The new prescriber: friend or foe?

pharmafile | November 22, 2007 | Feature | Sales and Marketing |  nursing, pharma, pharmacy, sales 

Reading some newspapers a few weeks ago, you might reasonably have imagined a war was going on. The GP newspaper Pulse revealed that nurse prescribing had nearly doubled during its first year, and the newspapers were full of doctors on the warpath. After reading the many harsh things said about the dangers of prescribing nurses, the reader might well have feared that thousands of inadequately-trained nurses were prescribing powerful drugs they knew little about. And industry strategists and analysts might reasonably have stopped for a moment to wonder whether 2007 would be the year pharma had to switch the focus of its marketing away from doctors and on to nurses.

In truth, there is a revolution going on in terms of prescribing. It's currently being led by nurses, who are easily the biggest new group of prescribers, but pharmacists are hard on their heels, and the optometrists, chiropodists/ podiatrists and physiotherapists are not so far behind. Despite the headlines, what we're seeing is a quiet, slow kind of revolution that will only come to affect pharma marketing gradually over time. What's more, much of what is happening in nursing in particular is taking place with explicit support from many doctors.

Where did it all start?

The story of nurse prescribing started with Neighbourhood Nursing, a 1986 government report led by the Conservative peer Baroness Cumberlege. Cumberlege reported that nurses were wasting time because, although they often knew what their patients needed and regularly filled out the necessary prescription, they were, nevertheless, obliged to rely on a GP to rubber-stamp it. Aware that this was often unnecessary and a waste of time for everyone, Cumberlege and her colleagues proposed that nurses should be allowed to prescribe.

In the 1980s, the process moved on as two reports by public health physician Dr June Crown began by proposing patient-group directions (PGDs) that would allow nurses to give medicines to particular groups of patients without a doctor being present, and went on to argue that community nurses, district nurses and health visitors should be allowed to prescribe from a limited formulary. The Crown proposals were translated into NHS reality in the mid-90s.

By now, the direction of travel was established and big changes came quickly. In 2000, the government consulted on proposals that nurses should qualify for a new, wider class of prescribing. Independent Extended Prescribing arrived in 2002, initially for minor injuries and minor illness, palliative care and health promotion, and it allowed specially qualified nurses to prescribe from a defined list of about 120 prescription medicines and certain other pharmacy and general sale medicines.

Then, yet another kind of nurse prescribing came on board and was rolled out in 2004. This was Supplementary Prescribing for nurses and pharmacists. Nurses qualified for Independent Extended Prescribing could upgrade their qualification to undertake this new type of prescribing, in which an agreed individual management plan for the patient gave the parameters for what could be prescribed.

Under this arrangement, the nurse or pharmacist could prescribe for any condition and from almost the entire formulary, so long as they were working within the parameters of the patient's management plan. The exceptions were the controlled drugs and unlicensed treatments, but they were included later.

In parallel with Supplementary Prescribing, Independent Extended Prescribing was being developed to include more conditions and drugs, and finally, yet another round of consultations concluded that both nurses and pharmacists should be able to prescribe any treatment, with the exception of some CDs, for any condition within their own competence, and that they would be expected to prescribe within locally defined protocols. Full-scale nurse and pharmacist independent prescribing was finally introduced in the spring of 2006.

Noisy opposition

Now, a year on, how much has changed? Out of a nursing population of 670,000, just 10,000 nurses are qualified to independently prescribe, and a few tens of pharmacists have completed training and have taken up the baton. When all nurse prescribing is totted up, it adds to only one per cent of the bill for prescribed medicines, which hardly amounts to a significant change.

Yet there has been a great deal of resistance from some parts of the medical profession, as the Royal College of Nursing Joint Prescribing and Medicines Management Adviser Professor Matt Griffiths acknowledges: "A central complaint has been that the nurses are asked to complete a full-time course of only 26 days in order to qualify. But that fails to take account of the fact that these nurses have to complete a minimum of three years of practice before they can begin the course. To that you can add the three-year course for the RGN qualification, a couple of years specialising and working towards first their diploma and then their degree, and some have master's degrees and even PhDs. Some 75 to 80% of nurse prescribers have a degree, if not a master's degree or PhD.

