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Jason Hall, clinical teaching fellow at the school
of pharmacy, University of Manchester
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Since the first pharmacist prescribers are about to issue their first
prescriptions, it is worth pausing to consider if there are any lessons
that can be learnt from our knowledge of the introduction of nurse prescribing
that would help smooth the path for the novice pharmacist prescriber.
It is 17 years since nurse prescribing was first recommended in a Government
report and we now have almost 10 years’ experience of nurse prescribing.
The first nurse prescribers were community nurses and they included district
nurses, health visitors and a much smaller number of practice nurses.
These nurses prescribe from a limited list of medicines and appliances
termed the Nurse Prescribers’ Formulary. More recently, all registered
nurses have been eligible to be trained as prescribers and prescribe
from a wider range of items known as the Nurse Prescribers’ Extended
Formulary. How-ever, Prescription Pricing Authority figures indicate
that community nurses account for 95 per cent of all nurse prescribing
costs.
Looking back at the delayed introduction of nurse prescribing following
its first recommendation, it appears that the Government’s greatest
concern was the impact that this might have had on an already increasing
drugs bill. These fears subsided following reports that nurse prescribing
did not add to prescribing costs. Nurse prescribing costs may be lower
than was once expected because some nurses are not making use of their
prescribing rights, with around a quarter of trained prescribers not
regularly prescribing according to one study.1
This lack of a cost pressure has meant that many primary care trusts
have not made the monitoring of nurse prescribing a priority. It is perhaps
not surprising, given the financial pressures on the National Health
Service, that their focus has been actual and potential overspends due
to GP prescribing.
However, the targeting of prescriber support should not just be determined
on the basis of financial risk but should also consider the prescribers’ needs.
Therefore their level of prescribing should be reviewed, in addition
to performance against prescribing indicators. One could argue that the
needs of a prescriber are greatest at the start of their prescribing
career and a lack of support during this period could prevent their development
into confident prescribers, resulting in a lost opportunity for improving
patient care. Prescriber support can take a variety of forms that include
targeted information, training, access to help and advice, user-friendly
administrative systems, peer review and performance feedback.
Targeted information and training can help address confidence problems
and several studies suggest that community nurse prescribers lack confidence
in prescribing. There are a number of possible explanations. Having to
wait up to 18 months to receive a prescription pad following qualification,
as has happened, does not help their confidence, and this could be avoided
provided there is collaboration between those responsible for training,
registration and issuing prescription pads. One could point to the relatively
brief period of training (two days plus a distance learning package)
compared to supplementary prescribers (26 taught days and 12 days learning
in practice) and claim that this is less
likely to be a problem for supplementary prescribers. However, most of
the community nurses interviewed1 believed that their original training
was satisfactory but they lacked ongoing training. It has been reported
that support mechanisms for prescribers are weak and some nurse prescribers
uncertain whom to consult for support.
Research carried out within my department has identified that prescribing
administrative systems vary. In those places with higher levels of prescribing,
the systems appear to have evolved and the nurses consider them to be
user-friendly. But in places with low levels of nurse prescribing, the
systems appear cumbersome and were perceived by nurses to be a barrier.
Since both supplementary and independent prescribers are required to
share a common record there is less need for separate communication channel
which should simplify the administrative systems. It is also hoped that
the supervised learning in practice component of the training will provide
supplementary prescribers with the opportunity to become confident in
such procedures. However, supplementary prescribing will have its own
administrative systems and central to these are the clinical management
plans. It is rare for administration systems to be perfect at the first
attempt so it is important that trusts reflect on prescribers’ experience
with such systems and also work with other trusts to share good practice.
Many nurses claim that they have not received feedback on their prescribing
and complain that they have little knowledge of their performance. Systems
have developed to allow GPs to review their prescribing, but as yet it
appears that many places have not developed systems for nurses. It is
likely that the bulk of prescribing costs will remain with doctors for
the foreseeable future and therefore pharmacist prescribers could well
receive as little feedback as nurse prescribers. However, if little attention
is paid now to encouraging good practice then it may be more difficult
in the future.
The area of prescribing where community nurses are most active is in
wound management and it was acknowledged before the introduction of nurse
prescribing that GPs were simply endorsing nurses’ clinical decision
making in this area. It could be argued that nurse prescribing has been
most successful where it has involved little change to their clinical
practice and areas that involved role development, such as smoking cessation,
have not taken off to the same extent. This could reflect a resistance
to change or that the training addressed how to prescribe rather than
what to prescribe. Trusts considering the therapeutic areas in which
they wish pharmacists to prescribe should consider the extent to which
it represents a development of their role and tailor their support accordingly.
The Department of Health has said that supplementary prescribing aims “to
provide patients with a quicker and more efficient access to medicines” and
over time it is “likely to reduce doctors workloads”. There
have been reports that time is saved for patients as nurses can write
the prescription there and then, rather than chasing doctors to write
prescriptions. It was also hoped that nurses would save time but the
time required for administration related to nurse prescribing and discussing
medicine usage with patients appears to offset any time saved elsewhere.
It may be that this different use of time represents a more effective
use of time that pharmacist prescribers will relish. However, both pharmacists
and their managers will need to consider what aspects of their current
role they will no longer be able to perform in order to ensure that they
have sufficient time to prescribe.
Supplementary prescribing should benefit patients by improving their
access to prescribers but pharmacist prescribers must have sufficient
confidence to take on the role. Trusts can facilitate this by ensuring
pharmacists work in areas where they have the opportunity to prescribe
with protected time to enable them to do so, by developing systems for
the routine monitoring of supplementary prescribing, by engaging in discussion
with prescribers and other trusts and by providing ongoing support and
feedback that meets the needs of prescribers.
Reference
1. Luker K, McHugh G, Nurse prescribing from the community nurse’s
perspective. Interntional Journal of Pharmacy Practice 2002;10:273–80. |
The Pharmaceutical Journal