An Evaluation of the Expansion of Nurse Prescribing in Scotland

CHAPTER ONE : INTRODUCTION

Introduction

1.1 This report evaluates nurse prescribing in Scotland from its extension in 2001 up to the creation of Nurse Independent Prescribers in 2006. It explores the effect of nurse prescribing in Scotland on patients, the public, nurse prescribers themselves, other nurses, medical and allied health professionals and the health service. It identifies the benefits of, and obstacles to, such prescribing for patients, health professionals and health service delivery.

1.2 Prescribing activity by nurses potentially provides a range of benefits including: continuity of patient care; greater and quicker access of patients to treatments which may, or may not, involve some sort of prescription; the release of doctors' time for other activities; more rapid treatments with patient safety benefits; enhanced and greater use of nurse's skills; and greater health service cost effectiveness.

1.3 There are also potential obstacles to such developments including: a lack of skilled and trained nurse prescribers; safety problems for patients; disengaged nurses and other health professionals; and unresponsive health service organisations.

1.4 This study aimed to provide evidence on how nurse prescribing has operated in Scotland since 2001, how nurse prescribers were prepared for their role, what effects such prescribers have had on patients, fellow health professionals and NHS organisations.

1.5 The projects objectives were to examine:

• The implementation and operation of the extension of nurse prescribing;
• The impact of nurse prescribing on the appropriate use of nurses' skills;
• Patient benefit from nurse prescribing and patients' perceptions of their experiences of care;
• Measure the impact of nurse prescribing extension on workloads;
• Assess the extent to which public health and patient safety are safeguarded; and
• Different approaches to nurse prescribing training.

1.6 The methods used to address these objectives were designed to identify the nature of nurse prescribing and gain a holistic picture of how such prescribing was working in Scotland, through quantitative and qualitative methods. The research comprised the following elements:

• Overview of the development of nurse prescribing in Scotland and associated legislation;
• A review of the relevant literature;
• A postal survey of all nurse prescribers on Nursing and Midwifery Council ( NMC) databases in 2004;
• A survey of public attitudes to nurse prescribing in 2003 and repeated in 2007;
• Interviews with stakeholders;
• Case studies of the work of a representative range of nurse prescribers located in two NHS Boards and in a range of organisational and patient settings; AND
• A detailed study of nurse prescriber education.

Details of the methodology and research methods used to conduct the study are supplied in chapter 3.

Overview of legislation

The first nurse prescribers

1.7 The Scottish Government has produced a number of policy documents highlighting the need for changes in the way in which health care is delivered to ensure that the needs of the population are addressed within current resources. Delivering for Health ( SE 2005), Delivering Care, Enabling Health ( SE 2006a) and Visible, Accessible and Integrated Care ( SE 2006b) all highlight the significance of nurse prescribing in extending existing roles and developing new roles for nurses and Allied Health Professionals. There has been a parallel drive by Westminster, via reserved legislation, to increase prescribing powers to nurses and Allied Health Professionals ( AHPs) over the last five years.

1.8 Nurse prescribing first became part of the Westminster policy agenda following the Cumberlege Report ( DHSS 1986), which included the following recommendation:

'The DHSS should agree a limited list of items and simple agents which may be prescribed by nurses as part of a nursing care programme, and issue guidelines to enable nurses to control drug dosage in well defined circumstances'.

Subsequently, the first Crown report (DoH, 1989) recommended that suitably qualified nurses, with a district nursing or health visiting qualification, working in the community should be authorised to prescribe, in defined circumstances, from a limited formulary. The primary legislation that permitted initial nurse prescribing was the 'Medicinal Products: Prescription by Nurses Act 1992', although the necessary secondary legislation to this did not come into effect until 1994. Following a successful pilot programme, the Department of Health (DoH) introduced nurse prescribing for district nurses and health visitors in 1996. In the same year nurse prescribing for district nurses and health visitors was also introduced in Scotland.

1.9 Although the recommendations on nurse prescribing included in the Cumberlege report were the foundation of nurse prescribing, they were not the start of actual nurse prescribing. Nurse Prescribing Pilots began in England almost a decade later, and were introduced in Scotland in 1996.

Independent prescribing

1.10 DoH's (2006) working definition of independent prescribing is

'Prescribing by a practitioner responsible and accountable for the assessment of patients with undiagnosed and diagnosed conditions and for decisions about the clinical management required, including prescribing'.

