NON MEDICAL PRESCRIBING POLICY AND PROCEDURES

NON MEDICAL PRESCRIBING POLICY AND PROCEDURES Version: Ratified by (name of Committee): Final Quality and Safety Committee Date ratified: June 2009 Date issued: October 2009 Expiry date: June 2012 (Document is not valid after this date) Review date: November 2011 Lead Executive/Director: Name of originator/author: Target audience: Vicky Preece, Associate Director for Nursing and Therapies Sue Lunec. Senior Pharmaceutical Adviser Non-medical prescribers employed by the PCT or employed by contractors The following policies should be read in conjunction with this document: WPCT Consent to Treatment Policy WPCT Clinical Record Keeping Guidelines If you would like this information in other languages or formats (i.e. large print) please contact the Communications Team on 01905 760020 or email communications@worcestershire.nhs.uk

CONTRIBUTION LIST Key individuals involved in developing the original document and updating with minor changes Name Jane Freeguard Sue Lunec Sue Warner Vicky Preece Lisa Levy Designation Head of Medicines Management and Pharmacy Senior Pharmaceutical Adviser Associate Director of Provider Services Associate Director of Nursing Associate Director of Provider Services Original policy circulated to the following individuals for comments Name Designation Ursula Hare Prison Cluster Manager Anita Griffiths Practice Development Nurse, Sexual Health Directorate Marie McCurry Associate Director of Provider Services Sandra Hulme Associate Director of Provider Services Little Sarah Acting Smoking Cessation Service Manager Sue LaHiff Matron, Evesham Community Hospital Sue Chauhan PCT pharmacist Linda Ingles Matron, Malvern Community Hospital Deborah Narburgh Team Leader, Wyre Forest Community Unit. Ginny Snape Matron, Tenbury Community Hospital Maria Wilday Matron / Hospital Manager, Princess of Wales Community Hospital Karen Young Matron Pershore Hospital Lesley Way Patient Safety Officer Carol Clive Infection Control Consultant Nurse PCT Non-medical Prescribing Forum Page 2 of 26

CONTENTS 1. Introduction 4 2. Authority to Prescribe 4 3. Legal Requirement 3.1 Community Practitioner Nurse Prescribers 4 3.2 Nurse and Pharmacist Independent Prescribers 5 3.3. Supplementary Prescribers 5 4. Specific Prescribing Arrangements 5 4.1 Controlled Drugs 5 4.2 Prescribing licensed medicines for unlicensed uses, so-called off-label 6 4.3 Unlicensed medicines (products without a UK marketing authorisation) 7 4.4 Borderline Substances 7 4.5 New Drugs on the market 7 4.6 Private Prescriptions 7 4.7 Appliances / Dressings in Part IX of the Drug Tariff 8 5. Selection of nurses, pharmacists and allied professionals for training 8 6. Notification of qualification to prescribe 9 7. Prescription forms 9 8. Ordering of prescription pads 10 9. Security of the prescription pad 11 10. Loss or Suspected Theft of the prescription pad or forms 11 11. Good Practice, Ethics and Common Prescribing Issues 12 11.1 Prescribing decisions 12 11.2 Who to write prescriptions for 12 11.3 Informing patients 12 11.4 Prescribing for self, family and friends 13 11.5 Completing a prescription form 13 11.6 Dispensing and administration of prescribed items 14 11.7 Verification of prescribing status 15 12. Record Keeping 15 13. Adverse Reaction Reporting 16 14. Legal & Clinical Liability 16 14.1 Liability of prescriber/professional indemnity 16 14.2 Liability of employer 17 15. Budget Setting and Monitoring 17 16. Clinical governance in independent prescribing 18 16.1 Continuing Professional Development 18 16.2Non medical Prescribing and the BNF/Drug Tariff 18 17. Policy Monitoring 18 18. References 19 Appendix A - Non Medical Prescribing Procedures 20 Appendix B: Approval of Non-Medical Prescribers Competence and Scope of Practice 21 Appendix C - Order Form FP10 Prescription Pads Non Medical Prescribers 24 Page 3 of 26

