Extended and Supplementary Prescribing

Supports modernisation in the NHS Vision for Pharmacy More staff, working differently NICE/CHAI Improving working lives Junior Hospital Doctors hours Working Time Directive Skill-mix

Benefits of Supplementary Prescribing Improved access Improved patient choice Greater flexibility for management of patients Re-distribution of prescribing workload Improved job satisfaction for supplementary prescriber Formalises some vicarious prescribing that currently goes on

Latest DoH position "We need to fundamentally transform the NHS by giving and extending choice. Nursing and midwifery has a central part to play in this transformation because you are close to people - you listen to them and they listen to you. Patients must play a bigger role in their health care and your help is vital in helping them to learn how to manage their condition." Mr Reid also announced that independent nurse prescribing would be expanded with the addition of a further 10 new medical conditions and more than 30 additional medicines to the list, which Extended Formulary nurse prescribers can prescribe. These conditions include acute attacks of asthma and animal and human bites. He also made clear that nurse prescribing would be further extended next year to include emergency care. John Reid CNOs Conference 14/11/03

Role of Extended and Supplementary Prescribing Mode 1 and 2 prescribing – –Original legislation to allow health visitors and district nurses to prescribe from limited list Extended prescribing for nurses – –Allows independent prescribing from wider range of products, but still doesnt include all products Supplementary prescribing – –Very few limits to drugs that can be prescribed, but must be done in conjunction with independent prescriber and clinical management plan

What is Supplementary prescribing? A voluntary prescribing partnership between the independent prescriber and a supplementary prescriber, to implement an agreed patient-specific Clinical Management Plan with the patients agreement. The Supplementary Prescriber must be a Registered Nurse, Registered Midwife or Registered Pharmacist. Coming soon – optometrists, physiotherapists, other AHPs

Supplementary Prescribing is not restricted SRx to specific clinical conditions decision to introduce SRx arrangements for a specific patient will depend on agreement between the independent and the supplementary prescriber, and the patient

Prescribing Partnerships Voluntary Share responsibility Professionally accountable for own decisions If responsibility moves from one medical practitioner to another, the supplementary needs to forge new partnership

Independent prescriber responsible for: the initial clinical assessment of the patient and the formulation of a diagnosis, the development of a written clinical management plan, in conjunction with the supplementary prescriber, following diagnosis ensuring the clinical management plan is kept up-to-date informing the supplementary prescriber of the limits of responsibility delegated to that supplementary prescriber providing access to the patients record for the supplementary prescriber.

Independent prescriber responsible for: providing advice and support to the supplementary prescriber as required carrying out a review of patients progress at appropriate intervals, depending on the nature and stability of a patients condition, or at the request of the supplementary prescriber, and normally not longer than 1 year from the initial assessment resuming full responsibility for the patients care at the request of the supplementary prescriber

Supplementary prescriber responsible for: monitoring and assessing the patients progress as set out in the clinical management plan, and as appropriate to the medicines prescribed, including the reporting of any adverse reactions contributing to the clinical management plan prescribing for the patient in accordance with the agreed clinical management plan changing the medicine prescribed, within the limits set out in the clinical management plan, if monitoring of the patients progress indicates that this is clinically appropriate

Supplementary prescriber responsible for: accepting clinical responsibility and professional accountability for their prescribing decisions and practice working at all times within their clinical competence and their professional Code of Conduct, consulting the independent prescriber as necessary and particularly if a matter falls outside their own clinical competence.

Supplementary prescriber responsible for: as soon as possible, and preferably contemporaneously, recording clinically relevant facts, including prescribing and monitoring activity, in the patients medical records. referring prescribing responsibility back to the independent prescriber if the agreed clinical reviews are not carried out within the intervals specified in the clinical management plan or if monitoring of the patients progress indicates that this is appropriate

Principles of SR x there should be benefit to patients and the NHS supplementary prescribing should support but not replace multi-disciplinary care patient safety should be paramount prescribing and dispensing responsibilities should, where possible, be separate in keeping with the principles of patient safety and governance.

How can SR x be used in Practice? Ongoing management of long-term conditions – –Asthma, diabetes, hypertension, mental health – –Heart Failure, COPD Management of out-patients – –HRT clinic, renal patients, HIV/AIDs, anti-coag. In-patient settings with predictable pathways – –Nausea in oncology, post-operative pain

The clinical management plan MUST – –specify the range of medicines that may be prescribed – –specify the range and circumstances within which the supplementary prescriber can vary the dosage, frequency and formulation of the specified range of medicines as appropriate. – –when to refer back to the independent prescriber – –contain relevant warnings about any known sensitivities of the patient to particular medicines – –Include arrangements for the notification of any adverse drug reactions. – –Start date and review date (max 12 months)

Before starting The nurse or pharmacist must – –successfully complete the specified training and preparation for SRx – –record their SRx competency on the relevant professional register – –agree with their employer that SRx should be included in their job description. – –make arrangements for Rx pads, prescribing budget or other arrangements (e.g. patients prescription charts in hospitals)

Training and preparation - nurses consultation, decision-making, therapy and referral influences on and psychology of prescribing prescribing in a team context clinical pharmacology including the effects of co-morbidity and recognition of potential adverse drug reactions

Training and preparation - nurses evidence-based practice and clinical governance in relation to nurse prescribing legal, policy and ethical aspects professional accountability and responsibility prescribing in the public health context.

Managed Entry System Single system for SW WDCs for application for training All applications go to one place Ensures appropriate practitioners are applying and training will be used in suitable situation Can help to form networks of supplementary prescribers

Process for Application Decision that supplementary prescribing is necessary and appropriate Fill in Application form and send to Project Team Project Team consider applications and approve / advise where necessary Approved applicants apply to university Applicant undertakes supplementary prescribing training Supplementary prescriber uses training. Project team provide support and links to prescriber networks

Points to Consider Availability of mentors Backfill Candidate ability to undertake distance learning study Whether qualification will be used after training Whether there are other ways to fulfil the role e.g. PGDs

Course providers Pharmacists Pharmacists –Bath Nurses Nurses –Gloucestershire –Bournemouth –Plymouth –Oxford Brookes –Plymouth

Further Information All information can be found on the website » » » »National information at Contacts – –Kim Hogan – Avon, Gloucestershire, Wiltshire » – –Alaster Rutherford – Devon and Cornwall » – –Danielle Gorman – Dorset and Somerset »