In 1997 the DoH set up the 'Review of Prescribing, Supply and Administration of Medicines'. In 1999, the second report of the review recognised the potential benefits to patients of extending prescribing responsibilities to healthcare professionals other than doctors and dentists and the few district nurses and health visitors who were already qualified (DoH, 1999) and NMC 2006).

1.11 This led in 1999, to the DoH report 'Making a Difference' which strengthened and maximized the contribution of nursing, midwifery and health visiting, and in 2001 the Scottish Executive Health Department's 'Nursing for Health: A review of the contribution of nurses, midwives and health visitors to improving the public's health in Scotland' ( SE, 2001b) and 'Caring for Scotland - The Strategy for Nursing and Midwifery in Scotland' ( SE, 2001a). These documents reaffirmed both the UK and Scottish Governments' intentions to extend the roles of nurses, midwives and health visitors to make better use of their knowledge and skills, including making it easier for them to prescribe. All four countries of the UK subsequently adopted many of the principles contained within 'Making a Difference' in particular the extensions to the role of the nurse in relation to prescribing.

1.12 In 2000, the ' NHS Plan' (DoH, 2000) and 'Caring for Scotland' ( SE, 2001a) and 'Delivering for Health' ( SE, 2005) in Scotland were published. All these documents called for the empowerment of frontline staff and patients, the harnessing and expansion of skills of all healthcare professionals, the breaking down the traditional demarcations between clinical roles, and the increased flexibility of teamwork.

1.13 In support of this, following a consultation which began in October 2000, the Westminster government announced in May 2001 that nurse prescribing would include more nurses and would cover a wider formulary (Nurse Prescribers' Extended Formulary). Extended nurse prescribing was also rolled out in Scotland (from 2002) supported by the necessary extended training which was made available to any first-level registered nurse or registered midwife.

What could Extended Formulary Nurse Prescribers prescribe?

1.14 Nurse prescribers who had completed the necessary training to prescribe from the Nurse Prescribers' Extended Formulary list could legally prescribe all General Sale List ( GSL) and pharmacy medicines prescribable by general practitioners ( GPs), together with a list of almost 180 specified Prescription Only Medicines ( POMs) and prescribe all items from the Nurse Prescribers' Formulary.

Supplementary prescribing

1.15 In April 2003 legislation by Westminster made it possible for health care workers other than doctors to train to become supplementary prescribers. Supplementary prescribing is defined as a voluntary partnership between the independent prescriber (a doctor or a dentist) and a supplementary prescriber to implement an agreed, patient-specific Clinical Management Plan ( CMP), with the patient's agreement ( NMC 2006). Supplementary prescribing was rolled out in Scotland in 2003.

What can supplementary prescribers prescribe?

1.16 Nurses, pharmacists, physiotherapists, radiographers, podiatrists and optometrists can prescribe in partnership with a doctor (or dentist). Nurse and pharmacist supplementary prescribers are able to prescribe any medicine including a limited range of Controlled Drugs and unlicensed medicines that are listed in an agreed CMP. All supplementary prescribers may prescribe for any medical condition, provided they do so under an agreed, patient-specific CMP.

1.17 Supplementary prescribing may continue to have a role for nurse independent prescribers, particularly for newly qualified prescribers, or complex situations where there is clearly a need for a team approach to prescribing, or when a patient's clinical management plan ( CMP) includes certain controlled drugs or unlicensed medicines ( NMC & SEHD 2006).

Nurse Independent Prescribing

1.18 Between 2003 and 2005, work continued to expand the Nurse Prescribers Extended Formulary ( NPEF) and by 2005, there were 240 Prescription Only Medicines ( POMs), along with all the Pharmacy (P) and General Sale List ( GSL) medicines which nurses could prescribe in the formulary.

1.19 In October 2005, the Committee on Safety of Medicines ( CSM) considered responses to two previous consultations that examined options for the future of nurse prescribing along with the introduction of independent prescribing for pharmacists. They recommended that suitably trained and qualified nurses and pharmacists should be able to prescribe any licensed medicine for any medical condition within their competence. This was agreed across the UK and legislation came into effect in 2006, which enabled all qualified Extended Formulary and Extended / Supplementary nurse prescribers to become Nurse Independent Prescribers and suitably qualified pharmacists (Pharmacist Independent Prescribers) to prescribe any licensed medicine. Nurse Independent Prescribers, within their own level of experience and competence, can prescribe a range of controlled drugs for specific medical conditions but Pharmacist Independent Prescribers cannot prescribe controlled drugs, although this may change in the future ( NMC 2006).

