Wednesday, 16 April 2008

Non-Medical Prescribing

"I haven't made up my mind yet whether I think nurses being able to prescribe is desirable.

This comment from Medically Brunette about prescribing got me thinking.

I work with non-medical prescribers and every year mentor more through the course. It should be a course based on aptitude and on the need of that person's role to prescribe in order to deliver better patient care. Really, it should be determined through a review of the Knowledge and Skills Framework (KSF) within the person's annual appraisal.

It doesn't work like that, in my corner.

Prescribing is something with such significant implication that the only folk I've mentored through the non-medical prescribing courses and continue to support are those who I work with closely who I've confidance in. I know, I know, it shouldn't be personal like this, but it is.

We've nurses, pharmacists and a physio who can prescribe. At the moment, legally, the nurses can be independent prescribers. I'm not comfortable with tossing them the BNF and sending them on their way, so we've quite constrained formularies they can use and they can only undertake supplementary prescribing. This means that I see a patient (usually with them), if a nurse wants to be involved in prescribing she suggests this then we all agree a clinical management plan (CMP), I type this up, the nurse actions it.

Benefits of this are :
- I still see every patient for diagnosis
- The nurse and patient and I agree a range of drug treatment options together, so I get to say what options are on the table and the patient gets to select from those what they want in the CMP
- It's typed up on a proforma so the CMP can be printed out and easily shared with one and all, making it clear to one and all what's being proposed
- The patient never then needs to see me just for a prescription
- When things change, the nurse has latitude to effect change with the patient (e.g. titrating dose as we've agreed) so things can be done quickly
- The nurses say they've become much more familiar with medications' benefits and consequences
- They're so cautious in prescribing that they collect massive amounts of information about what they do, so we've rich audit/clinical effectiveness data

Independent prescribing is on the horizon. What's the difference? Legally, in essence it means the nurse can prescribe what they wish, rather than what they've agreed with a doctor in a written CMP. Under supplementary prescribing if a nurse sees someone who's bereaved and could use some medication, they can't prescribe unless I see the patient and write a CMP with them. Under independent prescribing they could see the patient and start treatment, without me being involved at all.

Now, here's the rub.

Most nurses I work with, most of the time, are cautious and sensible enough that they'll work with what they know but won't touch anything that's outside their competencies. Nurse nurses, doctor doctors, we're all happy. Most senior nurses already guide on medication and I'm confrotable with this. A patient is on Drug X and stable with no side effects, things then slip, the nurse reviews this. I'd take issue with diagnosis but the nurse is certainly adept at triage (is the patient worse, yes/no) and if deteriorating can sensibly nudge up Drug X.

Initiating new medications can be a big thing, for various reasons. It's a tangible affirmation that a diagnosis is real (e.g. you can have quirky ideas or confused beliefs, fine, but when you're on your antipsychotic for schizophrenia for these, it's different). Medication often is long term. A year for antidepressants, often longer with antipsychotics and with mood stabilisers, usually lifelong for cognitive enhancers. It's not the same as a course of amoxycillin for an iffy chest. Psychiatric medications can have very significant side effects, so the risk benefit ratio often is in favour of not using medication. Critically, if the diagnosis is wrong then whatever you prescribe is inappropriate.

In my corner, independent prescribing that we're starting is paradoxically even more rigid than supplementary prescribing. In supplementary prescribing nurses have latitude to prescribe what they will within the agreed written CMP. In independent prescribing nurses can't put pen to paper on their FP10 without discussing it with me. For any script. For anything. The nurses wanted this, too. They can prescribe but 'phone me up to bat it out before doing so. The protocol for this is pages and pages long.

It's the only way I could work it - a robust clinical governance framework that ensures patients receive medication only when all relevant clinical implications have been thought through.


Dragonfly said...

Sounds fair.

Anonymous said...

I like the CMP scope for titration. It makes good sense.
I see it as not a lot different to an intern or even a reg working under a consultant - tho with obvious differences.
I don't think it would work in ward based settings tho unless you had only one or two supplemental nurse prescribers - as everyone has a different opinion.
I'd be stopping Clozaril most the time as I don't like seeing it's use as a social/behavioural control drug for aggressive non-psychotic patients.

The Shrink said...

That got me thinking. I had a look and, would you know, I've no patients on clozapine at all at the moment.

In fairness I tend to see it as having a use in extreme Parksinon's Disease dementia but seldom (erm, almost never) use it for functional problems.

But, of course, it's rare someone gets to a venerable age and then develops treatment resistant schizophrenia!

Zarathustra said...

Interesting post, Shrink.

Personally I suspect I'm unlikely to train as a nurse prescriber myself, but then I work in CAMHS where we probably prescribe less meds than any other branch of healthcare (at least that I can think of). Also, since most meds aren't licenced for children anyway, pretty much the only meds I'd be legally allowed to prescribe would be the ADHD meds.

My own feeling is that within our service it's a pretty straightforward matter to get a patient a prescription, but less easy to get them a course of psychotherapy. Therefore I feel that I'd benefit my service more if I upskilled in the psychotherapies than in nurse prescribing. This also seems to be the way my employers want me to go. Fair enough.

Disillusioned said...

Sounds good to me.

Agree completely with zarastrutha that in most circumstances psychotherapeutical training would be more relevant and useful for nurses than prescribing abilities.

Anonymous said...

As ever, that was an interesting entry. I'm not totally opposed to nurses prescribing, I can see it as an advantage for patient care in certain circumstances. There are of course problems with it, but I wouldn't say I'm all that qualified to say anything in detail. That's just my view as an NHS service user.