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Letters to the Editor
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Prescribing
Measuring competence
From Dr B. Hynam, MRPharmS
Extending prescribing rights is a key thrust of the NHS modernisation
programme. However, an equally important goal is that the NHS should
be safer. Indeed, one of the key recommendations of the Chief Pharmaceutical
Officer’s 2004 report, “Building
a safer NHS for patients — improving
medication safety,” is that “prescribers should be trained
and assessed as competent before being required to prescribe”.
Being trained and being competent are not the same thing.
There is an underlying assumption that prescribers will not prescribe
outside their area of competence. I feel uncomfortable about this assumption,
this reliance on self-assessment. What if the practitioner is “unconsciously
incompetent”? Most of us will have experienced worrying situations
of people dabbling in areas that they feel comfortable with but yet they
are clearly not up to scratch. Witness the Bristol cardiac surgery cases.
We would not want that with medicines. Safe and effective prescribing
is more than just being able to use the index of the BNF or MIMS.
The NHS has heavily invested in training programmes for nurse and pharmacist
prescribers. In general, these courses do not have a significant therapeutic
component. This would be difficult, considering the variety of specialties
involved. There is an assumption that a professional already has the
therapeutic knowledge to practise in his or her area, which may well
be the case. Often it appears that this revolves around how long the
practitioner has been in post. But longevity may not equate with true
expertise. In many situations the mentor may “sign off” a
practitioner although one wonders how robust that process is.
How to measure prescribing competence is not clear-cut. There are both
elements of therapeutic competence and practical competence. Many doctors,
at least in secondary care, where electronic prescribing has not arrived,
seem unable to write a legible prescription. Should this define them
as incompetent with the consequent withdrawal of prescribing rights?
Prescribing skills are rarely formally tested. Also, knowledge is not
the same as performance.
Perhaps there needs to be a prescribing licence, where prescribers demonstrate
and prove practically that they can and do prescribe clearly, unambiguously
and legally — the basic prescribing skills — as well as showing
they know the limits of their own capabilities. The National Prescribing
Centre has published excellent prescribing competence frameworks for
both pharmacists and nurses. Possibly the next step is to develop assessment
tools to measure these.
Maybe all potential prescribers ought to pass a practical prescribing
examination before being let loose with a prescription pad or chart.
There is no doubt that there are many competent prescribers around but
there are also many poor ones. With the drive to extend prescribing rights
there will be a lot more prescribers. Many of these will not have had
the benefit of the underpinning theoretical knowledge that some of us
believe is essential. I would hope that the initiative to extend the
numbers of prescribers will improve the quality of prescribing and patient
care. But there are risks. There needs to be some quantifiable assurance
that this extended prescribing is indeed of an acceptable and consistent
standard. There needs to be a measure of prescribing competence.
Brian Hynam
Director of Pharmacy,
Staffordshire General Hospital
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The
Pharmaceutical Journal