BEST PRACTICE GUIDANCE-SUPPLEMENTARY PRESCRIBING NON MEDICAL PRESCRIBING ADVISOR IMPLEMENTATION DATE: MAY 2009 REVIEW DATE: MAY 2010
Supplementary Prescribing The working definition of supplementary prescribing is: A voluntary partnership between a doctor or dentist and a supplementary prescriber to implement an agreed patient specific clinical management plan (CMP) with the patients agreement. What can be prescribed? There are no legal restrictions as to the clinical conditions that may be managed by a supplementary prescriber. The CMP may include any General Sales List (GSL), Pharmacy (P) or Prescription Only Medicine (POM) that is prescribable on the NHS. This includes: Controlled drugs-except those listed in schedule 1 of The Misuse of Drugs Regulations 2001 that are not intended for medicinal use. Products used outside their UK marketing authorisation (off label use) Drugs that do not have a UK medicinal market authorisation (unlicensed drugs). Best practice would dictate that a supplementary prescriber should agree not to prescribe any medicine outside his/her area of competence. Patient Consent The principle underlying the concept of supplementary prescribing-the prescribing partnership, must be explained in advance to the patient by either the independent or supplementary prescriber. The patient s consent (verbal or written) must be recorded in the CMP prior to entering into a prescribing agreement. Clinical Management Plans Essential Details An agreed clinical management plan (CMP) must be in place before supplementary prescribing can occur. This CMP must be patient specific and relate to the patient s condition which will be managed by the supplementary prescriber. More than one supplementary prescriber can be named on the CMP- a supplementary prescribing team-this may include nurses and prescribers from other professional groups. The CMP should be accessible from the patient record. Legally the CMP must include:
The name of the patient to whom the plan relates The illnesses or conditions which may be treated by the supplementary prescriber Reference to the medicines that may be prescribed by the supplementary prescriber- by named individual medicine or class of medicine. Any restrictions to the dose of the medicine (s) to be prescribed or the length of treatment Relevant guidelines utilised to inform prescribing practice. The circumstances within which the supplementary prescriber can vary the dosage, frequency and formulation of the specified medicines. The circumstances within which the supplementary prescriber should refer back to the independent prescriber. Known sensitivities of the patient to particular medicines Arrangement for notification of any adverse drug reactions The date on which prescribing arrangements commence and the date on which they should be reviewed The formal agreement to the CMP of the independent prescriber, the supplementary prescriber and the patient. Responsibilities Independent Prescriber-Doctor/Dentist The independent prescriber will be responsible for: the initial assessment of the patient, including diagnosing the patient and determining the medicines that may be prescribed by the supplementary prescriber under the CMP Reaching an agreement with the supplementary prescriber about the limits of their responsibility for prescribing and reviewwhich must be detailed in the CMP Carrying out a review of the patient s progress at appropriate intervals depending on the nature and stability of the patient s condition
Providing advice and support to the supplementary prescriber when required Appropriate sharing of the patient record with the supplementary prescriber Reporting adverse incidents within local and national risk management or clinical governance schemes Supplementary Prescriber The supplementary prescriber is responsible for: Working within their clinical competence and code of conduct and accepting professional accountability and clinical responsibility for their practice Prescribing for the patient in accordance with the CMP-this includes altering the medicines prescribed within the limits established in the CMP and monitoring and assessing the patient s progress as appropriate to their clinical condition and medicines prescribed Consulting the independent prescriber when necessary and passing prescribing responsibility back to the independent prescriber if they feel that the patient s condition can no longer be managed competently by them Documenting prescribing and monitoring activity in the patient record as soon as possible after the intervention and ideally within 24-48hrs. Reporting adverse incidents within local and national risk management or clinical governance schemes
References Department of Health, Social Services and Public Safety (DHSSPS) (2004) Best Practice Guidance for Supplementary Prescribing by Nurses within the HPSS in Northern Ireland DHSSPS Department of Health (DoH) (2007) Supplementary Prescribing-Clinical Management Plans DoH http://www.dh.gov.uk/en/healthcare/medicinespharmacyandindustry/prescriptions /TheNon-MedicalPrescribingProgramme/Supplementaryprescribing/DH_4123030 Nicol J (2008) Summary of supplementary prescribing and the use of the Clinical Management Plan (CMP) East and South East England Specialist Pharmacy Services.
