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	The Pharmaceutical Journal Vol 269 No 7227 p812-813 7 December 2002	This page Reprint Photocopy
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Drug tariff

Should nurses prescribe generically?

From Dr R. J. Schmidt, MRPharmS

May I have an explanation for a change that has appeared in the November 2002 Drug Tariff? The change is all the more surprising because it was not announced in the "advanced notice" section in the preface to the October 2002 tariff.

Ever since the Nurse Prescribers Formulary appeared in the Drug Tariff in 1994 [now Section XVIIB9(i)], there have appeared the following words at the head of the list of medicinal preparations: "These preparations will only be prescribable as listed." This instruction appears also in the British National Formulary where the Nurse Prescribers Formulary is reproduced together with details of NPF preparations, but with slightly different wording: "Although brand names have sometimes been included for identification purposes the non-proprietary names shown on the list should be used for prescribing purposes." Taken together, these instructions in the tariff and BNF clearly indicate that nurses should prescribe generically (except where no generic name exists) and that pharmacists should not dispense prescriptions written by nurse prescribers unless the prescribed preparation was written "as listed" in the tariff. Indeed, it is my recollection from the earliest days of nurse prescribing that nurses were to be obliged to write prescriptions generically and this would show the way for GPs who were at that time also being urged to move to generic prescribing.

I understand that the NPF is a "white list" and that it may therefore be unlawful to do other than prescribe the preparations in the NPF "as listed". Because the NPF is a white list, the Department of Health risks opening a can of worms by relaxing the requirement to prescribe preparations "as listed".

Putting common sense aside for a moment, what would be the legal position if a pharmacist received a nurse's prescription for Senokot tablets? According to my understanding, Schedule 10 of the NHS (General Medical Services) Regulations 1992 as amended (ie, the "black list") relates only to prescriptions written by GPs. This is why the NPF had to be made a "white list". So a prescription written by a nurse for Senokot tablets or Laxoberal elixir or Dulcolax tablets should now be reimbursable as a result of this recent change made in the November 2002 tariff.

Over the past eight years or so, generic prescribing by GPs has burgeoned and this in turn has helped to bring down the cost of medicines to the NHS (and hence benefited taxpayers). So why has the DoH now replaced "These preparations will only be prescribable as listed" with the words "Nurses are recommended to prescribe generically, except where this would not be clinically appropriate or where there is no approved generic name"? Has there been a change in policy? Is generic prescribing being relaxed? Perhaps the DoH could give an example of a preparation in the NPF for which there is published clinical evidence of non-bioequivalence between a proprietary preparation and another that might be dispensed against a generically-written nurse prescription. Why has this change been rushed through without even an advance warning notice being published in the October 2002 Drug Tariff?

Richard Schmidt
Barnoldswick, Lancashire

Dr GORDON GEDDES, head of information and technical services, Pharmaceutical Services Negotiating Committee, states:

In the view of the PSNC, the changes to the wording at the head of the list in Part XVIIB(i) do not affect the processing of prescriptions written by nurse prescribers. The facility whereby nurses may prescribe proprietary preparations as long as the non-proprietary description appears in the Nurse Prescribers' Formulary has two precedents.

Although contrary to the spirit of the Dental Practitioners' Formulary, orders on dental forms for proprietary preparations with a generic description in the formulary have been passed for payment. Since this is not detrimental to community pharmacy, the PSNC has never challenged this interpretation. Another example is the prescribing of certain appliances, eg, elastic hosiery, by brand name although only a compatible generic description appears in Part IXA of the Drug Tariff. Hence it is understandable that the NPF has been similarly interpreted.

On the above basis, I agree with Dr Schmidt that, were a nurse to order a scheduled drug such as Senokot tablets, then because senna tablets are included in the NPF, the prescription should be passed for payment because of the way the regulations are worded. Since this interpretation is as yet untested, the PSNC recommends that any such prescriptions are returned to the prescriber.

Please note that the Nurse Prescribers' Extended Formulary allows the prescribing by suitably trained nurses of all licensed P and GSL medicines prescribable on the NHS except Controlled Drugs and presentations and pack sizes that are not to be prescribed under the NHS (p522 of the November Drug Tariff).

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