescriber may not continue to prescribe, unless s/he negotiates and records in the patient record a new agreement to enter a prescribing partnership with the new independent prescriber. Supplementary prescribing partnerships involving more than one independent prescriber (e.g. shared care arrangements) are referred to in paragraph 22 below.

Characteristics of supplementary prescribing

17. The key characteristics of supplementary prescribing are:

• Supplementary prescribing may only take place after a specified point in the individual patient episode, i.e. after assessment and diagnosis by an independent prescriber and the development of a written CMP agreed between the independent and supplementary prescriber.

• The independent prescriber is responsible for the diagnosis and setting the parameters of the CMP, although they need not personally draw it up.

• The supplementary prescriber has discretion in the choice of dosage, frequency, product and other variables in relation to medicines only within the limits specified by the CMP. The Plan may include reference to recognised and authoritative clinical guidelines and guidance (local or national), whether written or electronic, as an alternative to listing medicines individually. Any guidelines referred to should be readily accessible to the supplementary prescriber when managing the patient's care.

• Supplementary prescribing must be supported by a regular clinical review of the patient's progress by the assessing clinician (the independent prescriber), at pre-determined intervals appropriate to the patient's condition and the medicines to be prescribed. The intervals should normally be no longer than one year (and much less than this if antibiotics are to be included in the CMP). However, as stated in paragraph 15 above, longer periods, during which the patient continues to be reviewed by the supplementary prescriber, may be appropriate when the patient's condition is stable and is expected to continue to be stable.

• The independent prescriber may, at any time, review the patient's treatment and/or resume full responsibility for the patient's care.

• The independent prescriber and the supplementary prescriber must share access to, consult, keep up to date, and use, the same common patient record to ensure patient safety.

18. The key to safe and effective supplementary prescribing is the relationship between the individual independent prescriber and the individual supplementary prescriber. These two professionals should:

• Be able to communicate easily.

• Share access to, consult, keep up-to-date, and use, the same common patient record.

• Share access to the same local or national guidelines or protocols, where these are referred to in the CMP.

• Agree and share a common understanding of, and access to, the written CMP.

• Ideally, jointly review the patient's progress at agreed intervals.

Responsibilities

19. The independent prescriber is responsible for:

• The initial clinical assessment of the patient, the formulation of the diagnosis and determining the scope of the CMP.

• Reaching an agreement with the supplementary prescriber about the limits of their responsibility for prescribing and review - which should be set out in the CMP.

• Providing advice and support to the supplementary prescriber as requested.

• Carrying out a review of patient's progress at appropriate intervals, depending on the nature and stability of a patient's condition.

• Sharing the patient's record with the supplementary prescriber.

• Reporting adverse incidents within local risk management or clinical governance schemes. NHS Quality Improvement Scotland (NHS QIS) have been asked to develop proposals for improving patient safety in Scotland, including how we might benefit from the work of the English National Patient Safety Agency (NPSA) in England (this is separate from Adverse Reaction Reporting - see paragraph 59-61 below).

20. The supplementary prescriber is responsible for:

• Prescribing for the patient in accordance with the CMP. Altering the medicines prescribed, within the limits set out in the CMP, if monitoring of the patient's progress indicates that this is clinically appropriate.

• Monitoring and assessing the patient's progress as appropriate to the patient's condition and the medicines prescribed.

• Working at all times within their clinical competence and their professional Code of Conduct, and consulting the independent prescriber as necessary.

• Accepting professional accountability and clinical responsibility for their prescribing practice.

• Passing prescribing responsibility back to the independent prescriber, if the agreed clinical reviews are not carried out within the specified interval (see paras 15 and 17 above) or if they feel that the patient's condition no longer falls within their competence.

• Recording prescribing and monitoring activity contemporaneously in the shared patient record or as soon as possible - ideally within 24 to 48 hours.

Working together

21. Independent and supplementary prescribers must be willing and able to work together and to assume the specific responsibilities listed above.

22. Independent and supplementary prescribers may work in more than one prescribing partnership, providing that in each case they work as described above.

The process

23. Before starting to undertake supplementary prescribing, the supplementary prescriber will need to:

• Successfully complete the specified training and preparation for supplementary prescribing, including all assessments and the period of learning in practice.

• Ensure that their supplementary prescribing competency is recorded on the relevant Nursing and Midwifery Council professional register.

• Agree with the independent prescriber to enter into a prescribing partnership with them, and record that agreement in the patient's record.

• Agree the CMP for a patient with the independent prescriber.