"These are very experienced and highly educated nurses. In all, they have usually had six or seven years of formal education. Some 90% have been nursing for at least 10 years, and a lot in excess of 15 years. These are senior nurses, many of them running specialist clinics and managing caseloads in diabetes clinics or asthma clinics. Before nurse prescribing, it tended to be the nurses who reviewed the patients and their medication, but now with their prescribing qualification, they are able to manage patients for their entire episode.

"Most of the nurses are in primary care, but in the last year, an increasing number have come from secondary care in intensive care, anaesthetics and cancer care. But prescribing just isn't going to be a skill that every nurse needs. Someone who is working at a junior level won't necessarily be prescribing."

How does Griffiths deal with the argument that nurses' training for prescribing is too lightweight? "We have made the argument that although the six-month course includes only 26 days in college, it also includes 12 days in practice and a requirement to produce a portfolio demonstrating their competence. Then there are Objective Structured Clinical Examinations (OSCEs), and essay and short-answer examination papers. More recently a calculations paper has been introduced.

"The nurses have to put together portfolios demonstrating their competence, including case studies of patients, giving details of diagnosis, consultations, consideration of treatment options, their choice of treatment, and the reasons, which include the evidence and national and local guidelines supporting their decision, costs, incidences where medicines should not be prescribed, safety issues, and patient compliance. There is a host of issues that they have to address laid out in the National Prescribing Centre's Maintaining Competence in Prescribing for nurses. It is a very highly assessed qualification."

And how do Griffiths and his colleagues at the RCN deal with with doctor protests over a doubling in nurse prescribing? "What's happening here is that because some of the treatments were previously prescribed under Patient Group Directives, it's difficult to tell what was effectively being prescribed by nurses before, or whether anything has really changed.

"The story highlighted some issues that we must monitor, but I think it was misleading. In the old days, you often found the diabetes or asthma nurse would do the medication reviews, and that they were signed off by the doctor. Later there were PGDs. Now nurses are taking responsibility for what they are recommending " that's the difference."

Although many doctors are worried about independent nurse prescribing and even oppose it, many individual nurses who decide to qualify for prescribing are clearly finding support. The argument is that if 10,000 independent prescribers have been signed-off as competent by their doctor medical supervisors, the implication must be that thousands of doctors have supervised and supported nurse colleagues through the process of becoming qualified.

Quite a few may even have been impressed with the demands placed on the nurses, Griffiths suggests. "There are quite a few doctors I've come across who have been pleasantly surprised by the standard of education required, and some have even said that they didn't have to go through the same processes to be able to prescribe themselves."

The doctors' view

When asked to talk about the issue of nurse prescribing, doctors' representatives at the BMA take a generally sanguine view. Dr Brian Dunn is a GP at Larne in Northern Ireland, chairman of the BMA Northern Ireland GP Committee, and the member of the BMA GP negotiating team for the UK, responsible for prescribing issues, and if anyone understands the doctors' position, it's him. "The BMA, in general, is reasonably in favour of non-medical people prescribing," he said. "Our big concern was the announcement by the government that nurses and pharmacists would be able to prescribe from the total pharmacy.

"A lot of nurse prescribing in the past has been done in the practice setting, with specialist nurses running a clinic and prescribing from a limited formularly in an area where they have expertise, and that's fine. Our concern is that people may now prescribe outside their expertise. Obviously, many have a very good knowledge of their own area of expertise, and to some extent the concerns are tempered by the fact that the vast majority of nurses and pharmacists are sensible, and won't prescribe outside their area of expertise. While, in theory, they have the whole formulary to prescribe from, people acting professionally will only prescribe from within their own area. But as far as I can see, there is no regulatory framework to ensure these groups will prescribe within their areas. This is one of the reasons why doctors feel aggrieved about the extension of prescribing powers to the other professional groups.

