UK Expands Prescribing Powers for Nurses, Pharmacists

Laurie Barclay, MD

November 21, 2005

Nov. 21, 2005 -- On Nov. 10, UK Health Secretary Patricia Hewitt announced that the UK Department of Health would expand prescribing powers for nonphysician healthcare professionals. Although UK nurses have long been prescribing drugs for minor injuries, experienced nurses and pharmacists who undergo specific training will be able to prescribe a much broader range of drugs, beginning in the first half of 2006.

"As part of government policy, the [UK Department of Health] proposed the extension of prescribing rights to other healthcare professionals for a number of reasons," Mary Tully, MRPharmS, PhD, told Medscape. She is a clinical lecturer in pharmacy and pharmaceutical sciences at the University of Manchester, United Kingdom, and a member of the Royal Pharmaceutical Society (RPS) of Great Britain.

"[The Department of Health] wished to make better use of existing skilled professionals and ensure more flexible multidisciplinary working," Dr. Tully said. "It was seen as one way to improve the quality of services to patients, whilst maintaining patient safety, increasing patient choice, and improving access to healthcare."

Primary legislation changes in the United Kingdom allow the extension of prescribing authority to nurses and pharmacists in any healthcare sector, public or private, according to Dr. Tully. National Health Service (NHS) regulations, on the other hand, determine what drugs can be prescribed at NHS expense, and in what manner. The ultimate effect of the new policy on practice patterns, patient safety and convenience, and healthcare costs remains to be determined. The implications these developments may have for US healthcare is also still unknown.

"The Royal College of Nursing (RCN) has been lobbying for nonmedical prescribing for around 20 years," RCN national prescribing adviser Matt Griffiths, RGN, FAETC, IESP, told Medscape. He cited a 1986 government report, known as the Cumberlege report, showing that "this highly trained group of professionals were having their time wasted by waiting for doctors to sign prescriptions for drugs that they were competent to prescribe."

In contrast to the enthusiasm of the RCN and RPS for the new proposal, which is the most radical of five that were considered by the UK government, the British Medical Association (BMA) voiced grave concerns about the implications for patient safety.

"This is an irresponsible and dangerous move," Paul Miller, chairman of the BMA consultants' committee, said in a news release. "Patients will suffer. I would not have me or my family subject to other than the highest level of care and prescribing, which is that provided by a fully trained doctor."

Hamish Meldrum, chairman of the BMA committee for general practitioners (GPs), also questioned the disparity in training between the medical profession and that of other healthcare professions. "While we support the ability of suitably trained nurses and pharmacists to prescribe from a limited range of medicines for specific conditions, we believe only doctors have the necessary diagnostic and prescribing training that justifies access to the full range of medicines for all conditions," he said in a news release. "This announcement raises patient safety issues, and we are extremely concerned that the training provided is not remotely equivalent to the five or six years every doctor has undertaken."

Prescribing by nurses entered the UK policy agenda in 1986, when NHS regulations were amended to allow suitably trained community nurses to prescribe independently, at NHS expense, from the limited Nurse Prescribing Formulary, Dr. Tully said. In 2001, changes in primary legislation allowed suitably trained nurses to prescribe independently from an extended, but still limited, formulary.

At present, there are three main types of nonmedical prescribers in the United Kingdom, according to Mr. Griffiths. "District nurse" and "health visitor" prescribers began prescribing in the mid-1990s, with limited training and access to a restricted formulary consisting primarily of lotions and creams, as well as a few prescription-only medicines (POMs). The new legislation will not affect these prescribers, which currently number about 28,000.

Beginning in 2002, "independent extended nurse prescribers" were permitted to prescribe from a limited formulary to address minor injury, minor illness, health promotion, and palliative care. Except for palliative care, the four categories were removed, and more conditions and drugs were added, now allowing these nurses to prescribe about 250 POMs and all other pharmacy and general sales list medicines deemed prescribable by the NHS. Of the approximately 6,100 of these nurses now qualified in the United Kingdom, about 5,600 are also trained as "supplementary nurse prescribers."

Supplementary prescribing is defined as "a voluntarily prescribing partnership between an independent prescriber (a doctor or dentist) and a supplementary prescriber (a registered nurse, midwife, or pharmacist) to implement an agreed patient-specific clinical management plan with the patient's agreement," according to Dr. Tully.

In addition to about 5,600 nurses, the supplementary prescribers also include about 600 pharmacists, all of whom have a signed a clinical management plan (CMP) to take over the prescribing for a given patient for up to one year. The CMP is a "rather bureaucratic system," Mr. Griffith said, in that it must meet strict criteria and be signed by a doctor or dentist, and the patient must give informed consent.