• Make arrangements with their employer and/or the independent prescriber for access to prescription pads or other mechanisms for prescribing which are appropriate to the setting, for example patients' drug charts in hospitals.

• Arrange for access to an identified budget to meet the costs of their prescriptions.

• Reach agreement with their employer that supplementary prescribing should form part of their professional responsibilities.

Conditions and health needs that can be included

24. There are no legal restrictions on the clinical conditions that may be dealt with by a supplementary prescriber. Supplementary prescribing is primarily intended for use in managing specific chronic medical conditions or health needs affecting the patient. However, acute episodes occurring within chronic conditions may be included in these arrangements, provided they are included in the CMP.

Patient consent

25. Wherever it is proposed to manage a patient's condition through the use of supplementary prescribing, the principle underlying the concept of supplementary prescribing (i.e. a prescribing partnership) must be explained in advance to the patient by the independent or supplementary prescriber and their agreement should be obtained.

26. The agreement of the patient to the prescribing partnership should be recorded in the CMP and patient record. Without such agreement, supplementary prescribing may not proceed.

WHO CAN UNDERTAKE SUPPLEMENTARY PRESCRIBING?

Which nurses can be supplementary prescribers?

27. A nurse supplementary prescriber must be a 1st level Registered Nurse or Registered Midwife whose name in each case is held on the NMC professional register, with an annotation signifying that the nurse has successfully completed an approved programme of preparation for supplementary prescribing.

Selection of nurses to be trained

28. The selection of nurses who will receive training in prescribing is a matter for local decision, in the light of potential benefits for patients and local NHS needs. No nurse shall be required to undertake training unless s/he wishes to do so. All individuals selected for prescribing training must have the opportunity to prescribe in the post they will occupy on completion of training.

29. In addition to fulfilling the legal criteria for eligibility to prescribe, applicants who are selected for prescribing preparation will need to meet the following:

• Should have the ability to study at level 3 (degree level).

• At least three years' post-registration clinical nursing experience. Nominees will usually be at E grade or above.

• The support of their employer to confirm that:

  • their post is one in which they will have the need and opportunity to act as a supplementary prescriber;

  • for nurses in primary care, they will have access to a budget to meet the costs of their prescriptions on completion of the course;

  • they will have access to continuing professional development (CPD) opportunities on completion of the course.

30. There are likely to be many nurses in any local health organisation who meet these criteria. The three key principles that should be used to prioritise potential applicants are:

• patient safety;

• maximum benefit to patients and the NHS in terms of quicker and more efficient access to medicines for patients;

• better use of nurses' skills.

All programmes of preparation for nurses and midwives prepare them to be both independent and supplementary prescribers - there is no separate educational provision.

Only education programmes that meet the standards set by NMC and approved by NES in Scotland can lead to annotation on the professional register. Guidance from NES on education programmes in Scotland offers full information about the programmes. This is available via the NES website: www.nes.scot.org.uk

TRAINING AND PREPARATION FOR SUPPLEMENTARY PRESCRIBING

31. Nurses preparing to be supplementary prescribers will undertake a specific programme of preparation at degree level (level 3). This programme comprises at least the equivalent of 26 days with a Higher Education Institution plus 12 days "learning in practice", during which a designated supervising medical practitioner will provide the student with supervision, support and opportunities to develop competence in prescribing practice. The programme of preparation may be spread over a period of three to six months. Such nurses will also qualify to prescribe independently from the Nurse Prescribers' Extended Formulary. The nurse will also need to undertake an element of self-directed learning. Those nurses who have already qualified to prescribe from the Nurse Prescribers' Extended Formulary will only need to undertake the equivalent of an additional one to two days preparation on supplementary prescribing.

32. It will be for NHS organisations to determine which nurses to put forward for the programme of training and preparation.

33. In November 2002, the Nursing and Midwifery Council (NMC) agreed a set of standards for the preparation of nurse, midwife and health visitor prescribers. A copy of these is attached at Annex A. NHS Education for Scotland (NES) is responsible for quality assuring the specific programmes that Higher Education Institutions put forward for approval. Although some universities and pharmaceutical companies already offer training and education in aspects of pharmacology and medicines management, only NES approved programmes of preparation for nurse prescribing will be accepted by NMC when recording a nurse's qualification. Higher Education Institutions offering the specific programme of preparation may accredit the nurse's prior learning.

34. The programme will be part time over a period of up to six months. In addition to the time spent on the formal programme, it is important that employers of nurses undertaking the programme should recognise the demands of private study and provide support where necessary.