Appendix 1 CLINICAL MANAGEMENT PLANS 1. Nurse/AHP template-blank 2. Pharmacist template-blank 3. Nurse/AHP completed CMP 4. Pharmacist completed CMP
NURSE/AHP TEMPLATE CLINICAL MANGEMENT PLAN-BLANK Name of Patient: Patient medication sensitivities/allergies: Patient identification e.g. ID number, date of birth: Independent Prescriber(s): Supplementary Prescriber(s) Condition(s) to be treated Aim of treatment Medicines that may be prescribed by SP: Preparation Indication Dose schedule. Specific indications for referral back to the IP. Guidelines or protocols supporting Clinical Management Plan: Frequency of review and monitoring by: Supplementary prescriber Supplementary prescriber and independent prescriber Process for reporting ADRs: Shared record to be used by IP and SP: Agreed by independent prescriber(s) Date Agreed by supplementary prescriber(s) Date Date agreed with patient/carer
PHARMACIST TEMPLATE CLINICAL MANAGEMENT PLAN-BLANK linical Management Plan atient name: NHS number: DOB: DR/sensitivities: Process for reporting ADRs: edical problem Goals of therapy Treatment Plan Guidelines or protocols Details of medicines that may be prescribed by SP Monitoring Circumstances for referral back to IP supporting CMP greed by dependent escriber: equency of review by dependent prescriber: Date: Agreed by supplementary prescriber: Frequency of review by supplementary prescriber: Date: Agreed with patient date: Shared record to be used by IP and SP
NURSE/AHP COMPLETED CLINICAL MANAGEMENT PLAN Name of Patient: Patient medication sensitivities/allergies: John Brown Patient identification e.g. ID number, date of birth: 07/01/1965 0101 Independent Prescriber(s): Dr. Smith & Partners Condition(s) to be treated Asthma Medicines that may be prescribed by SP: Supplementary Prescriber(s) Nurse 1, nurse 2 and nurse 3 Aim of treatment Control of asthma symptoms, prevention of exacerbations and achievement of best possible pulmonary function, with minimal side effects. Preparation Inhaled short acting beta 2 Agonists Inhaled steroids Long acting beta 2 agonist Leukotreine receptor antagonist Indication Relief of asthma symptoms at step 1 and above Prevention of asthma symptoms at step 2 and above Prevention of asthma symptoms at step 3 and above Dose schedule As detailed in: BNF 57 section 3 BTS/SIGN Asthma Guidelines 2008, chapter 4 (pharmacological management) and chapter 5 (inhaler devices), up to and including step 3. Specific indications for referral back to the IP Diagnosis in doubt Failure to achieve stated aims of treatment at step 3. Prednisolone Acute exacerbation As per BNF and guidelines above Failure to respond to prednisolone in an exacerbation Guidelines or protocols supporting Clinical Management Plan: Practice asthma guidelines Consult practice formulary for first choice of drug and device British Guideline on the Management of Asthma (2008) British Thoracic Society and Scottish Intercollegiate Guidelines Network Fife Formulary Frequency of review and monitoring by: Supplementary prescriber Supplementary prescriber and independent prescriber 3 yearly As indicated by response to Treatment, but no less than annually Process for reporting ADRs: SP to report to IP and record in records. Yellow card notification Shared record to be used by IP and SP: Computerised record Agreed by independent prescriber(s) Date Agreed by supplementary prescriber(s) Date Date agreed with patient/carer
PHARMACIST COMPLETED CLINICAL MANAGEMENT PLAN Clinical Management Plan XXXX Medical Practice Patient name: CHI Number: DOB: ADR/Sensitivities: Process for reporting ADRs: SP to record in patient notes, complete yellow card & inform IP Medical Problem Goals of therapy Treatment Plan Guidelines or protocols Details of medicines that may Monitoring Circumstances for referral supporting CMP by prescribed by SP. back to IP Essential 1. Reduce BP Thiazide diuretics +/- K 1. BP - 4/52 following 1. BP not at target and not 1. SIGN 2007 Hypertension < 140/85mmHg. sparing diuretic initiation of new therapytolerating other agents. 2. BHS IV Guidelines 2004. 2. Promote continued Beta adrenoreceptor and 3-6/12 when stable.2. BP not at target and taking 3 3. NHS Fife ADTC Guidance on adherence to therapy. blocking drugs 2. U+Es - prior to use, agents management of hypertension 3. Reinforce lifestyle Dihydropyridine calcium at each dosage increase3. Unresolved compliance issues 4. Fife Formulary modification to help channel blockers and 4/52 after reaching reduce CVD risk. Alpha adrenoreceptor max tolerated dose. i.e. Smoking cessation blocking drugs diet, exercise, alcohol. Angiotensin converting enzyme inhibitors Angiotensin II receptor antagonists (ACE inhibitors, AIIRAs, diuretics.) Annually thereafter. 3. Blood glucose/ urinalysis annually. Dose schedule as per BNF 57 and British Hypertension Society Guidelines Frequency of review Frequency of review As dictated by monitoring Shared record to be Gpass + paper notes by Independent 12 months by Supplementary and patient progress. used by IP & SP: held in GP surgery. Prescriber: Prescriber: Agreed by Agreed by Date agreed Independent Supplementary with Patient: Prescriber: Date: Prescriber: Date: