An Evaluation of the Expansion of Nurse Prescribing in Scotland

CHAPTER SEVEN: PATIENT PERSPECTIVES OF NURSE PRESCRIBING

Introduction

7.1 This chapter reports on patients' perceptions and experiences of nurse prescribing particularly in relation to quality of care and different access routes to health services. The views of other stakeholders, such as patient representative groups and various health professionals, on the benefits of nurse prescribing to patients are also reported

7.2 The main source of information on patients' perceptions comes from a module of questions included in the omnibus survey ¹⁶, Scottish Opinion Survey, conducted by TNS with the general public. The module of questions was first included in the September 2004 survey and, using the same questions, was included in the February 2007 survey covering a period of major growth in the extension of nurse prescribing in Scotland.

7.3 The stakeholder views are drawn from other elements of the study including the initial stakeholder interviews and interviews with various stakeholders (including patients and health professionals) from the case studies.

Omnibus survey results

Awareness of Nurse prescribing

7.5 In 2004, just over a third of those sampled (36%) were aware that nurses, health visitors and midwives could prescribe medicines. By 2007, this proportion had risen to over half (52%) of the sample. In both surveys those in the older age groups 55-64 and above 64 had the greatest awareness possibly due to their experiences of the health care system. The least aware were those in the 16-24 age group who would have had least knowledge of the health care system. Men were less likely than women to be aware that nurses etc could prescribe medicines (2004: 34%:38%; 2007: 48%:56%). There were only small differences in awareness between geographical areas.

7.6 Those in the higher socio-economic groups were more likely to be aware of nurse prescribing than those in the lower socio-economic groups. (Table 7.1) This pattern of awareness of nurse prescribing was apparent in both 2004 and 2007.

Table 7.1 Awareness of nurse prescribing by socioeconomic group

Socioeconomic group	2004			2007
	%	Unweighted base	Weighted base	%	Unweighted base	Weighted base
AB	45	178	204	59	181	217
C1	34	298	284	55	276	290
C2	31	217	214	50	198	210
DE	36	323	313	47	352	290

Experience of nurse prescribing

7.7 In 2004, 12% of respondents reported that they had received prescribed medicines from a nurse, health visitor or midwife for themselves (10%) or as a carer (2%). By 2007 the proportion of respondents receiving prescribed medicines from a nurse, health visitor or midwife had risen to 16% (13% for themselves, 4% as a carer) of the sample.

Location of nurse prescribing

7.8 In 2007, the percentage of respondents receiving prescriptions at their GP surgery or health centre from a nurse, health visitor or midwife increased showed the greatest increase (table 7.2). In contrast, prescribing by nurses in hospital wards showed a decline of 1% between 2004 and 2007.

Table 7.2 Location in which patient had received nurse prescription*

Location	2004		2007
	%	N	%	N
GP surgery or health centre	63	75	78	124
Own home	10	12	11	18
Hospital Ward	8	10	7	11
Outpatients	6	7	6	10
Nursing home	2	2	-	-
A & E	1	1	1	2
Minor injuries clinic	1	1	1	2
Occupational Health Department	-	-	1	2
Community Hospital	-	-	3	4
Pharmacy	-	-	2	3
Others	10	12	1	2

*Base: 2004 120 (103 unweighted), 2007 160 (unweighted 168)

Satisfaction with nurse prescribing

7.9 Of those respondents receiving a nurse, health visitor or midwife prescription in the 2004 survey over two thirds (67%) were satisfied with nurse prescribing. A further 23% were quite satisfied. 5% were quite or very dissatisfied. By 2007, the proportion of those very satisfied with nurse prescribing had risen to 75% and with a further 21% being quite satisfied. Only 2% were quite or very dissatisfied with nurse prescribing.

7.10 Satisfaction with nurse prescribing showed no clear relationship with age. In the 2004 survey, those respondents in age group 45-54 were least likely to be very satisfied (32%) with nurse prescribing whilst those in the 25-34 age group were most likely to be very satisfied (94%). In the 2007 survey there was less variation in the proportion of respondents very satisfied between the age groups.