35. The programme for nurses and midwives includes an assessment of theory and practice that must be passed by nurses, before the student's entry on the NMC register can be annotated to indicate that they hold the prescribing qualification for Extended Formulary nurse prescribing and supplementary prescribing.

36. Central funding is being made available to meet the costs of training. NHS employers may also, of course, utilise their own training funds for this purpose.

Preparation for independent prescribers

37. It is highly desirable that independent prescribers who wish to take part in a supplementary prescribing partnership first undertake a short period of preparation related to the nature of supplementary prescribing and their responsibilities in the partnership. This will not necessarily require attendance at a Higher Education Institution: learning materials may be made available for use in the workplace.

Continuing Professional Development (CPD)

38. All nurses have a professional responsibility to keep themselves abreast of clinical and professional developments. Supplementary prescribers will be expected to keep up-to-date with best practice in the management of conditions for which they may prescribe, and in the use of the drugs, dressings and appliances. Nurses may use the learning from this activity as part of their Post Registration Education and Practice (PREP-CPD) activity. NES has commissioned work on CPD that will be available from the autumn of 2003.

EVALUATION AUDIT AND CLINICAL GOVERNANCE OF SUPPLEMENTARY PRESCRIBING

39. Supplementary prescribing needs to take place within a framework of clinical governance. Clinical supervision sessions for nurses provide an excellent opportunity for reflection on prescribing, as well as other aspects of practice. The model of clinical supervision should be agreed at local level, taking account of other staff support mechanisms and resources. It should be monitored and evaluated regularly.

40. A general review of supplementary prescribing arrangements should be carried out as part of the overall prescribing monitoring arrangements.

41. The supplementary prescriber together with his or her employer must put in place specific actions regularly to evaluate the safety, effectiveness, appropriateness and acceptability of their prescribing.

42. Other assistance with identifying audit methodologies and interpreting findings should be available through the employing organisations' normal clinical governance mechanisms.

THE CLINICAL MANAGEMENT PLAN (CMP)

43. The Clinical Management Plan is the foundation stone of supplementary prescribing. Before supplementary prescribing can take place, it is obligatory for an agreed CMP to be in place (written or electronic) relating to a named patient and to that patient's specific condition(s) to be managed by the supplementary prescriber. This should be included in the patient record. Regulations specify that the CMP must include the following:

• The name of the patient to whom the plan relates.

• The illness or conditions which may be treated by the supplementary prescriber.

• The date on which the plan is to take effect, and when it is to be reviewed by the doctor or dentist who is party to the plan.

• Reference to the class or description of medicines or types of appliances which may be prescribed or administered under the plan.

• Any restrictions or limitations as to the strength or dose of any medicine which may be prescribed or administered under the plan, and any period of administration or use of any medicine or appliance which may be prescribed or administered under the plan.

• The arrangements in place for communication between independent and supplementary prescribers and for record maintenance.

[NB: The CMP may include a reference to published national or local guidelines. However, these must clearly identify the range of the relevant medicinal products to be used in the treatment of the patient, and the CMP should draw attention to the relevant part of the guideline. The guidelines also need to be easily accessible]

• Relevant warnings about known sensitivities of the patient to, or known difficulties of the patient with, particular medicines or appliances.

• The arrangements for notification of:
  a) suspected or known reactions to any medicine which may be prescribed or administered under the plan, and suspected or known adverse reactions to any other medicine taken at the same time as any medicine prescribed or administered under the plan; and
  b) incidents occurring with the appliance which might lead, might have led or has led to the death or serious deterioration of state of health of the patient.
  [ See paragraph 59 about Adverse Reaction Reporting]

• The circumstances in which the supplementary prescriber should refer to, or seek the advice of, the doctor or dentist who is party to the plan.

44. The CMP should be kept as simple as possible. It may refer to national or local evidence-based guidelines to identify the medicines that are to be prescribed, or circumstances in which dosage, frequency or formulation should be changed. There is no need to repeat the advice in these guidelines in the body of the CMP itself, nor need the CMP repeat detailed patient information that is contained in the patient's record shared by both prescribers, unless such information is essential for clarity and patient safety.