"The one advantage of being registered with the General Medical Council is that you can prescribe, and Chief Medical Officer Sir Liam Donaldson and the government are bringing in more and more stringent demands on doctors to be re-certified. I don't think the demands on pharmacists, for example, are going to be as stringent as they are for doctors. There's a feeling that doctors are trying to keep control and not let anything go, but the real issue is patient safety. Doctors are concerned that things are done properly; we're not just trying to defend our own area. We'll be happy if the nurses, pharmacists and optometrists act responsibly."

Dr Dunn's point of view is based on experience of the reality of nurse prescribing. "In fact, our own practice nurse is probably one of the highest prescribing nurses in Northern Ireland," he said. "This is because we've encouraged her and she's working within a formulary, and we're confident that what she's prescribing is appropriate She has eased our workload – giving children paracetamol and creams for nappy rash and so on saves the patient from having an appointment with the doctor. So I think it's positive, if it's done in the right way."

What's happening in practice?

The first independent evaluations of nurse prescribing are beginning to come through. "The University of Southampton conducted the first independent evaluation of nurse prescribing, and found that patient satisfaction was very high, and this has been confirmed by further research," said Professor Griffiths. "Karen Luker and her colleagues in Manchester have also done some work on patient satisfaction with nurse prescribing. We are building up a picture of patient attitudes, and it does seem to be very positive.

"The University of Southampton has also done research with the hospitals in Peterborough that showed the diabetes nurse there was reducing errors. When a nurse repeat-prescribes, they are obliged to assess the patient fully, so there's a double-check."

Furthermore, error rates appear to be extremely small, at least at present. Griffiths points out that when the National Patient Safety Report in June identified 60,000 medication errors over 18 months across prescribing, dispensing and administering, not one nurse prescribing error was identified, even though there are 10,000 nurse prescribers.

And there seem to be no rogue prescribers. "We haven't had anyone up in front of the NMC, even though it has very strict guidance on prescribing," said Griffiths. "I'm sure there will be errors in the future, but I'm pleased that nurses are rolling prescribing out responsibly and safely."

Benefits for pharma

Martin Anderson, director of the ABPI of NHS policy and partnerships, believes non-medical prescribing has potential benefits for the pharma industry. "We're all about access to medicines, so if you can produce adequately trained professionals to prescribe, that's potentially good for us. But there are potential dis-benefits that depend on the constraints put upon prescribers. There's some research that indicates that nurses, initially, are more inclined to conform to protocols and guidelines. That can be a good thing for pharma, depending on who writes the protocols and guidelines, and what's in them.

"The same research shows that after a while the nurses tend to become more relaxed about protocols. Like doctors, they start by working to the recognised best practice, and as they gain practical knowledge, they feel more confident about cases where the protocol is not appropriate for the individual."

A more revolutionary change that's now clearly in view is that nurses could take over much of medical treatment. "If diagnostic skills are good enough, and this might be by working in partnership with doctors, once you've got a diagnosis, the treatment protocols are quite standard," said Anderson.

This is quite a thought: doctors making diagnoses, while medical management is dealt with by prescribing nurses and pharmacists. It's entirely consistent with the political direction of travel, but it's fair to say if doctors caught a whiff of this, they could become very unhappy indeed. But this can only be far into the future, if ever. More immediately, non-medical prescribing is unlikely to produce a significant growth in prescriptions, and although its present controlled rate of growth suggests non-medical prescribers are not about to become an important new population of prescribers that pharma needs to reach, no doubt they will become important in time.

"At some point, non-medical prescribers will become significant in terms of prescriptions, and pharma will want to work with and influence those people. We don't know when this will be. The uptake is very slow and is starting from a very low base " so, it will be a number of years yet – more than two, but perhaps not as many as 20," concluded Anderson.

Gavin Atkin is a freelance writer specialising in medical and pharmaceutical topics. He can be contacted at gmatkin@gmail.com