7.11 There were few respondents in any age group in either the 2004 or 2007 survey who were quite or very dissatisfied with nurse prescribing. However, caution needs to be exercised in relation to these figures, since they are based on small numbers of respondents.

7.12 In both surveys there was an inverse relationship between socio economic group and reported satisfaction with nurse prescribing. Hence a smaller proportion of respondents in group DE reported that they were very or quite satisfied with nurse prescribing compared to those in socioeconomic group AB (2004: 82% vs. 100%: 2007: 84% vs. 100%).

7.13 In the 2004 survey respondents in all areas showed high levels of satisfaction with nurse prescribing however respondents from the West were less likely to be very or quite satisfied with nurse prescribing than respondents from the East/South or the North (86% vs. 96% vs. 93%). There was very little difference between the different areas in the 2007 survey.

7.14 All those respondents who were either satisfied or dissatisfied with nurse prescribing were asked the reasons for their satisfaction or dissatisfaction. These are given in table 7.3 (respondents may have given more than one reason).

Table 7.3 Patient satisfaction with nurse prescribing*

	2004	2007
	%	%
Reasons for satisfaction
Quicker and easier than going to a doctor	28	22
Saved getting an appointment with the doctor	15	27
Got what they needed/very effective prescription	12	6
Nurse was as good and as convenient as the doctor	9	22
Nurses were trained and qualified	9	12
Trusted the nurse's judgement	9	-
Nurses were easier to talk to than doctors	7	8
Saved the doctor time	3	-
Repeat prescription/didn't need a doctor	2	4
Other	4	7
Reasons for dissatisfaction
Prefer doctor/doctor better qualified	3	1

*Base: 2004 113 (unweighted 98) and 2007 156 (unweighted 163)

7.15 In both surveys the primary reasons given for satisfaction with nurse prescribing were associated with the ease and rapidity of access to nurses rather than doctors. By the 2007 survey confidence in nurses as prescribers seems to have increased with an increase in the proportion of respondents reporting that nurses were as good and convenient as the doctor and that nurse were trained and qualified.

7.16 Trusting the nurse's judgement did not appear as a category in the 2007 survey and may have accounted for the increase in the proportion of the previous two reasons for satisfaction.

7.17 Only 3% of respondents in the 2004 survey and 1% in the 2007 survey thought they should have received a prescription from a doctor rather than a nurse.

Comparison of nurse and doctor prescribing

7.18 All those surveyed who had been prescribed medicines by a nurse, health visitor or midwife were asked how this compared to being prescribed medicines by a doctor.

Table 7.4 Comparison of nurse/doctor prescribing*

	2004	2007
	%	%
Much better	9	16
Bit better	14	12
About the same	72	69
Bit worse	3	2
Much worse	1	-
Don't know	2	1
Total	101*	100

* Base: 2004 120 (unweighted 103) and 2007 160 (unweighted 168)

** Totals may not add up to 100 due to rounding.

7.19 There was little difference in the response between the two surveys. More than two thirds of respondents in both years of survey felt their experience of nurse prescribing was about the same as being prescribed medicines by doctors. Although the proportion who felt the experience was about the same dropped slightly in 2007 compared to 2004 (72% compared with 69%) this was more than compensated for in the increase in proportions who felt the experience was a bit better or much better in the 2007 survey (see table 7.4).

7.20 A quarter of all females (25%) and a fifth (20%) of males who had been prescribed medicines by nurses, health visitors or midwives reported that nurse prescribing was much better or a bit better than being prescribed medicines by doctors. The difference between the sexes with respect to nurse prescribing increased in the 2007 survey with 30% or females and 23% of males reporting that nurse prescribing was much or a bit better than being prescribed medicines by doctors.