45. Following diagnosis by the independent prescriber, the independent and supplementary prescriber will probably need to discuss the CMP before the document itself is prepared. Either the independent or supplementary prescriber may draft the CMP; however, both must formally agree to the CMP before supplementary prescribing can begin. The agreement of the patient must also be sought, and that agreement recorded in the CMP. Without it, supplementary prescribing cannot proceed. [ See paragraphs 25 and 26]

46. The independent prescriber and supplementary prescriber must share access to, consult and use, the same common patient record. Shared electronic records are ideal, but existing paper records or patient-held records can also be used. The CMP may need to contain different levels of detail, if the independent and supplementary prescriber work in different locations (e.g. a hospital-based independent prescriber and an outreach supplementary prescriber in the patient's home). Potential templates for CMPs can be found at Annexes B and C to this document, and have been posted on the Scottish Executive Health Department website: www.show.scot.nhs.uk/sehd/nurseprescribing - see also paragraph 14 above. The website will be updated as appropriate with advice on producing CMPs and other practical aspects of setting up a supplementary prescribing partnership.

47. It is for the independent prescriber to determine the extent of the responsibility he or she wishes to give to the supplementary prescriber under the CMP. The independent prescriber will clearly need to take account of the experience and areas of expertise of the supplementary prescriber, and the professional relationship between the independent and supplementary prescriber(s), when coming to this decision.

48. The CMP comes to an end:

• At any time at the discretion of the independent prescriber.

• At the request of the supplementary prescriber or the patient.

• At the time specified for the review of the patient (unless it is renewed by both prescribers at that time).

• Where there is a sole independent prescriber and he or she is replaced for whatever reason. In these circumstances the CMP must be reviewed by their successor.

MEDICINES PRESCRIBABLE UNDER SUPPLEMENTARY PRESCRIBING ARRANGEMENTS

49. The CMP may include any General Sales List, Pharmacy, or Prescription Only Medicine prescribable at NHS expense, with the current exception of Controlled Drugs ( but see also paragraph 12 above). This includes the prescribing of:

• Antimicrobials.

• "Black triangle" drugs and those products suggested by the British National Formulary to be "less suitable" for prescribing.

• Products used outside their licensed indications (i.e. "off-label" use), provided that the product is licensed for use in the UK. Such use must have the joint agreement of both prescribers and the status of the drug should be recorded in the CMP.

NB. Unlicensed drugs (that is, a product that is not licensed in the UK) may be included in the CMP only where:
a) a clinical trial is being undertaken under a clinical trials certificate or an exemption; and
b) their use has the joint agreement of both prescribers and the status of the drug is recorded in the CMP.

50. The independent prescriber will need to be aware of the high-risk nature of many drugs prescribed under local shared care guidelines (e.g. Methotrexate) and the specific monitoring requirements to support the safe and efficacious use of these drugs. Before undertaking a supplementary prescribing arrangement involving any high-risk drug, the independent prescriber will need to assure him/herself that the supplementary prescriber has the level of skill/knowledge to take part in such an arrangement.

51. A supplementary prescriber must not agree to prescribe any medicine if s/he feels that his/her knowledge of the medicines s/he may be asked to prescribe falls outside his/her area of competence.

THE PATIENT REVIEW

52. The patient review must take place after the interval stated in the CMP. This may be a joint review by both prescribers seeing the patient together. Where this is not possible, the independent prescriber should review the patient, and subsequently discuss future management of the patient's condition(s) with the supplementary prescriber. Both prescribers must record their agreement to the continuing or amended CMP, and the patient's agreement to the continuation of the supplementary prescribing arrangement, in order for the CMP to remain valid. They should then set a new date for review. Prescribing by the supplementary prescriber after the date of review, and without recorded agreement to the next phase of the CMP, should not continue.

GOOD PRACTICE, ETHICS AND ISSUES COMMON TO ALL SUPPLEMENTARY PRESCRIBERS

Stock items

53. In primary care settings, prescriptions should not be written when an item has been administered to a patient using GP surgery or clinic stock items, because the cost of these items is already covered through the GP10A stock order system.

Informing patients

54. Supplementary prescribers must ensure that patients are aware of the scope and limits of supplementary prescribing and how the patient or client can obtain other items necessary for their care.

Prescribing for self, family and friends

55. This is a matter for the independent prescriber to decide when setting up the CMP. However, it is strongly recommended that (as for doctors and dentists) nurse supplementary prescribers should, wherever possible, not be placed in the position of prescribing for close family members, as judgement may be impaired and important clinical examination may be difficult/impossible. They should not prescribe for themselves.

