Understanding the role of nurse prescribers
The role of the non-medical prescriber (NMP) in Wales has been expanding since it was first introduced in 2000.
But until Molly Courtenay, professor of health sciences at Cardiff University, presented the findings of one of the first detailed studies into NMPs at the chief nursing officer’s annual conference in Wales earlier this year, there was little understanding about how prolific the role is, or could be across the country.
The majority of the respondents to the survey, carried out between March and May this year, were nurse prescribers.
Professor Courtenay says the study is a way to kick-start the sharing of good practice among NMPs across the country and provides impetus to form a national forum to unite professionals in the field.
District nursing and health visitor prescribing was introduced in 2000 in Wales enabling them to qualify as prescribers, however they could only independently prescribe a limited list of items.
The extension of prescribing legislation for non-medical professions came into effect in 2007 in support of the government’s modernisation agenda for health and social care in the country.
‘Prescribing capability provides opportunities for nurses and other non-medical healthcare professionals to transform their practice,’ Professor Courtenay explains.
‘Non-medical prescribing has enabled the development of new roles, better use of skills, improved access to medicines and autonomous practice. A lot of evidence is now available with regards to the benefits it brings.
‘Patients report they are able to access their medicines faster and are satisfied with the care they receive. There has been a reduction in unnecessary appointments; patients no longer have to wait to see a doctor to get their prescription signed and NMPs also save the NHS money.’
Inconsistencies still exist
But in spite of all the benefits, there is still inconsistency in the way the role has been taken up and implemented across organisations.
A report published by the RCN back in 2012 flagged up there had been little attempt to develop the legislation strategically in key areas such as the community or emergency care. The report stated that, instead, uptake often relied on the initiative of the individual nurse or department head and the goodwill of surrounding medical colleagues.
The year extended prescribing legislation for non-medical professions came into effect
Professor Courtenay believes that opportunities exist to share learning ensuring that organisations are aware of the drivers for its implementation, the advantages and the conditions necessary to support the role.
The interim findings of the survey led by Professor Courtenay and a project team from Cardiff University centre around the views of 379 NMPs including nurses, pharmacists and allied health professionals.
Of these, 86% were independent prescribers and 6% were supplementary prescribers; more than 7% said they do not prescribe although they are qualified.
One of the emerging themes highlights Professor Courtenay’s point about patchy implementation of the role.
She says: ‘There was a lot of professional experience among the prescribers with almost 70% qualified and practising in their field for 5 years or more before training as a prescriber, but when it came to implementation of the NMP role it was inconsistent across health boards.
'At some it was high, others low, which pretty much aligns with the picture in England across healthcare organisations.’
Half of the respondents were educated to the level of a master’s degree and just over half were working in secondary care in a hospital setting.
‘Less than 10% were in general practice. This appears to be the opposite of the situation in England and it’s an important point because what is supposed to be happening is care moving out into the community,’ says Professor Courtenay.
‘We will be exploring the reasons for this further with some of the participants and the health boards.’
Number of survey respondents who are using their qualifications and prescribing in Wales
She says that the survey showed 93% of respondents are using their qualifications and prescribing compared to around 75% of prescribers in England.
Over a quarter of respondents prescribe between 1 and 5 items a week and 15% prescribe more than 50.
NMPs in Wales are prescribing across a wide range of areas with high levels of prescribing in respiratory, wound care and cardiovascular, according to the study.
‘Many of the NMPs were prescribing via a hospital medicines chart and issuing hospital specific prescriptions, some were doing remote prescribing via telephone and email. Others were using their qualification to recommend to GPs in their notes what to prescribe,’ says Professor Courtenay.
The survey examined safety and clinical governance structures at the NMPs’ workplaces; 72% said they were unable to access their own prescribing data, 63% revealed their employer did not provide them with regular data to monitor their prescribing practice and almost half were not involved in developing local formularies and guidelines.
‘The main reason hampering expansion of NMP numbers was no time due to workload and no funding for backfill,’ reveals Professor Courtenay.
Of the respondents, 13% said there was no vision to support the role and 11% claimed that extra responsibility with no financial remuneration could be a factor.
More roles to fill
Alison Davies, RCN Wales associate director of professional practice believes that if services are being designed to provide far more care in primary and community settings, a greater number of advanced nurse practitioner roles are required.
‘This is because nurses who are able to prescribe are well placed to provide holistic care to people with a range of health needs,’ Ms Davies says.
‘Importantly, providing the ongoing support required by nurses who prescribe is absolutely key to providing the highest level of care to people, along with ensuring nurses can maintain and further enhance their prescribing skills.
‘This includes access to education, regular clinical supervision and the ability to access appropriate continuing professional development.’
Recent information provided by the Department of Health in England shows there are 29,000 community nurse practitioner prescribers, 28,000 nurse independent/supplementary prescribers and 1,000 allied health professional prescribers across the UK. There are around 800 NMPs in Wales.
Although some healthcare organisations may be slow to acknowledge the benefits of NMPs, the Royal Pharmaceutical Society (RPS) has recently published an updated competency framework for all prescribers across the UK.
The framework was originally published by the National Institute for Health and Care Excellence (NICE) as a resource only for England, but it expired in 2014.
'Prescribing is far more than just writing prescriptions'
When the updated framework was launched in July this year the RPS said it now reflects the increasing prevalence of multiple comorbidities and numbers of non-medical prescribers.
RPS president Ash Soni said earlier this year that the society is calling for legislative change to enable any experienced prescribing professional working in a multidisciplinary environment to monitor any healthcare professional learning to prescribe.