7.21 The reasons given for finding nurse prescribing experience better or worse than prescribing by a doctor are given in table 7.5.

7.22 Comparisons of the nurse/doctor prescribing experience were very positive in both surveys. Saving time and convenience were the most frequently reported reasons in both 2004 and 2007 surveys as to why respondents felt the experience of nurse prescribing was better than being prescribed medicines by a doctor. In the 2007 survey, respondents were also reporting that nurse prescribing was as good as doctor prescribing and that nurses were easier to communicate with. These reasons did not appear in the 2004 survey and may be an indication that by 2007 respondents had had more experience of nurse prescribing.

Table 7.5 Reasons for finding nurse prescribing better or worse than GP prescribing*

	2004	2007
	%	%
Quicker/easier/saves time	49	32
Nurse has more time than doctor	16	-
Saved getting an appointment with a doctor	0	28
Nurse easier to talk to/communicate with than doctors	0	14
Repeat prescription/don't need doctor	0	2
Convenient/satisfied/as good as a doctor	0	17
Other	15	4
Prefer GP/ GP better qualified	10	7
Don't know/not stated	10	2

*Base: 2004 32 (unweighted 28) and 2007 48 (unweighted 50)

Benefits of nurse prescribing for patients

7.23 In the 2007 survey respondents identified a number of benefits that had flowed from nurse prescribing in Scotland and listed very few drawbacks. In a number of instances, multiple benefits from nurse prescribing that often were inter-connected were described. Occasionally respondents indicated that nurse prescribers produced a better diagnosis because of the greater time they spent with individual patients. There were contradictory messages too which may have related to the personal contact a patient had with a particular health professional or to the health professionals gender.

7.24 In 2007, respondents reported that the benefits of nurse prescribing related to:

• How the system was able to fulfil patients practical needs - such as the ability to obtain a speedy prescription - not always medication;

"Because all we have to do is phone and ask - it's not like antibiotics though it's more like creams or pads or things like that for the elderly clients"

• The impression that nurse prescribers would free up doctors' time. The assumption being that doctors would then be able to concentrate on other matters important to patients;

"Because you're more likely to see a nurse quicker than a doctor especially for meds. It also takes the pressure off the doctor to treat more serious ailments"

• The time spent with a patient and for some the knowledge that the nurse prescriber appeared to possess about the individual patient. This translated into personalised care;

"You get time to talk over your symptoms more and get the right diagnosis"

"It was instant. It was more thoughtful, it was helpful"

7.25 As stated previously, the findings presented in the preceding sections must be treated with caution as they are based on a small number of respondents. However, benefits of nurse prescribing have been explored in other elements of the study.

Stakeholder perspectives on patient benefits of nurse prescribing

Initial stakeholder interviews

7.26 Initial stakeholder groups interviewed included some patient advocacy groups. They believed there could be significant benefits to patients accruing from nurse prescribing. All stakeholder groups recognised the potential for a wide range of benefits. These included:

• Patient focus;
• Continuity of care over a longer period linked to better integrated patient journeys and holistic care in some cases;
• Quality of care with more time to inform patients, explain diagnoses and discuss treatments for patients and their carers; and
• Patient time and access were improved to prescribing services/staff. This includes access - in surgeries and in out of hours working - for patients and carers.

7.27 Stakeholders were, however, aware that patients might either view nurse prescribers as second rate doctors or not competent. None of the stakeholders interviewed held these views themselves.

Views of patient representative groups

7.28 Patient groups, especially those for chronic conditions, flagged up time issues with regard to GPs who prescribe for them. One UK wide organisation interviewed reported that in their 2006 patients' 'panel', 52% of panel members said they did not feel they got enough time to talk to GPs about medication and specifically about side effects. They hoped that nurse prescribing would improve this situation. In addition, 84% of panel members said they felt comfortable with nurses being able to prescribe (their) medicines.