Policy and Procedures for Non Medical Prescribing 1. INTRODUCTION The aim of this document is to promote legal, safe and effective non medical prescribing. The Prescribing Procedures relating to this Protocol form an addendum to Worcestershire Primary Care Trust s Medicines Policy. Prescriptions must communicate information to many people in a standard and clear way that cannot be misinterpreted. Please refer to the prescribing section of the PCT Medicines Policy and the British National Formulary for details of prescribing procedures. 2. AUTHORITY TO PRESCRIBE Only qualified non medical prescribers employed by Worcestershire PCT or working on behalf of Worcs PCT, or employed by General Practices within Worcestershire are authorised to prescribe. They must be registered with the PCT Medicines Management Team. Prescribing may only be for patients registered with GPs in Worcestershire or GPs in border PCTs with whom the PCT has a contractual agreement. Non medical prescribers employed within the Sexual Health Service may prescribe to all patients attending for treatment. Non medical prescriber within the prison service may prescribe for all inmates as appropriate. The PCT Medicines Management Team will maintain a register of non medical prescribers in Worcestershire; all prescribers will be required to provide evidence of their eligibility to prescribe and provide management agreement of their competence and scope of practice. Qualified non medical prescribers include Community Practitioner Nurse Prescribers, independent prescribers and supplementary prescribers. All Prescribers must work within their own level of professional competence and expertise, and must seek advice and make appropriate referrals to other professionals with different expertise. Prescribers are accountable for their own actions, and must be aware of the limits of their skills, knowledge and competence. Nurses must act within the NMC Code of professional conduct: standards for conduct, performance and ethics. Pharmacists must act within the Royal Pharmaceutical Society of Great Britain s Code of Ethics and Standards. 3.0 LEGAL REQUIREMENTS 3.1 Community Practitioner Nurse Prescribers (formerly known as District Nurses and Health Visitors) They may prescribe independently from a limited formulary of products designed to meet the needs of their patients (the Nurse Prescribers Formulary for Community Practitioners). This consists of appliances, dressings and some medicines, including a small number of Prescription Only Medicines (POM). Details of the Formulary are set out in both the British National Formulary and the Part XVIIB (i) of the Drug Tariff. The appropriate training for prescribing from this Formulary is now incorporated into the basic training of all District Nurses (DN) and Health Visitors (HV) and is planned for other community nurses. Page 4 of 26