Implementation

1.20 Independent prescribing for nurses in Scotland was introduced in a phased implementation which began in 1996 and is now complete. 2006 saw the publication of Non Medical Prescribing: Guidance for Independent Nurse Prescribers and for Community Practitioner Nurse Prescribers in Scotland ( SEHD, 2006), and this document, to guide implementation, was supported by the publication by the nursing regulator of "Standards of proficiency for nurse and midwife prescribers" ( NMC, 2006).

Education and training

1.21 Since 1999, preparation to prescribe from the Nurse Prescribers' Formulary was included in the district nursing and health visiting / public health nursing pathways of specialist practitioner programmes. Until 2006, such prescribing was integral to the education of all district nurses, health visitors / public health nurses and the small number of practice nurses who have successfully completed the assessment requirements of either the stand alone or integrated course and whose prescribing status is noted on the Professional Register held by the Nursing and Midwifery Council ( NMC). These training programmes remain for Community Practitioner Nurse Prescribers, but in 2006, the NMC (see above) set out standard for the educational preparation of Independent Nurse Prescribers. These standards have to be met by Higher Education Institutions ( HEIs) in order to run approved nurse prescribing educational programmes. During training the potential nurse prescriber is supervised by a Designated Medical Practitioner who is responsible for assessing whether learning outcomes are met and assures clinical competency levels of nurse prescriber trainees.

Nurse prescribing numbers in Scotland

1.22 The number, scale and scope of the work of nurse prescribers in Scotland developed rapidly since 1997. Further increases in the numbers and functions of nurse prescribers are also planned or underway. The number of nurse prescribers in Scotland has grown from 6 in 1996 to over 3,200 by March 2006 ( ISD, 2007). The future holds further possible expansion with the introduction of an extension to the Nurse Prescribing Scheme. Over the same period, between 1996 and 2006, nurse prescribing, although small in relation to that of GPs, grew from fewer than 2,000 prescription items in 1996/97 to over 447,000 by 2005/06 (see table 1.1). The gross ingredient cost rose from £15,386 to over seven million pounds. Volume increased by 15.4% and cost by 15.7% between 2004/5 and 2005/06. The reasons for such increases are not necessarily obvious and could link to factors other than more prescribers prescribing more items. For instance, demographic factors such as the growth of the older population, many of which are managed by nurses, may have a part to play.

Table 1.1 The increase in nurse prescribing in Scotland

Year ending 31 March	Number of Prescribed Items	Gross Ingredient Cost (£)
1997	1,871	15,386
1998	17,006	143,086
1999	55,487	539,127
2000	100,666	1,072,407
2001	175,414	2,052,182
2002	247,931	3,234,981
2003	295,104	4,224,857
2004	335,826	5,110,590
2005	387,938	6,243,183
2006	447,787	7,222,794

Source: Information Services, Healthcare Information Group ISD, 2007

1.23 From April 2002 extended formulary nurse prescribers were able to prescribe a wider range of medicines for a broader range of medical conditions - minor injuries, minor ailments, promoting healthier lifestyles and palliative care, and as detailed above. Over this period, with the introduction of different categories of nurse prescriber, the nature and type of nurse prescribers and their numbers has changed. So, in 2005/06, 52% of all nurses prescribing was carried out by District Nurses, 14% by Health Visitors, 17% by supplementary prescribers, 7% by extended prescribers and 2% by Practice, Community and triple duty nurses ³ ( ISD, 2006).

1.24 The enhancement of the nurses', midwives' and health visitors' role by the introduction of extended, supplementary and independent nurse prescribing is seen by many as one of the most significant developments in the delivery of patient care over the last century (Harrison, 2003). The Scope of Professional Practice ( UKCC, 1992) provides a legal framework for nurses, midwives and health visitors to practice and prescribe within the scope of their professional competence. The potential 'added value' that may arise from nurse prescribing has been reported elsewhere (Brooks, 2001 and DoH, 1999a and Luker et al, 1997) although much of this evidence comes from the experiences of district nurses and health visitors who have been permitted to prescribe from a very limited range of medicines since 1994. Clark (2002) highlights that nurses have more prolonged contact with their patients and are in a good position to carry out an assessment of the patient's condition, monitor and observe compliance, and observe responses to treatment along with observation of side effects. The expansion of nurse prescribing that has occurred as a result of recent legislative changes will give more opportunities for nurses to provided added value to the patient's engagement with the NHS.