7.29 Other information from focus groups and interviews conducted for the study revealed the following;

"We think nurse prescribing has the potential to increase accessibility and quality of care with the proviso of appropriate first class training and support, clear lines of clinical accountability and responsibility within health teams, clear lines of communication throughout the health service and equal access to high quality services for all people with (chronic disease condition) and we would want it to be evaluated by clinical outcomes rather than cost effectiveness".(Patient support group)

7.30 There was a clear vision for nurse prescribing by patient representative groups but it was recognised that it needed to be implemented appropriately;

"We do feel that because most people with (the chronic disease) are in touch with practice nurses, we feel that would be the place - for practice nurses to prescribe and discuss medicines and their side-effects".(Patient support group)

"Too few people have medication reviews with GPs - more reviews might happen if there were more nurse prescribers - and this is linked to valuing self management plans' - teaching medication use is part of this package". (Patient support group)

7.31 Nurse prescribing was thought to be of great benefit in the management of long term conditions within primary care;

"We feel that given appropriate training and scope that there would be a crucial role for nurse prescribers with (-) care packages, self management etc". (Chronic disease support group)

"It would appear that many chronic disease patients attend their practice nurses for review. However no patient has reported a practice nurse being able to prescribe- 'it's great seeing a nurse but if they can't prescribe what is the point". (Chronic disease support group)

7.32 For those with chronic conditions, stakeholder groups generally considered that trained nurse prescribers who specialised in a condition would have much to offer. One stakeholder observed that;

"Some people with (disease) would see that being prescribed drugs by their specialist nurse may be a quicker route than waiting to see a consultant. If nurses were prescribing for patients it would be important that this be the specialist nurse who has an in depth knowledge of the condition and the various symptoms that can be experienced".

7.33 For people with long term conditions time issues with GPs were again raised;

"We are also aware of people being prescribed medication but being unaware of what it does or how to take it. This is probably due to the lack of time available within the GP appointment system, but can lead to people with diabetes taking medication inappropriately or not being aware of possible side effects of medication, especially hypoglycaemia. The same is true of devices and monitoring equipment, where something is prescribed but not explained".

"Research from Tayside has shown that the majority of people with diabetes do not collect enough blood glucose testing strips to test even once a day. Perhaps this is partly due to the fact that they have never been taught the importance of testing, nor how to carry out the test".

7.34 One of the stakeholders interviewed (Diabetes UK) considered that nurse prescribing could overcome some of these issues, making access to much needed medication easier and ensuring that appropriate education was available at the time of prescribing.

Views of case study participants

Patient perspectives on nurse prescribing

7.35 The 6 main case studies explored patient views on nurse prescribing in a wide range of settings: primary and secondary care, rural and urban communities, community hospitals and Accident and Emergency. Patient perceptions of the extension and impact of nurse prescribing were remarkably positive across all case studies (see table 3.2 for more information on interviewees).

Awareness

7.36 Patients within the nurse-led specialist service (case study 4) knew more about nurse prescribing than patients in general practice. Interestingly, those patients interviewed in the rural and remote primary care case study were all unaware of nurse prescribing (case study 2), whereas patients in the urban and semi-rural GP practices (case study 1 & case study 3) had some limited knowledge. Levels of knowledge and awareness of nurse prescribing were linked to greater and relevant patient experience within healthcare, particularly amongst those receiving specialist care and those with complex health needs within primary care.

Patient care benefits

7.37 Patients found quicker and easier access to treatment to be the most beneficial aspect of nurse prescribing. Patients experienced - or hypothesised that - nurse prescribing enabled prescriptions to be received quicker and more easily because there was no need to involve the doctor in issuing the prescription. Most patients valued a complete package of care from their nurse prescriber/s rather than having to access GP services. There was an evident degree of trust in nurse prescribers shown by both patients and carers. Such patients and carers had close relationships with the nurse prescribers, leading, they suggested, to patients having confidence in the prescriptions given.