Community Practitioner Nurse Prescribers may not prescribe unlicensed products or medicines outside of their product license off-label except for nystatin off-label for neonates. Where Community Practitioner Nurse Prescribers are absolutely clear that the diagnosis is one of oral thrush, they may prescribe nystatin at the dose recommended in the Childrens BNF (100 000 units 4 times daily after feeds). An exception for nystatin is allowed on the basis that there is no systemic absorption of the product and the use of the product in treatment of oral thrush is long-established. 3.2 Nurse and Pharmacist Independent Prescribers A Nurse Independent Prescriber (formerly Extended Formulary Nurse Prescriber) must be a 1st level Registered Nurse, Registered Midwife or Registered Specialist Community Public Health Nurse whose name in each case is held on the Nursing and Midwifery Council professional register, with an annotation signifying that the nurse has successfully completed an approved programme of preparation and training for nurse independent prescribing. A Pharmacist Independent Prescriber must be a registered pharmacist whose name is held on the membership register of the Royal Pharmaceutical Society of Great Britain (RPSGB), with an annotation signifying that the pharmacist has successfully completed an education and training programme accredited by the RPSGB and is qualified as an independent prescriber. Nurses and pharmacists who have successfully completed an independent prescribing course can prescribe any licensed medicine within the specific arrangements listed below. 3. 3 SUPPLEMENTARY PRESCRIBING Supplementary Prescribers (nurses, pharmacists, physiotherapists, radiographers, chiropodists/ podiatrists and optometrists) can prescribe in partnership with a doctor (or dentist). Supplementary prescribers are able to prescribe any medicine, including Controlled Drugs, unlicensed medicines and off-label medicines that are listed in an agreed Clinical Management Plan. All supplementary prescribers may prescribe for any medical condition, provided that they do so under the terms of a patient-specific Clinical Management Plan (CMP) agreed with a doctor, dated and with a specified review date. The Plan will be drawn up, with the patient s agreement, following diagnosis of the patient. Supplementary prescribing may well still be the most appropriate mechanism for prescribing, for instance where a nurse or pharmacist is newly qualified as a prescriber or where a team approach to prescribing is clearly appropriate, or where a patient s Clinical Management Plan includes certain Controlled Drugs or where the nurse or pharmacist wishes to prescribe a new drug on the market. There are no legal restrictions on the conditions that may be treated under supplementary prescribing, although it is expected to be used for the management of chronic medical conditions. PCT employees should contact the Medicine Management Team for help with clinical management plans. 4. SPECIFIC PRESCRIBING ARRANGEMENTS 4.1 Controlled Drugs Nurse independent prescribers may prescribe some Controlled Drugs but currently Pharmacist Independent Prescribers may not currently prescribe any Controlled Drugs (community pharmacists can sell Schedule 5 Controlled Drugs). Prescribers are reminded Page 5 of 26

that diazepam and nitrazepam are schedule 4 controlled drugs and temazepam is a schedule 3 controlled drug. Nurse and pharmacist supplementary prescribers are able to prescribe any medicine, including Controlled Drugs, unlicensed medicines and off-label that are listed in an agreed Clinical Management Plan. Nurse Independent Prescribers are able to prescribe Controlled Drugs, solely for the medical conditions indicated: Palliative care - diamorphine, morphine, diazepam, lorazepam, midazolam, or oxycodone, buprenorphine or fentanyl for transdermal use; Pain relief in respect of suspected myocardial infarction - diamorphine or morphine Acute or severe pain after trauma including in either case post-operative pain relief - diamorphine or morphine ; Treatment of initial or acute withdrawal symptoms, caused by the withdrawal of alcohol from habituated persons - chlordiazepoxide hydrochloride or diazepam; Tonic-clonic seizures diazepam, lorazepam, midazolam Other conditions codeine phosphate, dihydrocodeine tartrate or co-phenotrope; The appropriate route of administration for these CDs can be found in the table below: Substance Buprenorphine Chlordiazepoxide hydrochloride Codeine phosphate Co-phenotrope Diamorphine hydrochloride Diazepam Dihydrocodeine tartrate Fentanyl Lorazepam Midazolam Morphine hydrochloride Morphine sulphate Oxycodone hydrochloride Route of administration Transdermal Oral Oral Oral Oral or parenteral Oral, parenteral or rectal Oral Transdermal Oral or parenteral Parenteral or buccal Rectal Oral, parenteral or rectal Oral or parenteral 4.2 Prescribing licensed medicines for unlicensed uses, so-called off-label Nurse and Pharmacist Independent Prescribers may prescribe medicines independently for uses outside their licensed indications/uk marketing authorisation (so called off-licence or off-label ). They must however, accept professional, clinical and legal responsibility for that prescribing, and should only prescribe off-label where it is accepted clinical practice e.g. contraception prescribing off label supported by the Faculty for Sexual and Reproductive Health. Prescribers should follow locally approved guidelines when prescribing off-licence medicines. The prescriber should explain the situation to the patient/guardian, where possible, but 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 of the employing organisation. Page 6 of 26