1.25 Table 1.2 shows the changes in the number of items prescribed by nurse prescribers in Scotland for each chapter of the British National Formulary ( BNF). This shows that as more extended and supplementary prescribers qualified so associated prescribing increased in a range of areas of the BNF. However, it should be noted that a number of policy and pharmaceutical changes may have been responsible for the variations, but it is virtually impossible to identify these specifically. For example, between 2001 and 2003 it is likely that the majority of nurses' prescriptions were being written by district nursing and health visiting prescribers. It is also possible that each year additional items were added onto the drug tariff. It is also likely that further increased prescribing in 2006 also demonstrates activity as a resulting from the opening up of the BNF to independent prescribers

1.26 The additional opportunities for nurses, midwives and health visitors to prescribe across a wider range of medicinal products bring a number of professional benefits, for example the additional training and responsibility. These opportunities have had a major impact on primary care, (see above paragraph 1.21), where nurses play a major role in the prescribing process but have to leave the final element; the signing of the prescription, to the medical practitioner. There are however a number of challenges (Finnie and Wilson, 2003) for 'new' nurse prescribers, many of which will come from the expansion of nurse prescribing within secondary care settings, such as clinical nurse specialists and nurses working within accident and emergency departments under the auspices of supplementary prescribing where nurse prescribing, has historically been less prevalent.

Table 1.2 Nurse prescribing - number of prescribed items ( ISD, 2007)

BNF Description	2001	2002	2003	2004	2005	2006
Gastro-intestinal system	5,054	5,789	6,264	7,121	8,050	8,441
Cardiovascular system	4	7	10	187	1,272	3,628
Respiratory system	0	1	39	1,116	6,236	14,653
Central nervous system	5,433	13,121	20,592	24,947	30,892	36,128
Infections	2,053	2,778	3,299	5,302	9,771	19,066
Endocrine system	1,079	1,330	1,532	1,685	2,667	4,317
Obstetrics, gynaecology & UT disorders	192	159	484	3,116	8,243	13,785
Malignant disease	0	1	0	17	49	67
Nutrition and Blood	94	89	119	478	1,013	1,476
Musculoskeletal & joint disease	1	7	38	563	1,724	2,571
Eye	4	18	230	1,432	2,975	4,832
Ear, nose and oropharynx	1,664	2,409	2,944	4,227	5,675	7,393
Skin	38,707	53,066	64,463	68,885	75,849	59,335
Immunological products & vaccines	1	1	12	913	3,159	5,595
Anaesthesia	1,059	1,599	1,995	1,947	2,236	2,478
Other drugs & preparations	499	564	530	477	544	645
Dressings	101,627	140,079	161,100	179,131	186,970	193,875
Appliances	8,302	11,345	13,485	14,605	18,573	45,687
Incontinence appliances	5,685	8,466	9,941	10,815	11,167	10,735
Stoma appliances	1,976	3,336	4,788	5,831	6,689	6,466
Unknown Code	1,763	3,272	3,239	3,031	4,184	6,614
Total	175,197	247,437	295,104	335,826	387,938	447,787

Report overview

1.27 This report identifies the context, aims and objectives of the research in chapter one. Chapter 2 explores recent relevant research on nurse prescribing with particular reference to Scotland. Chapter 3 describes the research methodology and the research methods used to explore the project objectives. Chapter 4 examines nurse perspectives on nurse prescribing, and Chapter 5 examines stakeholder perspectives. Chapter 6 provides an evaluation of the initial education courses or 'programmes of preparation' for nurse prescribers in Scotland. Chapter 7 looks at patient perceptions and those benefits of extending nurse prescribing that patients identified. Chapter 8 investigates the impacts of nurse prescribing on health service organisation in Scotland. Chapter 9 contains an analysis of some of the public health and patient safety elements of nurse prescribing. Chapter 10 provides a brief overview of the project and our main conclusions.

1.28 It should be noted that it was agreed in the first year of the project that the results of the study would be fed back to practitioners when completed and, where relevant, to benefit practice. This specifically applied to the evaluation of nurse prescribing education and a number of findings from that work were communicated to NHS Education for Scotland ( NES) and incorporated into practice during the course of the project.