Patient preferences for care

7.38 Quality of care and access was more important to patients than 'who' provides the care. Patients discussed the benefits of having a 'good relationship' with their doctor or nurse. Consequently, some patients who had an established relationship with their GP, particularly older patients, were more likely to see their GP whereas others had established relationships with nurse prescribers, particularly in midwifery and amongst those who preferred to consult a female health professional. A patient in case study 1 described her preference for a GP for her children's health issues, whereas her nurse prescribing midwife was preferred over her GP for any issues relating to her own pregnancy care. Some patients also preferred to see a GP for what they categorised as more serious health conditions; for example Alzheimer's disease, heart conditions and chronic conditions. Other patients perceived nurses and doctors differently: doctors broadly being responsible for diagnosis and treatment and nurses for minor injuries and advice. Patients generally reported satisfaction and positive experiences of care from both GPs and nurses and no major preferences were flagged for nurse prescribing or medical prescribing.

Safeguards

7.39 Patients wanted high nurse prescribing standards through training and assessment but identified practice as a necessary aspect of development. Some patients thought only nurses comfortable with prescribing should undertake the training and others suggested a degree of GP checking of nurse prescriber prescriptions;

"This sounds daft and it's not in relation to me but just in society with so many drug addicts, I think it would have to be very well controlled, you know, checked upon because there are so many devious people nowadays that they could be threatened, just the same as a doctor could but somehow a nurse seems nearer their…you know what I mean"? (patient)

Nurse Prescriber knowledge and training

7.40 Patients were largely positive about nurse prescribing but some questioned whether nurse prescribers had the same level of knowledge as a doctor, particularly on the subject of diagnosis. They emphasised the need for adequate training and supervision. This perspective could be situation dependent and some patients regarded nurses as more knowledgeable in certain areas than doctors and vice versa. Patients were generally more concerned with the health professional's level and area of knowledge with regard to their own medication or condition than they were with job titles. Decisions on whether to consult a nurse or a doctor revolved around perceptions of the health professional's knowledge and expertise in the area;

"[I mean to me a doctor is more responsible in that they have more medical knowledge of the conditions that people have, than a nurse, you know after all these years of medical school that a nurse wouldn't have but as far as prescribing is concerned if they know basically what the conditions are and know all the backgrounds of the drugs then I'm quite happy and that's what would be the expectation. I don't expect them to have the same knowledge as a doctor but I do as far as treatment is concerned".(patient)

Communication and team-working

7.41 Patients valued team-working within healthcare and were eager for different health professionals to communicate about their care. One patient (case study 4) described his preference for hospital-based medical staff and nurses to make joint decisions on his specialist care.

"What I would imagine would be that nurses keep in touch with doctors occasionally and discuss patients sort of thing…I think it would be to the nurses advantage to consult with the consultant occasionally you know".(patient)

7.42 Some patients also discussed the benefit of GPs being able to 'back-up' the prescribing decisions of nurses so that joint decisions could be reached.

Nurse Prescriber views on benefits to patients

7.43 Although the nurse prescribers interviewed worked in a wide variety of geographical and clinical settings, there was a high degree of unanimity about the benefits to patients that they perceived flowed from nurse prescribing activities.

Improvements in patient care

7.44 There was a general view that aspects of care were being carried out better by nurse prescribers than by GPs, particularly in relation to the specialist nurse-led service and the set-up of specialist clinics within GP practices. For example, in the specialist service (case study 4), recommendations for long-term medication were not always followed-up and acted upon in primary care. Nurse prescribing in this area should ensure that patients were up to date with their medication and in receipt of continued care from the service. Non-prescribing nurses held the same opinion and felt more confident that their recommendations would be acted upon because nurse prescribers are able to follow through the full care of their patients. In the past there had been cases where patients were being 'overlooked' when discharged into the community.

