The long road to full prescribing powers

In 1978, the RCN proposed that nurses should have the authority to prescribe dressings and topical treatments. Almost 40 years later, there are 73, 970 nurse prescribers in the UK, more than 10% of the profession. As the RCN celebrates its 100th anniversary, this article looks at the history of nurse prescribing.

If nurse prescribing had a ‘big bang’ moment, it is almost certainly 2006, when the whole of the formulary was opened up to independent extended nurse prescribers for the first time.

‘I never expected to get it in my working lifetime, as there had been so many hoops to jump through,’ says Barbara Stuttle, chair of the Association for Prescribers – formerly the Association for Nurse Prescribing – and director of nursing and quality at Colchester Hospital University NHS Foundation Trust.

Initially, the pace of change had been frustratingly slow, with many believing that it was only due to concerted lobbying by the RCN that nurse prescribing finally began to gather momentum. ‘There’s no question that the RCN was extremely influential and instrumental in pushing it forwards,’ says Dr Stuttle.

Waste of time

The story began at least 20 years earlier, when a report by Baroness Julia Cumberlege, who later became RCN vice-president, examined the care given to patients at home by district nurses and health visitors. Neighbourhood Nursing: a Focus for Care showed that nurses were wasting time asking GPs for prescriptions for simple items. It recommended that nurses should be able to prescribe from a limited list.

Three years later, the Department of Health set up an advisory group, chaired by Dr June Crown – now president of the Association for Prescribers – to examine the issue in more detail. The report said: ‘It is well known that in practice a doctor often rubber stamps a prescription decision taken by a nurse. This can lead to a lack of clarity about professional responsibilities and is demeaning to nurses and doctors.’

But it would be another three years before the primary legislation permitting nurses to prescribe a limited range of drugs was finally passed in 1992. Seven years later, with all district nurses and health visitors now able to prescribe from their own formulary, a second Crown report advocated expanding prescribing to other groups of nurses.

Former Conservative MP Roger Sims and Baroness Julia Cumberlege in 1992 unveiling the Private Members Bill that led to district nurses and health visitors being able to prescribe

In 2000, the first extended independent nurse prescribers were trained and began prescribing for patients at walk-in centres, emergency departments and GP surgeries. Then between 2002 and 2006, policy changes came much more rapidly, with independent extended nurse prescribers today enjoying virtually the same prescribing rights as doctors.

But former RCN national prescribing adviser Molly Courtenay, now a professor at Cardiff University, says only about half of nurses in the community who can prescribe from their own formulary are doing it.

Types of nurse prescribers

Nurse independent prescribers can prescribe any licensed or unlicensed drugs within their clinical competence, with almost full access to the British National Formulary achieved in 2006.

Community practitioner nurse prescribers are district nurses, health visitors and school nurses who can prescribe from a limited formulary for community practitioners. This includes over-the-counter drugs, wound dressings and applications.

Nurse supplementary prescribers can prescribe any drug listed in a patient-specific clinical management plan. It’s most useful for nurses who care for patients with long-term conditions, such as diabetes or asthma.

‘The biggest reason seems to be that the formulary agreed more than 20 years ago remains unchanged. We’ve moved on and roles have changed, but it’s stayed the same,’ she says.

In contrast, about 80% of those who can prescribe from the whole formulary regularly use their prescribing powers. ‘For those nurses who don’t, it’s often because they have moved into a position where they no longer need it – management, for example,’ says Dr Courtenay, who also chairs the Nurse Prescribers’ Advisory Group.

Dr Stuttle believes nurses who are reluctant to use their prescribing abilities are not working in the best interests of their patients. ‘All nursing has to do now is own it and be responsive,’ she says.

Without prescribing, both nurses agree that many of today’s nursing roles could not have happened. ‘We’ve come an incredible way and I’m proud of nursing. I feel privileged to have played a part,’ says Dr Stuttle.

This article is for subscribers only