"The supplementary prescribers are able to prescribe any medicines, including unlicensed and controlled drugs, once this arrangement has been set up," Mr. Griffiths said."This is great for chronic disease management, but no good for first contact care, where the patient is often unknown."

"In 2003, further changes in primary legislation allowed both nurses and pharmacists to act as supplementary prescribers of any drug, other than controlled drugs, again following a period of didactic and practical training," Dr. Tully explained.

Thanks to recent developments, more UK practitioners are now able to prescribe in this fashion, including physiotherapists, radiographers, podiatrists, and optometrists. However, Mr. Griffiths believes that supplementary prescribing will remain in place and may still be the chosen way to prescribe for more junior staff, or where competence is being developed. Because of the great diversity in nonmedical professionals, having only a limited list of medicines or conditions available in their permitted formulary may not be practical.

"Opening the entire formulary, with the exception of some controlled drugs, is very helpful," Mr. Griffiths said. "Nurses, as well as all other health professionals, will work within their own competencies and code of conduct. Just because they can prescribe from the entire formulary doesn't mean they will!"

Even before the new UK prescribing policy was introduced, more nurses have taken on partnerships in general practice, and nurses and pharmacists are finding "new and innovative ways of working that suit patient choice," Mr. Griffiths explained. Recent research by Latter and colleagues from the University of Southampton showed that independent extended nurseprescribing was safe, effective, and associated with a high degree of patient satisfaction.

"The new legislative changes last week allow suitably trained nurses and pharmacists to act as independent prescribers, with responsibility for 'the assessment of patients with undiagnosed or diagnosed conditions and for decisions about the clinical management required, including prescribing,' " Dr. Tully said. "Acting within their professional competence, they will be able to prescribe any drugs, other than controlled drugs, without having a patient-specific CMP agreement by an independent prescriber in advance. Prescribing complex medication regimens at hospital admission or discharge, for example, are not, and never have been, amenable to the constraints of CMPs."

Nurses wishing to prescribe according to the new policy must be registered nurses, with a minimum of three years postregistration experience. This should not present a significant obstacle for most; a recent evaluation showed that about 90% of UK registered nurses had more than 10 years of postregistration experience.

Other requirements are that they should already have the specialist skills, qualifications, and experience within their own field; they must be seconded with managerial support; and they must complete a 38- to 40-day course over six months, under the supervision of a medical mentor. The course is at degree level, and assessments include written examinations, essays, and objective structured clinical examinations.

Nurses seeking expanded prescribing privileges must also complete a portfolio demonstrating the evidence they use as the basis for each theoretical prescribing decision. To demonstrate competence and growth, this portfolio should be maintained upon qualification. Nurse prescribing can also be audited from the prescription pricing authority (each nurse has an individual identifying number).

"Each practitioner must maintain their skills with continuing professional development (CPD), and a good place to start looking at an individual's needs is the 'maintaining competence' series of booklets available from the National Prescribing Centre," Mr. Griffiths said. "These are used at an individual's annual performance development review and can help both individual and manager plan for the required CPD."

Each nurse prescriber is registered with the Nursing & Midwifery Council (NMC), which disciplines and removes practitioners, if required. With the help of focus groups containing nurses, members of other healthcare professions, patient groups, and the general public, the NMC is currently finalizing their guidelines for prescribers.

"From my own experience, I have found that these practitioners are much more careful when prescribing or supplying medicines than are nurses who do the same under another method called Patient Group Directions (PGDs)," Griffiths said. "PGDs is a widespread system here in the UK, and it requires very little training."

Although Dr. Tully said that all pharmacists would be eligible to become independent prescribers, she does not believe that all will choose this option. Those who do will undergo a period of training and become registered with the RPS of Great Britain or the Pharmaceutical Society of Northern Ireland. Pharmacists in the European Union currently receive 1,000 hours of training in pharmacology and therapeutics as part of their undergraduate training, and supplementary prescribers also receive an additional 25 days of didactic training and 12 days of practical training in the process of prescribing. At this time, it is still unclear exactly what training will be required for independent pharmacist prescribers before they are eligible for registration with the RPS.

"Independent prescribers will have an extended professional role, with the increased responsibilities and accountabilities that might be expected to accompany it," Dr. Tully said. "Services provided by independent pharmacist prescribers will free up doctors' time from prescribing for minor conditions or in routine situations and allow them to concentrate on patients with more complex problems. In addition, they would not have to accept the responsibility for prescribing by supplementary prescribers, which would be held by the independent prescribers in their own right."

