Non-Medical Prescribing Policy

Non-Medical Prescribing Policy Document Description Document Type Policy Service Application Primary Care Version 1.0 Ratification date July 2016 Review date July 2018 Lead Author(s) Clair Huckerby Sukvinder Sandhar Pharmaceutical Adviser and Medicines Optimisation Lead Primary Care Pharmacist Change History Version Date Comments Reviewers - This Document has been reviewed by Version Date Name Title/Responsibility 0.1 June 2016 Jas Johal Pharmaceutical Consultant 0.1 July 2016 Prescribing Sub Dudley CCG Committee Version Date Name Title/Responsibility 1.0 July 2016 Dr D Jenkins Chair, Area Clinical Effectiveness Committee DOCUMENT STATUS: This is a controlled document. Whilst this document may be printed, the electronic version posted on the intranet is the controlled copy. Any printed copies of the document are not controlled 1

Ref. Contents Page 1.0 Introduction 3 2.0 Aims and Objectives 3 3.0 Scope 3 4.0 Duties 3 5.0 Categories of Non-Medical Prescribing 4 6.0 Criteria for NMPs to prescribe 5 7.0 Application Process for Non-Medical Prescribing 6 8.0 Verification and Authorisation to Prescribe within Dudley CCG 6 9.0 Prescriptions 7 10.0 Legal and Clinical Liability 9 11.0 Pharmaceutical Industry 9 12.0 Record Keeping 9 13.0 Prescribing Errors 9 14.0 Adverse Drug reactions 10 15.0 Drug Alerts and Recalls 10 16.0 Competency Framework for Prescribers 10 17.0 Continuing Professional Development 10 18.0 References 11 Appendices 1.0 Appendix 1:Review of Activity and Scope of Practice 11 2.0 Appendix 2: Non-medical prescriber Joining a GP practice or code centre 11 3.0 Appendix 3: Non-medical prescriber Leaving a GP practice or code centre 11 2

1.0 Introduction The NHS Plan in 2000 highlighted the need to organise and deliver services around the needs of patients. As part of this commitment, prescribing expanded to allow a wider group of health care professionals to undertake prescribing roles. Prescribing practice within the NHS today consists of medical prescribing by doctors and non-medical prescribing by specially trained nurses, pharmacists and allied health professionals such as physiotherapists, opticians and podiatrists. Under current legislation nurses, pharmacists, physiotherapists, podiatrists and optometrists can all undertake a further qualification to become an independent prescriber. Nurses can also undertake training to become community practitioners. Non-medical prescribing can improve patient care by ensuring timely access to medicines and treatment for patients who would otherwise have to wait to see a doctor; it also releases doctors to care for patients with more complex health care needs. This Policy explains how non-medical prescribing operates within Dudley Clinical Commissioning Group (CCG). 2.0 Aim and Objectives The aim of this policy is to promote legal, safe and effective non-medical prescribing and to support the development and implementation of non-medical prescribing throughout the CCG. Objectives Provide clear guidance to support Non-Medical Prescribers (NMPs) in prescribing safely, efficiently, cost effectively and within their area of competence. Define the process for the implementation of NMP within the CCG. Ensure that all NMPs are supported to prescribe safely and effectively within an agreed framework that is consistent across the CCG. This policy should be read in conjunction with other local policies (available on the Dudley CCG intranet site) and relevant professional body s guidance on non-medical prescribing and medicines management. 3.0 Scope This policy applies to all activities related to non-medical prescribing undertaken by NMPs employed by Dudley CCG and its member practices ((including independent contractor staff). This includesnurse Independent /Supplementary Prescribers and Pharmacist Independent /Supplementary Prescribers. 4.0 Duties Non-Medical Prescriber The NMP must act in accordance with the standards set by their registering and professional body for prescribing and comply with their registration requirements. The prescribers must act within their own professional competence and expertise when prescribing and work in line with local guidance (or evidence-based national guidance approved locally e.g. NICE) and the local formulary. 3