‘We want to see legislative change so any experienced practising prescriber working within a multidisciplinary team can mentor any health professional. This would give greater access to the support needed when undertaking a prescribing course,’ he says.
The framework is due to be reviewed every 4 years but may be updated earlier if any significant changes to prescribing occur during that time.
Independent consultant for prescribing and medicines management Matt Griffiths has pushed for the expansion of non-medical prescribing and praises the framework as an outstanding guide for prescribers: ‘Prescribing is far more than just writing prescriptions, very often it is about reducing doses or even stopping medicines.
'Financial support is of course always helpful but educational and mentoring support is also vital.
‘The NHS is struggling and nurse prescribers and practitioners bring another set of professionals who are able to deliver entire episodes of care.’
Recognition of efforts
A Welsh government spokesperson says the valuable role non-medical prescribers play in delivering care in NHS Wales is recognised: ‘We provide funding on an annual basis to support a range of health professionals to be trained to undertake this role.
'The annual budget was increased to £300,000 in 2014/15 to support additional professional groups within the NHS to undertake this training and for this to be available to more staff in order to support the workforce modernisation and redesign agenda across NHS Wales.
'It's not about being a mini doctor but about being a maxi nurse'
‘We are extending non-medical prescribing rights to other groups of healthcare professionals and are currently developing legislation that will enable prescribing rights for therapeutic radiographers and dieticians working within NHS Wales.’
Professor Griffiths adds that nurse prescribers need support when they qualify to be able to build their confidence and competence in prescribing.
‘Nurses need the freedom to grow which in turn allows them to deliver services. It's not about being a mini doctor but about being a maxi nurse.’
Case study 1
Heulwen Wyatt, nurse prescriber in paediatric dermatology, Aneurin Bevan University Health Board
Currently all children with eczema in Gwent are seen by me. The initial consultation includes obtaining a medical, social and drug history before the nurse examines the child's skin. Education and a practical demonstration are provided regarding application of topical medications, a written treatment plan is given and the nurse prescribes the necessary medication.
I also conduct follow-up appointments, providing continuity for the child and family.
With a consultant session costing more than £230 compared to a CNS session costing less than £100, the financial savings to the board have been significant. I can see children urgently if their skin deteriorates, which leads to a decrease in ward admissions. Having the ability to prescribe medication means that I can see children with complex medical issues in their home or school environment.
Being a nurse prescriber has increased my job satisfaction, reduced waiting lists, has created significant financial savings and most importantly provides an enhanced level of care for children with this chronic and debilitating condition.
Case study 2
Phil Hill, advanced nurse practitioner and non-medical prescriber Urgent Primary Care Out of Hours Service, Aneurin Bevan University Health Board
The health board manages the OOHs serving a population of more than half a million people when GP practices are closed. These prescribers predominately work out of three bases and a clinical call centre. Patients are screened by a call handler and the initial consultation is usually by telephone. Outcomes include self-care advice or referral to another service, such as A&E.
NMPs will also see existing patients waiting for consultation who are within their sphere of competence. Once diagnosis has been made the prescriber will either issue a prescription for a community pharmacy or will supply the medication. Often patients will require immediate treatment and review.
The emphasis is on prevention of hospital attendance but there is a low threshold for admission if treatments are unsuccessful. Advice from an OOHs GP is often invaluable. Occasionally patients just walk into the base with a medical emergency. These patients still require immediate treatment while waiting for the emergency services.
Case study 3
Sian Bodman Senior nurse for diabetes, diabetes Integrated care team, Aneurin Bevan University Health Board
After qualifying in Wales in 2006, supplementary prescribing by way of a prescription pad and clinical management plan was what we were required to do until the Welsh NHS could accommodate the role.
I tentatively started to use my prescription pads as a part of my consultation; I say tentatively, as I felt the whole institution was waiting for us to make errors and we were an experiment. From my perspective the consultations became complete – no more writing to a GP to request a treatment and the delay that entailed for patients. Patients appeared to accept this practice without concern on the whole and as the years pass they are less and less questioning.
I have so far had a 20-year career as a specialist nurse but the time since qualifying as an NMP has been the most efficient and satisfying. My knowledge and confidence has grown and although there have been some concerning moments – namely adverse drug reactions – my account in the yellow card scheme to notify reactions ensures I complete the audit circle. In my specialist area, lots of completely new drug classes mean reporting is essential.
Case study 4
Natalie Janes-Plumley, respiratory clinical nurse specialist practitioner/non-medical prescriber respiratory division, Aneurin Bevan University Health Board
The role of the NMP is to support the respiratory services in the assessment, diagnosis, treatment and management of patients within secondary and primary care settings. The role of the respiratory nurse has changed and developed over the years; nurses now work autonomously, setting up and running nurse-led clinics.
In my nurse-led clinics, there were gaps in the service due to access and delays of treatment. In 2007, it was agreed that an ANP and NMP qualification would benefit patients and the service. I qualified in 2010. Providing a one-stop shop is more convenient for patients, enhancing service efficiency overall.
Although based within secondary care, I run nurse-led clinics at a community hospital to bring services closer to patients’ homes. The role also supports the in-house, smoke-free service with assessment and appropriate use of nicotine replacement therapy.
The role also includes ensuring patients have the correct existing diagnosis and that treatment is optimal. Of late, with a number of new inhaler combinations and devices emerging, the NMP has played a key role in facilitating switching to newer, more cost effective agents and advising primary care on developments.