Some examples of how this could work in primary care are that pharmacists who perform medication reviews, as part of their contract with the NHS, will now be able to implement the changes that they have only previously been able to recommend to the general practitioner, thereby facilitating changes in a timely manner to avoid duplication of effort. For patients with minor ailments, community pharmacists are often the first point of contact, and plans are now in motion to formalize this contact and to direct patients away from busy GP clinics. Pharmacists involved in these minor ailment clinics will now be able to prescribe, at NHS expense, the same drugs that are currently prescribed by GPs.

"This would be administratively simpler, and thus cheaper, than existing ad-hoc pharmacy schemes, free up GP appointments, and ensure that patients who do not pay for their NHS prescriptions receive the same benefits from the pharmacy services," Dr. Tully said.

Potential advantages of the new system also apply to secondary care. When patients are hospitalized, pharmacists currently conduct medication histories and record this in the medical record. As independent prescribers, they would now be able to prescribe those drugs that remain appropriate, rather than asking a busy hospital physician to do so. Pharmacists could also write discharge prescriptions for patients going home, enabling them to manage the discharge process more efficiently, avoiding long delays when physicians have to return to wards to do this instead, and counseling patients in a timelier manner.

Before the new policy can be fully operational, independent pharmacist prescribers will need timely access to the patients' medical records, to check the previous medical history and record details of the care they have provided.

"In secondary care, this is easy to implement; in primary care, it is more difficult, due to the geographical separation of the community pharmacy and the GP practice where records are held," Dr. Tully said. "Practical solutions to this problem will probably have to be developed before the full benefit of independent prescribing can be seen in primary care."

To preserve patient safety while improving patient choice and convenience, appropriate safeguards will be necessary. All pharmacists are expected to adhere to the RPS Code of Ethics, and to that of the equivalent society in Northern Ireland, which state that pharmacists are expected to practice within their levels of professional competence.

"Although pharmacists are legally allowed to prescribe any drug, practically they would not expect to prescribe those drugs that were outside their areas of expertise," Dr. Tully said. "This is not dissimilar to current practice in medicine, where an endocrinologist would refer a patient to a colleague in neurology when recognizing the limits of his or her knowledge."

At this point, Dr. Tully believes that the effects of the new legislation on healthcare costs are difficult to predict. To date, there is no evidence that prescribing costs would increase, and existing studies that have evaluated costs for minor ailment clinics suggest that they would remain the same. However, less duplication of effort could reduce staff costs. In any event, the NHS will monitor the cost of pharmacist prescribing in the same fashion as it currently monitors physician prescribing, and it will address prescribing at the extremes of the norm in the same way as it now does for physicians.

Whether the UK directive of expanding prescribing powers would be feasible and beneficial in the US is still undetermined. At present, at least 42 US states have implemented collaborative drug therapy management (CDTM), in which pharmacists and prescribers establish agreements that outline the situations where pharmacists may initiate, modify, or discontinue medication therapy. Florida has already allowed independent prescribing authority for pharmacists, but within a limited formulary.

"US pharmacists collaborate with patients to 'make medications work' -- helping them understand why they are using the medication, how it might make them feel, what side effects they might feel -- all intended to help the patient reap the benefits of the medication and minimize the risks," Susan C. Winckler, RPh, Esq, told Medscape. She is vice president of policy and communications and staff counsel for the American Pharmacists Association (formerly the American Pharmaceutical Association) in Washington, DC.

"CDTM has greatly expanded access to valuable medications such as immunizations and emergency contraception, as well as helped individual patients manage their diseases," Ms. Winckler said. "CDTM agreements should be authorized in all 50 states, and expanded in existing states to better support physician-pharmacist-patient collaboration and access to medications and pharmacists' services."

State laws vary in their educational requirements concerning engaging in collaborative practice, and in prescribing privileges for nurse practitioners. New Medicare changes, and the allowance for "medication management" for pharmacists, may provide the impetus to expand prescribing privileges for nonmedical professionals.

Ms. Winckler believes that implementing CDTM in all states would expand patient access and improve medication use. "Expanding CDTM will help strengthen the healthcare team -- allowing greater collaboration and facilitating medication monitoring, management, and follow-up," she said. "When pharmacists initiate or modify medication therapy under such agreements, they communicate such actions back to the primary physician and help coordinate care."

Most of the studies included in a recent Cochrane review showing that pharmacist recommendations to change prescribing improved patient outcomes were conducted in the United States.

"Suitably trained pharmacists in the US should be well able to act as independent prescribers in much the same way as pharmacists in the UK, with relevant changes to legislation and with appropriate oversight by the relevant authorities," Dr. Tully concluded.

Reviewed by Gary D. Vogin, MD

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