PATIENT RECORDS

61. All nurses are required to keep contemporaneous records, which are unambiguous and legible. The NMC Standards for Records and Record Keeping outline the requirements of a nurse's records. The prescription details, together with other details of the consultation with the patient, should be entered into the record shared with the independent prescriber as soon as possible and preferably contemporaneously. It should be marked to indicate that it is the prescription of a supplementary prescriber, and should include the name of the supplementary prescriber. The maximum time to be allowed between writing the prescription and entering the details into the general record is for local negotiation, but best practice suggests that this should be immediately. Only in exceptional circumstances (e.g. the intervention of a weekend or public holiday) should this period exceed 48 hours from writing the prescription. Arrangements for the sharing of patient records should be put into place at the same time as the supplementary prescribing partnership is set up. The record of the nurse's or midwife's prescription should also be entered into the nursing patient record (where a separate nursing record exists) at the time of writing.

57. It is recommended that the record clearly indicates the date, the name of the prescriber, the name of the item prescribed and the quantity prescribed (or dose, frequency and treatment duration). For medicinal preparations, items to be ingested or inserted into the body, it is recommended that the name of the prescribed item, the strength (if any) of the preparation, the dosing schedule and route of administration is given, e.g. "paracetamol oral suspension 120mg/5mls, 5mls to be taken 4 hourly by mouth as required for pain, maximum of 20mls in 24 hours". For topical medicinal preparations, the name of the prescribed item, the strength (if any), the quantity to be applied and frequency of application should be indicated. For dressings and appliances, details of how to be applied and how frequently changed are useful. It is recommended that the advice given on General Sales List (also known as "Over The Counter") items be recorded, although this is not mandatory.

58. In some circumstances, in the clinical judgement of the supplementary prescriber, it may be necessary to advise the independent prescriber immediately about the prescription. This action should be recorded in the common patient record.

ADVERSE REACTION REPORTING

59. If a patient suffers a suspected adverse reaction to a prescribed, over-the-counter (General Sales List) or herbal medicine, the adverse reaction should be reported via the Yellow Card Scheme. The Yellow Card Scheme is a voluntary scheme through which healthcare professionals (including nurses and midwives) notify the Medicines and Healthcare Products Regulatory Agency (MHRA) Committee on the Safety of Medicines (CSM) of suspected adverse drug reactions (ADRs). The MHRA/CSM encourage the reporting of all suspected adverse drug reactions to newly licensed medicines that are under intensive monitoring (identified by a * symbol both on the product information for the drug and in the BNF and MIMS) and all serious suspected adverse drug reactions to all other established drugs. Serious reactions include those that are fatal, life threatening, disabling, incapacitating or which result in or prolong hospitalisation and/or are medically significant. The new electronic Yellow Card provides a simple and fast way to report suspected adverse reactions. The electronic Yellow Card, together with instructions on how to use it, is available on the MHRA website ( www.mhra.gov.uk). Health professionals are encouraged to report all suspected adverse drug reactions using this method, although hard copy Yellow Cards are also acceptable (and can be found bound to the back of the British National Formulary). The supplementary prescriber should also inform the independent prescriber of any reported ADRs.

60. The bulletin "Current Problems In Pharmacovigilance", issued by the MHRA and the CSM, contains advice and information on drug safety issues. The bulletin is produced four times a year. All supplementary prescribers are encouraged to consult the bulletin as a matter of routine. Copies are also available from the CSM's website, which can be found on www.mhra.gov.uk

Role of the National Patient Safety Agency

61. If a patient suffers harm due to an adverse incident involving medication, or if harm could have been caused to the patient (a near miss), the incident or near miss should be reported by the supplementary prescriber using both local and national reporting systems. The National Patient Safety Agency (NPSA), was established in England in 2001 to improve the safety of NHS patient care, by promoting a culture of reporting and learning from adverse incidents across the NHS. The NPSA information is shared with devolved health services in Scotland and Wales. The Agency will develop, implement and manage a new reporting system, which will collect information on adverse incidents and near misses so that lessons can be learnt at local and national level. It will develop solutions to try to ensure that the same errors are not repeated. NHS Quality Improvement Scotland has been asked to develop proposals to improve patient safety in NHSScotland, including how we might benefit from the work of the Agency. Further information on the NPSA can be found on its websitewww.npsa.nhs.uk

LEGAL AND CLINICAL LIABILITY

Liability of employer

62. Where a nurse or midwife is appropriately trained and qualified and prescribes as part of their professional duties with the consent of their employer, the employer is held vicariously liable for their actions. In addition, nurse supplementary prescribers are individually professionally accountable to the Nursing and Midwifery Council (NMC) for this aspect of their practice, as for any other, and must act at all times in accordance with the NMC Code of Professional Conduct.