The prescriber must be able to justify any action or decision not to act, taken in the course of their professional practice; Maintain a portfolio of their Continuing Professional Development & identify individual training needs with the relevant employing practice/line or commissioning manager see section 11.6 It is recommended that each NMP updates the employing practice or their line / commissioning manager by completing the Activity Review and Scope of Practice Agreement (Appendix 1) on an annual basis or as any changes to practice/ prescribing occur. NMPs must ensure that patients are aware they are being treated by a NMP and the scope of their prescribing practice may mean referral onto another health care professional if necessary. GP Practice/Line/ Commissioning Manager As the employing practice/commissioning manager has a legal responsibility for the quality of care and patient safety, they must ensure: the NMP has the adequate skills and knowledge to carry out the role the NMP is registered with the NHS Business Services Authority (NHSBSA) include an accurate summary of the NMP s prescribing responsibilities within the job description/service level agreement Support appropriate Continuing Professional Development (CPD). It is recommended that during annual PDRs or the equivalent contract review, an activity and scope of practice review is conducted (see Appendix 1) this will include: - an outline of clinical responsibility - evidence of competency as described in the Single Competency Framework for all Prescribers. NMP Lead The NMP lead will provide leadership for and have oversight of: NMP educational events NMP prescribing trends fitness to practice requests from NHS England Registration of NMPs with the NHSBSA collaborative working with higher education institutes 5.0 Categories of Non-medical Prescribing 5.1 Independent Non-Medical Prescribing Independent prescribers are nurses, pharmacists and physiotherapists who have completed a prescribing programme and have a recordable qualification on their professional register. An independent non-medical prescriber takes responsibility for undertaking a clinical assessment of the patient, establishing a diagnosis/impression and developing a clinical management plan, as well as responsibility for prescribing where necessary and the appropriateness of any prescription. An independent non-medical prescriber is also responsible for accurate documentation. 5.2 Supplementary Prescribing Supplementary prescribing is a three-way voluntary partnership between the patient, an independent prescriber (doctor, dentist) and a supplementary prescriber who has completed the necessary education and training. Between them, the independent and supplementary prescribers should draw up and agree an individual Clinical Management Plan for each patient before supplementary prescribing begins. 4

The independent prescriber and supplementary prescriber will jointly agree which patients may benefit from supplementary prescribing and which medicines the supplementary prescriber will prescribe under the terms set out in the clinical management plan. Each clinical management plan must have the agreement of the patient before supplementary prescribing can commence. Supplementary prescribing is designed to enable the supplementary prescriber to take on the medium to long-term management of an individual patient. However, if a patient moves from one independent prescriber to another the supplementary prescriber may not continue to prescribe, unless they are able to negotiate and record in the patient record a new agreement to enter into a prescribing partnership with the new independent prescriber. 5.2.1 Clinical Management Plans Clinical management plans (CMPs) are a legal requirement for supplementary prescribing. The Department of Health guidelines on creating CMPs can be accessed on: http://webarchive.nationalarchives.gov.uk/20130107105354/http://www.dh.gov.uk/assetroot/ 04/11/00/33/04110033.pdf http://webarchive.nationalarchives.gov.uk/+/www.dh.gov.uk/en/healthcare/medicinespharma cyandindustry/prescriptions/thenon- MedicalPrescribingProgramme/Supplementaryprescribing/DH_4123030 Examples of templates for CMPs that can be used to develop personalised plans can be accessed on http://www.dh.gov.uk/assetroot/04/06/84/28/04068428.rtf http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digital asset/dh_4068428.rtf 6.0 Criteria for NMPs to Prescribe Practitioners who satisfy ALL the following conditions will be entitled to prescribe within Dudley CCG: Works within a GP practice or within Primary care in the CCG area Has access to a budget from which to prescribe Is authorised/required by the employing body to prescribe Has successfully completed an approved prescribing / extended prescribing training course Is registered with the appropriate regulatory body (e.g. NMC, GPhC) as a prescriber Is registered with the NHSBSA Has appropriate indemnity insurance in place to cover activities related to prescribing NMPs may only prescribe in their area of competence with agreement of their employer and this must be reflected in the NMP s job description/service level agreement/service specification. NMPs must maintain their level of competence in the areas in which they prescribe and actively engage in continuing their professional development. 7.0 Application Process for the Non-Medical Prescribing Qualification It is the decision of the employing organisation with the guidance of the NMP Lead to determine whether a practitioner is put forward for the training programme. Applicants 5