Community Practitioners Nurse Prescribers may not prescribe medicines independently for uses outside their licensed indications/uk marketing authorisation (so called off-licence or off-label. Supplementary prescribers are able to prescribe any medicine, including unlicensed medicines and off-label that are listed in an agreed Clinical Management Plan. 4.3 Unlicensed medicines (products without a UK marketing authorisation) Nurse and Pharmacist Independent Prescribers and Community Practitioners Nurse Prescribers are not permitted to prescribe unlicensed medicines. Drugs that are intended to be mixed together prior to administration e.g. drugs for a syringe driver or drugs for intra-articular injection, are deemed to be unlicensed products once mixed. The Medicines and Healthcare products Regulatory Agency (MHRA) has acknowledged that this is a long term and acceptable practice and has indicated that it would not prosecute under these circumstance. However, the PCT has agreed that independent prescribers should not prescribe drugs that are intended to be mixed prior to administration. Community Practitioners Nurse Prescribers are not permitted to prescribe unlicensed medicines. Nurse and pharmacist supplementary prescribers are able to prescribe any medicine, including unlicensed medicines, off-label medicines and those intended to be mixed prior to administration as long as they are listed in an agreed Clinical Management Plan. 4.4 Borderline Substances All NHS prescribers need to abide by any NHS terms of service under which they operate. For example, if operating under new GMS, borderline substances may be prescribed but the prescription will need to be marked ACBS. A list of Advisory Committee of Borderline Substances (ACBS) approved products and the circumstances under which they can be prescribed, can be found in part XV of the Drug Tariff. Although this is a non-mandatory list, Nurse and Pharmacist Independent Prescribers should normally restrict their prescribing of borderline substances to items on the ACBS approved list. They should also follow any additional locally approved guidance such as those for prescribing for gluten enteropathies. 4.5 New Drugs on the market It does not follow that non-medical prescribers can automatically prescribe new medicines on the market even if they are licensed for use in the area of expertise practiced by the prescriber. Competence to prescribe drugs that fall outside the group of drugs with which the practitioner has worked alongside the mentoring doctor will need to be considered very carefully by the prescriber and the manager. The non-medical prescriber should ensure they are familiar with the Summary of Product Characteristics (SPC) of the drug and are competent to assess the patient for suitability to receive the medication and are competent to recognise and manage any side-effects. Specific training alongside a doctor and supplementary prescribing using a patient specific clinical management plan should be undertaken if the drug falls significantly outside of the prescribers current competence e.g. a drug that works in a different manner to the drugs with which the NMP is familiar. The PCT Pharmaceutical Team should be consulted if appropriate. 4.6 Requests from patients and medical practitioners There may be times when it would be convenient for non medical prescribers to prescribe for patients when they are short of a drug supply or to prescribe at the request of a medical Page 7 of 26

practitioner. NMPs must understand that the clinical responsibility for a drug lies with the person signing the prescription. If the NMP would not normally prescribe or initiate a particular drug then they must not do so at the request of a patient or doctor. 4.7 Private Prescriptions Independent prescribers are entitled to issue private prescriptions for any licensed medicine, except most Controlled Drugs. Supplementary prescribers may also issue private prescriptions for any medicines covered by a patient s clinical management plan. In the course of their employment, PCT staff should not write any private prescriptions, unless a specific exemption allowing private prescriptions for NHS patients is allowed under NHS regulations, e.g. medicines for travel purposes. 4.8 Appliances / Dressings in Part IX of the Drug Tariff Nurse and Pharmacist Independent Prescribers may also prescribe any appliances / dressings that are listed in Part IX of the Drug Tariff. 4.9 Drugs in Part XVIIIA and Part XVIIIB of the Drug Tariff No prescriber may prescribe on the NHS, drugs listed in part XVIIIA of the drug tariff so called black list. Drugs listed in part XVIIIB of the Drug Tariff, so called grey listed drugs may not be prescribed at NHS expense except in the specified circumstances and prescriptions must be endorsed SLS. 5. SELECTION OF NURSES, PHARMACISTS AND ALLIED PROFESSIONALS FOR TRAINING The selection of nurses, pharmacists and allied professionals to be trained as independent or supplementary prescribers will be carried out after assessment of local service and patient needs. All individuals selected for prescribing training must have the opportunity to prescribe in the post that they will occupy on completion of training and access to a budget to meet the costs of their prescriptions. Applications should be to the Associate Director of Nursing. The therapeutic area(s) in which they will prescribe should also have been identified before they begin training to prescribe. This will almost certainly be in the field in which they already hold considerable expertise. Applicants will be supported during their training and allowed some flexibility for self-directed study; they will have access to continuing professional development (CPD) opportunities on completion of the course. In addition to fulfilling the legal criteria for eligibility to prescribe, applicants who are selected for prescribing training will need to meet the following requirements: Nurses and allied health professionals should have the ability to study at Level 6 and should normally have at least three years post-registration clinical nursing experience, of which at least one year immediately preceding their application to the training programme should be in the clinical area in which they intend to prescribe. Health assessment module skills relevant to area of practice. Pharmacists should have the ability to study at a minimum of Quality Assurance Agency (QAA) for Higher Education level 3 and should usually have two years point registration experience. An identified medical supervisor Page 8 of 26

