Extended prescribing by UK nurses and pharmacists
http://www.100md.com
《英国医生杂志》
With more evidence and strict safeguards, it could benefit patients
Earlier this year the United Kingdom Department of Health consulted on options for extending prescribing by nurses and pharmacists.1 2 Last week the department announced that nurse and pharmacist independent prescribers will be able to prescribe any licensed drug except controlled drugs—the most radical of the options considered.3 This proposal heralds one of the most far reaching extensions of prescribing by nurses and pharmacists anywhere in the world.
The BMA has responded with dismay.4 One of the association's concerns is that it is not safe to prescribe without training in diagnosis. We accept that this is true in most cases but note that training is becoming available for many nurses and pharmacists in the UK. As a result, both professions are able to diagnose and manage acute illnesses in primary care, and some are already prescribing independently, albeit from a limited formulary. In secondary care specialist nurses diagnose and manage in a wide range of clinical fields.
Nevertheless, the potential for nurses and pharmacists to prescribe independently from virtually the whole of the British National Formulary5 is an important departure from current practice, and the wisdom of this policy deserves close scrutiny. Prescribing is one of the most powerful tools that health professionals can use in tackling disease, and yet it is also an important cause of patient harm.6 7 To prescribe safely and effectively across all therapeutic groups requires high levels of knowledge and skill, and, even with many years of training, balancing benefits against risks can be a difficult challenge.
A key question, however, for independent prescribing by nurses and pharmacists is that just because these professionals can prescribe any drug from the British National Formulary, does it follow that they will do so? Furthermore, is it likely that they will prescribe beyond their competencies?
Ideally, we would answer these questions with reference to the literature, but little high quality research has been done.8 9 One recent study, which has considerably influenced the Department of Health's policy, has been reassuring: independent nurse prescribers tended to prescribe for relatively minor conditions, and medically trained assessors found that they generally prescribed appropriately.10 Early data on prescribing by nurses and pharmacists in primary care suggest patterns in keeping with the skills of these professionals in treating minor illnesses and contributing to the management of patients with long term conditions (personal communication, Helen Kendall, Prescription Pricing Authority, 24 October 2005).
Nevertheless—given that evaluations of prescribing by nurses and pharmacists are not fully in the public domain, are mainly descriptive in nature, and have not all been subject to rigorous independent peer review—it is impossible to draw clear conclusions on the safety and appropriateness of extended prescribing. It is worrying that, before launching this new policy, the Department of Health has not waited for further evidence to accumulate, including studies that it has only recently commissioned.
While we do have concerns about the wisdom of extending prescribing now, we believe that most nurse and pharmacist prescribers will act within their areas of competence. For example, a fully trained specialist respiratory nurse might prescribe a short course of oral corticosteroids for a patient with acute asthma but would be extremely unlikely to alter the drug treatment of a patient with diabetes or epilepsy without training in managing these conditions.
To limit the potential risks from extended prescribing, health professionals must be trained to prescribe appropriately and safely in the clinical subjects in which they are likely to practise. The current schemes for training nurse and pharmacist prescribers are too short to fully equip a professional for independent prescribing practice. It is essential that additional training, support, and mentorship are available after such training programmes.
In addition, nurse and pharmacist prescribers must have access to all the tools they need to help them prescribe safely. One worrying finding from the recent study on independent nurse prescribing in primary care was that only 5% of nurses had access to systems providing computer generated prescriptions and most were probably missing out on the potential benefits of computerised alerts for drug interactions and allergies.10 This problem could have been predicted from the way that nurse prescribing was introduced whereby the guide for implementation11 expected nurses to hand-write prescriptions rather than being allowed to use a clinical computer system. Thorough risk assessments should be done nationally and locally before prescribing is extended to new clinical areas.
Also, it will be important to have strong clinical governance to help to identify any prescriber, medical or non-medical, exceeding his or her competency. With appropriate training, support, and governance in place, extended prescribing could combine the benefits of high quality pharmaceutical care with greater convenience and improved access to treatment for patients.
Anthony J Avery, professor of primary health care
(tony.avery@nottingham.ac.uk)
Division of Primary Care, University of Nottingham Medical School, Queen's Medical Centre, Nottingham, NG7 2UH
Mike Pringle, professor of general practice
Division of Primary Care, University of Nottingham Medical School, Queen's Medical Centre, Nottingham, NG7 2UH
See News p 1159
We thank Claire Anderson, Paul Bissell, Sue Latter, Paul Ward, and David Walker for comments.