should seek the support of their line manager in the first instance additionally the signature and support of the NMP lead at the CCG. 7.1 Designated Medical Practitioners The potential candidate for non-medical prescribing training must have a Designated Medical Practitioner (DMP). He or she must fulfil the criteria requirements for a DMP as outlined by individual non-medical prescribing course. The DMP will work with the trainee prescriber throughout their period of training. At the start of the training, an agreement should be put in place between the DMP and the trainee NMP on how this will work in practice. The DMP should have the support of the employing organisation or the GP practice to undertake the role and provide supervision support and opportunities for the development of competence of the student in prescribing practice. 8.0 Verification and Authorisation to Prescribe within Dudley CCG The CCG s non-medical prescribing lead has responsibility for overseeing the process of registering the patient with the NHSBSA. The NMP is required to complete the Non-medical prescriber Joining a GP practice or cost centre form (Appendix 2) and forward to the NMP lead for registration. 8.1 Newly Recruited NMPs Qualified NMPs recruited into the CCG to posts that require them to prescribe, will be required to provide evidence of their authority to prescribe, see section 8.3. It is recommended that NMPs complete the Activity Review and Scope of Practice form (Appendix 1) to declare their competence to prescribe, eligibility to prescribe and define their scope of prescribing practice. The NMP is required to complete the Non-medical prescriber joining a GP practice or cost centre form (Appendix 2) and forward to the Non-medical prescribing lead who will register the NMP with the NHS Business Services Authority. When registration is completed the NMP is able to prescribe. 8.2 Existing Non-Medical Prescribers To provide on-going assurance of their authority to prescribe, all existing NMPs are required to inform their employing organisation/line / commissioning manager if their job role changes, or if they acquire new skills and knowledge that would affect their prescribing practice. Therefore they are required to:- a) discuss at annual PDRs of any change in practice that could affect their prescribing practice b) it is recommended that the Activity Review and Scope of Practice Agreement form (Appendix 1) is completed as part of the PDR. c) attend at least one of the CCG s non-medical prescribing updates each year (or equivalent). 8.3 Authority to Prescribe Only qualified NMPs who are authorised by their employing organisation and following notification to the NHSBSA are registered to prescribe. All NMPs will be required to provide evidence of their: - eligibility to prescribe - registration that they are on their professional body s register 6

- competence and scope of practice to prescribe Non-medical prescribers are accountable for their own actions and must practice within their scope of practice and undertake further training to expand their scope of practice as necessary. - Nurses must act within the Nursing & Midwifery Council s Code of Professional Conduct, Standards and Ethics - Pharmacists must act within the General Pharmaceutical Council s Standards of Conduct, Ethics and Performance - Physiotherapists must act within the standards laid down by the Health and Care Professionals Council They must recognise when clinical problems are beyond their competence and seek advice and refer to other professionals with more clinical expertise. 8.4 Prescribing reflected in Job Descriptions Relevant job descriptions, person specifications, service level agreements should include a clear statement that prescribing is required as part of the duties of the role or service. All NMPs should ensure that their current job description, person specification and service level agreement adequately covers their prescribing role. Pay arrangements for staff covered by the NHS Terms and Conditions of Service Handbook (Agenda for Change) do not provide for additional remuneration to be paid to non-medical staff who undertake a prescribing role. 8.5 Changes in Prescriber s details If a NMP is no longer carrying out prescribing duties, e.g. has left employment, been suspended, or had his/her approval as a prescriber withdrawn for some reason, it is the responsibility of the NMP and their line manager to inform the NMP lead using the Nonmedical prescriber leaving a GP Practice or Cost Centre form (Appendix 3) in order to inform the NHSBSA. 9.0 Prescriptions 9.1 Issuing Prescriptions An independent prescriber can only issue a prescription for a patient whom they have assessed for care and should only write or print on a prescription bearing their own unique prescriber number. In addition supplementary prescribers should only prescribe for a patient who has an agreed CMP. Staff qualified to prescribe should not issue prescriptions on behalf of colleagues. Accountability for the prescription rests with the NMP who has issued the prescription. 9.2 Writing Prescriptions When possible, prescriptions should be computer generated. 9.3 Controlled Drugs Independent pharmacist and nurse prescribers can prescribe, administer and give directions for the administration of schedule 2, 3, 4 and 5 controlled drugs within their competence. Neither independent pharmacist nor nurse prescribers will be able to prescribe diamorphine, dipipanone or cocaine for treating addiction but may prescribe these items for treating organic disease or injury. 7

