17th October 2005 Dublin

2. Policy context Prescribing by district nurses & health visitors � mid 1990s Review of prescribing, supply and administration of medicines � 1999 The NHS Plan � 2000 Modernising the NHS Patient centred services More flexible Improved access Better use of resources Challenge existing roles Major changes in the way patients receive their medicines in the UK over the past 10 years or so. Began with prescribing by DN/s and HVs Already making prescribing decisions in the areas they were expert in � wound care etc. Prescribing by proxy Patients would benefit from a more streamlined service Resources would be saved. Changes in legislation Piloted and then rolled out � 22,000 trained Now integral to the preparation Review of prescribing, supply and administration of medicines Recommended extensions to prescribing by health care professionals other than doctors and the implementation of alternative ways of prescribing Big push with the advent of the NHS plan. 10 year plan, ambitious aims Extension of prescribing responsibilities fundamental to achieving these aims. Major changes in the way patients receive their medicines in the UK over the past 10 years or so. Began with prescribing by DN/s and HVs Already making prescribing decisions in the areas they were expert in � wound care etc. Prescribing by proxy Patients would benefit from a more streamlined service Resources would be saved. Changes in legislation Piloted and then rolled out � 22,000 trained Now integral to the preparation Review of prescribing, supply and administration of medicines Recommended extensions to prescribing by health care professionals other than doctors and the implementation of alternative ways of prescribing Big push with the advent of the NHS plan. 10 year plan, ambitious aims Extension of prescribing responsibilities fundamental to achieving these aims.

3. Aim of extending prescribing To maximise benefit to patients and the NHS, through increased flexible use of workforce skills Reiterate � patient safety is paramount to all of the developments Flags up the need for: Robust training which allows prescribers to achieve a high level of competency Good understanding of what this means alongside understanding accountability issues Having the opportunity to develop and maintain that competency through high quality support Need for local governance mechanisms Reiterate � patient safety is paramount to all of the developments Flags up the need for: Robust training which allows prescribers to achieve a high level of competency Good understanding of what this means alongside understanding accountability issues Having the opportunity to develop and maintain that competency through high quality support Need for local governance mechanisms

4. Mechanisms Medicines Act exemptions Patient specific directions Patient Group Directions (PGDs) Independent prescribing Supplementary prescribing Now have 5 options for patients to obtain the medicines they need. Quite complicated � bit difficult to explain in such a short time. Remember that in NHS terms, developments are very new and pace of change is very fast so hopefully things will be clearer as the developments progress First three are about supply and administration � absolutely not prescribing � which, in the UK we consider is always the best and safest option Differing features Used in differing circumstances Not a panacea to deal with every circumstance Used in conjunction with each other provide a very useful toolkit Medicines Act Exemptions � some POMs to be supplied and administered by certain HCPs Patient specific directions � a prescriber makes the prescribing decision and refers to another HCP for supply and/or administration Traditional route � prescription form in the community, medicine chart in hospital. Can also be applied to a clinic list � vacc and imms Deal with both acute conditions and long-term illness PGDs � following legislation, operating since 2000 Written instruction for the supply and administration of identified medicines in identified circumstances to a defined group of patients. Drawn up by individual organisations � strict criteria as to what they should contain Patients don�t have to see a doctor first and don�t have to be identified before presentation Very wide range of medicines � not unlicensed medicines No set training course � organisations are responsible for ensuring competency Intention that they would be used in exceptional circumstances � widely used, sometimes inappropriately Useful for one-off episodes (first contact services) not meant to be repeated �prescribing should be the route NEXT SLIDE Now have 5 options for patients to obtain the medicines they need. Quite complicated � bit difficult to explain in such a short time. Remember that in NHS terms, developments are very new and pace of change is very fast so hopefully things will be clearer as the developments progress First three are about supply and administration � absolutely not prescribing � which, in the UK we consider is always the best and safest option Differing features Used in differing circumstances Not a panacea to deal with every circumstance Used in conjunction with each other provide a very useful toolkit Medicines Act Exemptions � some POMs to be supplied and administered by certain HCPs Patient specific directions � a prescriber makes the prescribing decision and refers to another HCP for supply and/or administration Traditional route � prescription form in the community, medicine chart in hospital. Can also be applied to a clinic list � vacc and imms Deal with both acute conditions and long-term illness PGDs � following legislation, operating since 2000 Written instruction for the supply and administration of identified medicines in identified circumstances to a defined group of patients. Drawn up by individual organisations � strict criteria as to what they should contain Patients don�t have to see a doctor first and don�t have to be identified before presentation Very wide range of medicines � not unlicensed medicines No set training course � organisations are responsible for ensuring competency Intention that they would be used in exceptional circumstances � widely used, sometimes inappropriately Useful for one-off episodes (first contact services) not meant to be repeated �prescribing should be the route NEXT SLIDE

5. Independent prescribing The prescriber takes responsibility for: the clinical assessment and diagnosis the clinical management including prescribing the appropriateness of any prescribing Currently doctors, dentists and some nurses This is the �real deal�! Currently 2 types of independent nurse prescribers NEXT SLIDEThis is the �real deal�! Currently 2 types of independent nurse prescribers NEXT SLIDE