Competing interests: AJA is a co-investigator on a Department of Health funded study of supplementary prescribing by nurses and pharmacists. He has also advised the Royal Pharmaceutical Society of Great Britain on a study it commissioned on prescribing by pharmacists and commented on the appropriateness of nurse prescribing as part of a Department of Health funded study of independent nurse prescribing.
References
Department of Health, Medicines and Healthcare Products Regulatory Agency (MHRA). Consultation on options for the future of independent prescribing by extended formulary nurse prescribers. www.dh.gov.uk/assetRoot/04/10/40/58/04104058.pdf (accessed 14 Nov 2005).
Medicines and Healthcare Products Regulatory Agency (MHRA), Department of Health. Consultation on proposals to introduce independent prescribing by pharmacists. www.dh.gov.uk/assetRoot/04/10/48/81/04104881.pdf (accessed 14 Nov 2005).
Department of Health. Nurse and pharmacist prescribing powers extended . www.dh.gov.uk/PublicationsAndStatistics/PressReleases/PressReleasesNotices/fs/en?CONTENT_ID=4122999&chk=Mjc1MS (accessed 14 Nov 2005).
BMA. BMA calls for urgent meeting with Patricia Hewitt on plans to extend prescribing powers . www.bma.org.uk/pressrel.nsf/wlu/STRE-6HZJ4X?OpenDocument&vw=wfmms (accessed 14 Nov 2005).
British Medical Association, Royal Pharmaceutical Society of Great Britain. British national formulary. London: BMA, RPS, 2005. (No 50.)
Smith J. Building a safer NHS for patients: improving medication safety. London: Department of Health, 2004.
Chief Medical Officer. An organisation with a memory. London: Department of Health, 2000.
Kay O, Brien J. Pharmacist prescribing: review of the literature. J Pharm Pract Res 2004;34: 1-5.
Latter S, Courtenay M. Effectiveness of nurse prescribing: a review of the literature. J Clin Nurs 2004;13: 26-32.
Latter S, Maben J, Myall M, Courtenay M, Young A, Dunn N. An evaluation of extended formulary independent nurse prescribing. Southampton: University of Southampton, Department of Health, 2005. (www.dh.gov.uk/assetRoot/04/11/40/86/04114086.pdf.)
Department of Health. Extending independent nurse prescribing within the NHS in England. London: Department of Health, 2002.
Earlier this year the United Kingdom Department of Health consulted on options for extending prescribing by nurses and pharmacists.1 2 Last week the department announced that nurse and pharmacist independent prescribers will be able to prescribe any licensed drug except controlled drugs—the most radical of the options considered.3 This proposal heralds one of the most far reaching extensions of prescribing by nurses and pharmacists anywhere in the world.
The BMA has responded with dismay.4 One of the association's concerns is that it is not safe to prescribe without training in diagnosis. We accept that this is true in most cases but note that training is becoming available for many nurses and pharmacists in the UK. As a result, both professions are able to diagnose and manage acute illnesses in primary care, and some are already prescribing independently, albeit from a limited formulary. In secondary care specialist nurses diagnose and manage in a wide range of clinical fields.
Nevertheless, the potential for nurses and pharmacists to prescribe independently from virtually the whole of the British National Formulary5 is an important departure from current practice, and the wisdom of this policy deserves close scrutiny. Prescribing is one of the most powerful tools that health professionals can use in tackling disease, and yet it is also an important cause of patient harm.6 7 To prescribe safely and effectively across all therapeutic groups requires high levels of knowledge and skill, and, even with many years of training, balancing benefits against risks can be a difficult challenge.
A key question, however, for independent prescribing by nurses and pharmacists is that just because these professionals can prescribe any drug from the British National Formulary, does it follow that they will do so? Furthermore, is it likely that they will prescribe beyond their competencies?
Ideally, we would answer these questions with reference to the literature, but little high quality research has been done.8 9 One recent study, which has considerably influenced the Department of Health's policy, has been reassuring: independent nurse prescribers tended to prescribe for relatively minor conditions, and medically trained assessors found that they generally prescribed appropriately.10 Early data on prescribing by nurses and pharmacists in primary care suggest patterns in keeping with the skills of these professionals in treating minor illnesses and contributing to the management of patients with long term conditions (personal communication, Helen Kendall, Prescription Pricing Authority, 24 October 2005).
Nevertheless—given that evaluations of prescribing by nurses and pharmacists are not fully in the public domain, are mainly descriptive in nature, and have not all been subject to rigorous independent peer review—it is impossible to draw clear conclusions on the safety and appropriateness of extended prescribing. It is worrying that, before launching this new policy, the Department of Health has not waited for further evidence to accumulate, including studies that it has only recently commissioned.