Supplementary prescribers: Nurse, pharmacist, podiatrist, physiotherapist, radiographer and optometrist supplementary prescribers can prescribe any schedule 2-5 controlled drugs for any condition within their competence, as part of a patient specific, written clinical management plan (CMP) agreed with a doctor. Legal requirements for prescription writing must be followed refer to: the guidance from respective professional bodies, A guide to the good practice in the management of controlled drugs in primary care (England) http://www.npci.org.uk/cd/public/docs/controlled_drugs_third_edition.pdf The BNF - Prescription Requirements within the Controlled Drugs and Drug Dependence section. 9.4 Prescribing Medicines for Off-label/Un-licensed Use Nurse and pharmacist independent prescribers may prescribe medicines independently for uses outside their licensed indications/uk marketing authorisation (off-license/off-label) within their area of competence. They accept professional, clinical and legal responsibility for that prescribing, and should only prescribe off-label where it is accepted clinical practice. The prescriber should explain to the patient/guardian that the medicine is being used offlicense. Where a patient is unable to agree to such treatment, the prescriber should act in accordance with best practice in the given situation and within the policy/formulary of the organisation. Supplementary prescribers may prescribe products used outside their UK licensed indications. Any use of a medicine outside its product license must have the joint agreement of both the supplementary and independent prescribers and the status of the drug should be recorded in the clinical management plan. 9.5 Repeat Prescribing All prescribers are required to adhere to local/practice repeat prescribing policies NMPs should ensure patients are given regular medication reviews in line with local Medication Review Best Practice Guidelines. Supplementary prescribers need to review and prescribe in line with the clinical management plan. The patient should be seen with the independent prescriber at least once every 12 months. Unless more frequent reviews with the independent (medical) prescriber have been quoted on the clinical management plan. The NMP will be responsible for repeat prescribing during the period that they actively treat or manage the patient. Once they cease to do this responsibility will revert back to the GP. Before any treatment is given to a patient as a regular repeat prescription the prescriber must ensure they are satisfied that is it safe and appropriate to do so. The patient should always be involved in the decision to continue treatment. NMPs may issue a repeat prescription, but they do so in the knowledge that they are responsible as the signatory of the prescription and are professionally accountable for their practice. Before signing a repeat prescription the NMP must be satisfied that: It is safe and appropriate to do so and that secure procedures are in place to ensure that the patient /client are issued with the correct prescription. Each prescription is regularly reviewed and is only re-issued to meet clinical need. A regular review takes place, usually at either 3 to 6 monthly intervals or in line with the GP practice prescribing policy. Suitable provision is in place for monitoring each patient/client s condition and monitoring is up-to-date. 8