6. Independent prescribing by nurses District nurse/health visitor prescribers ~ 29,000 Mainly appliances and dressings Some pharmacy (P) and general sales list (GSL) medicines Few prescription only medicines (POMs) Qualification integrated into initial preparation Extended formulary prescribers ~ 6,000 All P and GSL medicines 240 POMs 110 conditions Awaiting decision on expansion Intensive training programme � competency based Big responsibility, need high levels of expertise in the area in which you practice. Means that you can complete episodes of care Patients clearly benefit Requires robust training and assessment For nurses � they are trained as both IPs and SPs, which again illustrates a �tool kit� approach Currently most useful for acute situations, health promotion and palliative care � but this may change very soon! Big responsibility, need high levels of expertise in the area in which you practice. Means that you can complete episodes of care Patients clearly benefit Requires robust training and assessment For nurses � they are trained as both IPs and SPs, which again illustrates a �tool kit� approach Currently most useful for acute situations, health promotion and palliative care � but this may change very soon!

9. Supplementary prescribing DH definition �� a voluntary prescribing partnership between an independent prescriber and a supplementary prescriber, to implement an agreed patient-specific clinical management plan with the patient�s agreement.�

10. In simple terms Diagnosis is reached (or best shot!) Doctor and SP decide whether the patient would benefit from being cared for by a prescribing partnership � with patient agreement A Clinical Management Plan is drawn up and agreed by all The SP takes over the management of the patient, including prescribing, within the parameters laid down in the CMP

11. Supplementary prescribers ~ 5,500 nurses ~ 600 pharmacists Awaiting decision to grant independent prescribing status Physiotherapists, radiographers and podiatrists in training Optometrists in training soon Intense training programme � competency based

12. Supplementary prescribing Features What can be prescribed? What can be treated? When can it be used? Features Must have a doctor in the prescribing partnership Supplementary prescriber must happy about managing the patient Patient must be involved and in agreement Good channels of communication CMP must be in place Prescribable � anything prescribable by doctors at NHS expense Conditions � no limit When � across all health economies although most useful for treating medium to long-term illnessFeatures Must have a doctor in the prescribing partnership Supplementary prescriber must happy about managing the patient Patient must be involved and in agreement Good channels of communication CMP must be in place Prescribable � anything prescribable by doctors at NHS expense Conditions � no limit When � across all health economies although most useful for treating medium to long-term illness

13. MAKING IT HAPPEN So what is needed to make all of this happen � safely! Lots � and it�s not without challengesSo what is needed to make all of this happen � safely! Lots � and it�s not without challenges

14. The prescribing role Significant development for the professions, individuals � and local organisations! Most common healthcare intervention Requires high levels of competency Robust training Credible support May have gathered this development is extremely significant � has a very high profile in the NHS. Complex business. Lots of scope for doing good, has its risks. Not just about writing a prescription � sometimes more about not writing a prescription. Anecdotal evidence from �new� prescribers many of whom felt they had been �prescribing through the back door�. Hadn�t realised just how complex reaching a prescribing decision is. Have to be competent in all the components of prescribing May have gathered this development is extremely significant � has a very high profile in the NHS. Complex business. Lots of scope for doing good, has its risks. Not just about writing a prescription � sometimes more about not writing a prescription. Anecdotal evidence from �new� prescribers many of whom felt they had been �prescribing through the back door�. Hadn�t realised just how complex reaching a prescribing decision is. Have to be competent in all the components of prescribing

15. Some challenges Designing curricula for initial training Mentoring Communicating the concepts and intentions Releasing staff Developing and maintaining competency

16. NPC competency frameworks DN/HV and EF nurse prescribers Nurse supplementary prescribers Pharmacist supplementary prescribers Optometrist prescribers AHP supplementary prescribers PGDs + a guide to good practice Monitoring the use of controlled drugs Pharmacist independent prescribers By sheer fluke � we have developed one or two competency frameworks! Foundation to ensuring safe prescribing. Not going into much detail � can access all of these on our website, explains how they were developed. Happy to explain later if anyone needs to know. By sheer fluke � we have developed one or two competency frameworks! Foundation to ensuring safe prescribing. Not going into much detail � can access all of these on our website, explains how they were developed. Happy to explain later if anyone needs to know.

17. What are they used for? Initial preparation Curriculum planning Identifying learning outcomes for local training programmes Portfolio building

18. Additional NPC support Publications MeReC publications Therapeutic reference sheets Competency documents Good practice in the management of CDs Glossary of prescribing terms Others E-learning Using evidence to guide practice Managing CDs (Autumn 2005) Therapeutic topics (Spring 2006)

19. And there�s more... Face-to-face Flexible, local therapeutic workshops Local therapeutic workshops for nurses Conferences, seminars etc Other activity Bespoke training and support packages

20. Mentoring Requirement of initial training programmes No central funding Issues with nurse-led services Understanding the concepts and role Knowledge and skill to carry out the role Support post-qualification

21. More information Department of Health www.dh.gov.uk National Prescribing Centre www.npc.co.uk Prescribing Support Unit www.psu.nhs.uk

22. And finally Extending prescribing responsibilities is fundamental to modernising the NHS in the UK Health-care professionals already have the knowledge and skills to make good, evidence �based decisions about the treatment patients need Prescribing is a complex activity � must be competency based Doesn�t stop at �qualification� Get it right and patients and services will benefit