While we do have concerns about the wisdom of extending prescribing now, we believe that most nurse and pharmacist prescribers will act within their areas of competence. For example, a fully trained specialist respiratory nurse might prescribe a short course of oral corticosteroids for a patient with acute asthma but would be extremely unlikely to alter the drug treatment of a patient with diabetes or epilepsy without training in managing these conditions.
To limit the potential risks from extended prescribing, health professionals must be trained to prescribe appropriately and safely in the clinical subjects in which they are likely to practise. The current schemes for training nurse and pharmacist prescribers are too short to fully equip a professional for independent prescribing practice. It is essential that additional training, support, and mentorship are available after such training programmes.
In addition, nurse and pharmacist prescribers must have access to all the tools they need to help them prescribe safely. One worrying finding from the recent study on independent nurse prescribing in primary care was that only 5% of nurses had access to systems providing computer generated prescriptions and most were probably missing out on the potential benefits of computerised alerts for drug interactions and allergies.10 This problem could have been predicted from the way that nurse prescribing was introduced whereby the guide for implementation11 expected nurses to hand-write prescriptions rather than being allowed to use a clinical computer system. Thorough risk assessments should be done nationally and locally before prescribing is extended to new clinical areas.
Also, it will be important to have strong clinical governance to help to identify any prescriber, medical or non-medical, exceeding his or her competency. With appropriate training, support, and governance in place, extended prescribing could combine the benefits of high quality pharmaceutical care with greater convenience and improved access to treatment for patients.
Anthony J Avery, professor of primary health care
(tony.avery@nottingham.ac.uk)
Division of Primary Care, University of Nottingham Medical School, Queen's Medical Centre, Nottingham, NG7 2UH
Mike Pringle, professor of general practice
Division of Primary Care, University of Nottingham Medical School, Queen's Medical Centre, Nottingham, NG7 2UH
See News p 1159
We thank Claire Anderson, Paul Bissell, Sue Latter, Paul Ward, and David Walker for comments.
Competing interests: AJA is a co-investigator on a Department of Health funded study of supplementary prescribing by nurses and pharmacists. He has also advised the Royal Pharmaceutical Society of Great Britain on a study it commissioned on prescribing by pharmacists and commented on the appropriateness of nurse prescribing as part of a Department of Health funded study of independent nurse prescribing.
References
Department of Health, Medicines and Healthcare Products Regulatory Agency (MHRA). Consultation on options for the future of independent prescribing by extended formulary nurse prescribers. www.dh.gov.uk/assetRoot/04/10/40/58/04104058.pdf (accessed 14 Nov 2005).
Medicines and Healthcare Products Regulatory Agency (MHRA), Department of Health. Consultation on proposals to introduce independent prescribing by pharmacists. www.dh.gov.uk/assetRoot/04/10/48/81/04104881.pdf (accessed 14 Nov 2005).
Department of Health. Nurse and pharmacist prescribing powers extended . www.dh.gov.uk/PublicationsAndStatistics/PressReleases/PressReleasesNotices/fs/en?CONTENT_ID=4122999&chk=Mjc1MS (accessed 14 Nov 2005).
BMA. BMA calls for urgent meeting with Patricia Hewitt on plans to extend prescribing powers . www.bma.org.uk/pressrel.nsf/wlu/STRE-6HZJ4X?OpenDocument&vw=wfmms (accessed 14 Nov 2005).
British Medical Association, Royal Pharmaceutical Society of Great Britain. British national formulary. London: BMA, RPS, 2005. (No 50.)
Smith J. Building a safer NHS for patients: improving medication safety. London: Department of Health, 2004.
Chief Medical Officer. An organisation with a memory. London: Department of Health, 2000.
Kay O, Brien J. Pharmacist prescribing: review of the literature. J Pharm Pract Res 2004;34: 1-5.
Latter S, Courtenay M. Effectiveness of nurse prescribing: a review of the literature. J Clin Nurs 2004;13: 26-32.
Latter S, Maben J, Myall M, Courtenay M, Young A, Dunn N. An evaluation of extended formulary independent nurse prescribing. Southampton: University of Southampton, Department of Health, 2005. (www.dh.gov.uk/assetRoot/04/11/40/86/04114086.pdf.)
Department of Health. Extending independent nurse prescribing within the NHS in England. London: Department of Health, 2002.