Quicker and more convenient access to treatment

7.45 Nurse prescribers within both general practice areas and acute settings perceived that patients would receive prescriptions quicker. Patients did not have to wait either for a doctor's authorisation or need to make a second appointment with a doctor if a prescription was required. Prompt and convenient access to care was more important to patients than 'who' provided the care;

"I guess most of the patients are completely unaware that we can prescribe……they don't actually care who prescribes for them as long as somebody does…… I guess the way they would notice it now was if we couldn't prescribe and we were saying you are going to have to wait until, you know the GPs not here on a Wednesday, so you're going to have to wait until tomorrow before we can order anything for you and that means it is going to be next week before it gets to you". (Rural nurse prescriber)

7.46 This was particularly true in the case of home visits in primary care where patients did not have any contact with the health centre at all when receiving prescriptions. The nurse prescribers reported that patients were pleased that trips to the health centre were not required.

7.47 Nurse prescribing had brought time and convenience benefits to patients, particularly in rural and remote areas (case study 1, case study 2 and case study 5) and especially where patients had to travel long distances or for long periods of time to hospital for out of hours care.

Complete package of care

7.48 Patients benefited from a more complete package of care, particularly in respect of carers who could now get everything they needed from the one person;

"I think all, all round you'll see that the patients are really happy that nurses can prescribe things, things that they are needing every day to provide, especially carers, to provide that package of care that they need. They're really relieved that nurses can do it. At first, I think they thought it was quite basic but then I think they realised it's really quite important that we can look after all these things".(independent nurse prescriber)

7.49 Community midwives (case study 1) found similar benefits because pregnant women did not have to see their GP and could get complete care from the community midwives.

7.50 Patients also had more options in relation to care with a nurse prescriber than they would have had with a GP who had greater time constraints. Patients' confidence in their own care would rise because they had contributed to the care decision-making process. Patient knowledge about nurse prescribing had increased and patients were more aware than they used to be that they could access the care that they needed through nurse prescribers as well as GPs.

Approachability

7.51 For midwifery (case study 1), it was believed that the current female prescribing team would be of benefit in relation to female issues, in terms of pregnancy and wider medical matters. For adolescent girls seeking emergency contraception, this might also apply. For example if there was only one GP in the practice who was male.

7.52 Nurse prescribers obtained more information from patients and had more time to spend with them. Hence patients had new or changing expectations of nurses in the sense that they now expect nurses to listen to them and so held them in different "esteem" to doctors;

"We do have a bit more time because it you are seeing somebody for wound care or whatever it is, we do have more time with them and patients tend to talk and confide and they just have, I think patients just expect nurses to listen to them. I think their expectations…they hold doctors in a different esteem altogether and they are always aware that every day they are rushed, whereas they don't see us in the same light at all. So I think we get more from patients informally than a doctor would". (Nurse prescriber)

7.53 This community nurse linked the benefits to the closer non-verbal aspects of nursing care, for example because they are more likely to touch patients during care and are therefore seen to have a more tactile relationship.

Patient education

7.54 Several nurse prescribers considered that they placed greater emphasis on patient education than their medical counterparts and hence would benefit patients further;

"Part of our role is for education as well for patients but I think we're at least giving them a bit of education about their tablets and what the effects are, whereas I think a lot of the time when they come into hospital they get started on tablets, nobody tells them what it is, why they are taking it or anything about that and I think you know at least that patient will ask questions and the majority of them know why they are taking these tablets. Before, I don't think they did". (Nurse prescriber)

Views of other health professionals

7.55 This next section brings together views of several different health professional groups on the benefits of nurse prescribing to patients.

Impact of nurse prescribing

7.56 GPs reported difficulty in assessing nurse prescribing impacts within practice, including effects on patient care because GPs were unaware of how much prescribing was going on and whether it was even being used. One GP reports a "hunch" that catheters were now being prescribed by nurses because he had seen a decrease in his personal prescribing of catheters.