9.6 Prescribing for Self, Family, Friends and Colleagues NMPs must not prescribe for themselves, and should avoid prescribing for family, friends and colleagues. Where it is necessary to prescribe for friends, family or colleagues this should only be undertaken in the context of that friend, relative or colleague being seen in a professional capacity e.g. where a friend, family or colleague is also a registered patient. 9.7 Security and Loss and Destruction of prescription pads Prescriptions are controlled stationary and should be kept securely in line with the GP Practice prescribing policy. 10.0 Legal and Clinical Liability All NMPs and employers of NMPs should ensure that the NMP has adequate professional indemnity insurance to cover prescribing activity. Each NMP is professionally accountable for their prescribing decisions, including actions and omissions, and cannot delegate this accountability to any other person. 11.0 Pharmaceutical Industry NMPs should only prescribe those medicines they know are safe and effective for the patient and the condition being treated. They must be able to recognise and deal with pressures e.g. from the pharmaceutical industry, patients or colleagues that might result in inappropriate prescribing. Should a practitioner experience conflict between their practice and local policy, there is a clear responsibility on the practitioner to address this with relevant approving committee for the policy in question. It is good practice for all NMPs to make an annual declaration of interest to their employer and maintain an up to date register of any other employment or engagement with external bodies, including any gifts, inducements and hospitality received.. 12.0 Record Keeping All health professionals are required to keep accurate, legal, unambiguous and contemporaneous records of a patient s care. Details of the prescription and any consultation with the patient should be entered onto the patient s care record at the time of the event or as soon as possible after the event. 13.0 Prescribing Errors To reduce the potential for errors NMPs must not dispense nor administer medication they have prescribed. NMPs must report all prescribing errors as incidents via the Datix system, reporting to the NMP Lead at the earliest opportunity. 14.0 Adverse Drug Reactions If a NMP suspects that a patient is experiencing/has experienced a drug reaction to a medicine or combination of medicines, the NMP (if a supplementary prescriber) will inform the clinician responsible for the patients continuing care. The NMP will evaluate the suspected adverse drug reaction in accordance with the guidance issued by the Committee on Safety of Medicines and decide if a yellow card needs completing to notify the committee of a suspected drug reaction. All serious suspected reactions to established drugs and all suspected adverse reactions to black triangle drugs should be reported through the Yellow Card Scheme at www.yellowcard.mhra.gov.uk. 9

15.0 Drug Alerts and Recalls Drug alerts and recalls via the Central Alerting System (CAS), a web-based cascading system for issuing patient safety alerts, important public health messages and other safety critical information and guidance to the NHS, are disseminated to relevant clinical staff including NMPs. The NMP lead will cascade to any pharmacist prescribers. All NMPs must ensure that they read and take appropriate action in relation to these alerts. 16.0 Competency Framework for Prescribers The competency framework (illustrated below) sets out what good prescribing looks like. Within each of the ten competencies there are statements which describe the activity or outcomes prescribers should be able to demonstrate. Prescribers are advised to formally review their prescribing competencies on an annual basis at least. The template of the framework is available can be downloaded from: www.rpharms.com/prescribingframework 17.0 Continuing Professional Development (CPD) All registered healthcare professionals have a professional responsibility to keep themselves abreast of clinical and professional developments and in line with the recommendations of their professional body. NMPs will be expected to keep up to date with knowledge and skills in the management of conditions for which they may prescribe, while the CCG will support NMPs to have continual access to relevant education and standardise further training provision. NMPs are encouraged to regularly review their prescribing practices and the financial/budgetary implications of their prescribing. The CCG is able to access prescription data electronically (via epact.net) to identify and audit the practice of each NMP. It is the responsibility of prescribers to co-operate with the CCG Pharmaceutical Public Health Team to audit prescribing. 18.0 References 1) DoH. Improving patient s access to medicines: A guide to implementing nurse and pharmacist independent prescribing within the NHS in England. London: DoH 2006 2) General Pharmaceutical Council (2012): Standards of conduct, ethics and performance 10

3) Royal Pharmaceutical Society: A Competency Framework for all Prescribers. Publication date: July 2016 4) Nursing and Midwifery Council (2006): Standards of Proficiency for Nurse and Midwife Prescribers. London. Available at: www.nmc-uk.org 5) BNF 70: September 2015 March 2016 Appendix 1 Annual review of NMP declaration form Appendix 2 Non-Medical Prescriber Joining a Appendix 3 Non-Medical Prescriber Leaving a 11