Professional indemnity

63. All supplementary prescribers should ensure that they have professional indemnity insurance, for instance by means of membership of a professional organisation or trade union.

DISPENSING OF PRESCRIBED ITEMS

Dispensing Doctors in primary care

64. Where a GP practice is a dispensing practice, prescriptions from supplementary prescribers can be dispensed by the practice but only for the dispensing patients of that practice. Dispensing Doctors cannot dispense prescriptions written by supplementary prescribers for patients of other practices.

65. When submitting prescription forms to Practitioner Services Division (PSD), dispensing practices should include them with their GP10 form count on their GP34 declaration and sort them as per existing instructions.

66. Reimbursement for prescriptions written by supplementary prescribers can be claimed by Dispensing Doctors; payment for the prescriptions submitted will be made to the senior partner.

Nurses required to dispense in primary care

67. As stated within the NMC " Guideline for the administration of medicines" (2002), a nurse may be required to dispense "under exceptional circumstances". Where this is likely to occur, the nurse's employer should be aware of this practice. In addition, paragraphs 64-66 must be adhered to.

68. The rules for dispensing and reimbursement of supplementary prescribers' prescriptions are the same as for GP prescriptions.

VERIFICATION OF PRESCRIBING STATUS

Role of the pharmacist on verification of prescribing status

69. Dispensing pharmacists should ensure that they know the local procedure for resolving any queries with the supplementary prescriber or their independent prescriber partner.

70. To enable pharmacists to check whether a prescription handed in for dispensing is bona fide, all NHS employers should keep a list of all supplementary prescribers employed by them. It is also recommended that the employing authority hold a copy of the prescriber's signature. Individuals should be prepared to provide specimen signatures to pharmacists, should that be required.

The NMC voice bank

71. Most enquiries from dispensing pharmacists will be resolved by telephoning the prescriber, or the prescriber's employer. However, for general queries about qualification (e.g. in the case of receiving a private prescription), the pharmacist can telephone the 24-hour NMC voice bank system. ¹ Pharmacists should clearly state that they are checking the prescribing status of an individual. They should then be asked to give the nurse prescriber's NMC number and name. If the pharmacist fails to state that s/he is checking prescribing status, the NMC operator will assume the pharmacist is the nurse's employer and will ask a number of further questions to which the pharmacist will not have the answer.

DISPENSING BY APPLIANCE CONTRACTORS

72. When a supplementary prescriber becomes aware that the patient intends to have a prescription dispensed by an appliance contractor, they must ensure that the prescription does not contain medicinal preparations (Appliance contractors cannot dispense medicinal preparations). Appliance contractors should submit as per existing instructions.

URGENT DISPENSING

73. Occasionally prescriptions may require dispensing out of normal pharmacy opening hours. The prescription form should be endorsed by the prescriber with the word "Urgent". A pharmacist may claim an additional fee for dispensing a prescription urgently. Arrangements for dispensing out of normal hours vary, but details may be available via NHS organisations, local pharmacies, NHS 24 or police stations.

DISPENSING OF ITEMS IN WALES AND NORTHERN IRELAND

74. Prescriptions written by supplementary prescribers in Scotland will only be dispensable by pharmacists in Wales and Northern Ireland when the devolved administrations amend their pharmaceutical regulations, to permit them to be dispensed at NHS expense.

DISPENSING ITEMS AGAINST A NURSE PRESCRIPTION IN HOSPITAL PHARMACIES

75. An up-to-date list of all qualified supplementary prescribers employed by the hospital will need to be kept in the hospital pharmacy. Pharmacy staff should check the prescriber against the list. The same process will apply for in-patient, outpatient and discharge prescriptions.

Prescribing information

76. The Primary Care Information Group (PCIG) within the Information and Statistics Division (ISD) provides information on prescribed items and costs to their NHS organisations in the form of routine reports and in response to ad hoc requests. Supplementary prescribers can expect to receive information via their NHS employer which will help monitor their prescribing. Prescribing by nurse supplementary prescribers will be reported to NHS Organisations jointly with information on Extended Formulary prescribing. Requests for information should be made on headed note paper by the prescriber's NHS employer and sent to the following address:

Primary Care Information Group
Information and Statistics Division
Trinity Park House
South Trinity Road
Edinburgh
EH5 3SE

77. Hospital employers may find it beneficial to collect and analyse prescribing data on supplementary prescribers alongside the routine monitoring of prescribing by doctors.