Saving time

7.57 Saving time was mentioned by several groups as a benefit of nurse prescribing. Both GPs and hospital based medical staff reported there may be savings in time waiting for prescriptions for patients in the sense that the time spent waiting for GPs and hospital based medical staff to authorise prescriptions would be taken out of the process. However, some respondents commented that there was a 24 hour turn round of prescriptions within some practice areas.

7.58 Being seen by one professional was also mentioned as a benefit of nurse prescribing by pharmacists. This not only saved time in delivering care but also saved time for both patients and health professionals;

"The patients are benefiting more, I mean simply because you're getting, you can short circuit a lot of the decision-making process…so it's short circuited a lot of things so people can make their own decisions but again it's back to just being able to do your job properly with confidence and if you have the ability to do it, do it".(Pharmacist)

7.59 Non prescribing nurses also reported that the main benefit to patients of nurse prescribing could be the 'one stop' professional. This view was re-iterated by paediatric nurse prescribers

7.60 Practice managers found nurse prescribing benefits were associated more with time-saving issues than improvement in patient care. Patients received prescriptions more quickly but they felt patient care was not affected. Time issues could be important in for example compliance with treatments.. One practice manager (case study 1) considered that patients may follow through treatment if they received their prescription without having to wait. If patients had to wait for treatment, they were more likely to leave prescriptions.

Appropriate prescribing

7.61 There was a GP perception that nurse prescribing within competency areas, particularly in dressings, meant that patients were more likely to obtain the correct quantity of the prescription that they needed. For example where GPs were unsure of whether requests were in terms of "boxes or pieces". In addition it was felt that there were instances where the nurse prescribers placed more emphasis on appropriateness;

"…you are more likely to find nurses are more particular about appropriateness than we are…frequently in consultations they (nurses) come up with something that you know I haven't heard of. So it's almost getting to know that kind of nurse perspective on things". ( GP)

7.62 Non-prescribing nurse were also of the view that in some areas for example, dressings and nurse-led service areas, nurse prescribers' knowledge was superior to that of many doctors so patients would benefit from this expertise.

Summary and conclusions

7.63 Across the 4 data collection sources - case studies, omnibus surveys, nurse prescriber surveys and stakeholder interviews - there was a remarkably high level of concordance relating to the benefits nurse prescribing could deliver for patients and demonstrated some reliability in the project findings. There was also a high level of agreement between patients, the public, nurse prescribers, physicians and other health professionals and health managers about the benefits of nurse prescribing to patients.

7.64 The time benefits were clear, the continuity of care element appeared important, and the thoroughness and patient safety concerns of the nurse prescribing process were suggested. Less clear was the evidence for other factors noted in the chapter. The workload and 'overload' problems of GPs seemed strong in patient and public perceptions and were perhaps accurate in terms of the 10/15 minute consultations that are the norm for GP.

7.65 The 'connected' perception that nurses were less busy and therefore have more time to prescribe was not well evidenced. With the extension of nurse prescribing, patients assumed that nurses must have more time or have re-allocated their roles to free up time for the new tasks. How exactly this was working and how raised patient expectations of access to nurses for prescribing will impact on nurses in the future is unclear. The perceptions here may not be correct but they are real and they are important influences on patients. As expectations may be raised about both the number and powers of nurse prescribers, it will be necessary for patients to be re-assured that resources are available to maintain if not build on nurse prescribing activity.

7.66 Historically, the 'care' element of nurses' work would have translated into more nurse conversations with patients and hence less 'remoteness' than GPs. This was where the observations about better patient education through nurses and perhaps better prescribing in certain areas may have emerged. Such education can potentially benefit individual patients, contribute to improved public health and reduce the financial burden on primary and secondary care from avoidable or unnecessarily rapid declines in illness conditions. The perceptions here may not have been correct but they were real and they were important influences on patients. As expectations may have been raised about both the number and powers of nurse prescribers, it will be necessary for patients to be re-assured that resources are available to maintain if not build on nurse prescribing activity. The impacts of nurse prescribing on health service organisations are now examined.