Nurses must be assessed as being competent to take a history, undertake a clinical assessment and make a diagnosis. For example, they must be able to carry out a comprehensive assessment of the patient s physiological and/or psychological condition, and understand the underlying pathology and the appropriate medicines regime. It is: the combination of expertise in the condition being treated appreciation of the patient s particular manifestation of it and the medicines which will be effective that make a proficient and competent prescriber Employers who put forward pharmacists for independent prescribing should assure themselves that the pharmacist is competent to prescribe in the area in which they will prescribe following training. Each applicant should have a medical prescriber willing and able to contribute to and supervise the 12 day learning in practice element of training. There are likely to be many nurses and pharmacists who meet these criteria. The three key principles that will be used to prioritise potential applicants are patient safety; maximum benefit to patients and the NHS in terms of quicker and more efficient access to medicines for patients; and better use of the professional s skills. The individual practitioners must also understand and accept the higher level of clinical responsibility associated with prescribing. 6. NOTIFICATION OF QUALIFICATION TO PRESCRIBE The Higher Education Institute will inform the Nursing and Midwifery Council of nurses who have successfully completed the non medical prescribers course and that a nurse has qualified as a prescriber. The Royal Pharmaceutical Society of Great Britain will be informed of all pharmacists who have successfully completed the prescribing course and are therefore qualified as a prescriber. The Health Professionals Council will be informed of all therapists who have completed the course and have qualified as a prescriber. The newly qualified non medical prescriber must complete a proforma (Appendix B - C) to declare their competence to prescribe and define their scope of prescribing practice. This must be sent, with confirmation of their registration with their professional body, to their manager who must take copies for their personal file and send both documents on to the Medicines Management Team. A Notification of Newly Qualified Non Medical Prescriber form will be completed and submitted to the Prescription Pricing Division of the NHS Business Services Authority (NHS PPD). The PPD will inform the contracted NHS secure forms contractor prescription printers of a non medical prescriber s inclusion on the list as eligible to prescribe. Once RR Donnelley is informed, prescription pads can be ordered. The process is outlined in full in Appendix A. 7. PRESCRIPTION FORMS Prescribers must inform the Medicine Management Team if they are linked to more than one computer since the NHS PPD must be informed. Non medical prescribers are able to use FP10SS forms for computerised prescribing. However, before computerised prescribing can commence, software must be configured to ensure the computer prescribing system correctly prints prescriber details as described below. Required details which must be printed on the form are: Page 9 of 26

Practice employed Nurse Independent /supplementary Prescribers Nurses registered to prescribe in one GP practice may use the green FP10SS computer generated prescription forms which must be overprinted with the words NURSE INDEPENDENT/SUPPLEMENTARY PRESCRIBER with PN in the right hand column and show the prescriber s name and PIN number and the practice senior partner s name, practice address and practice code in the prescriber address box. PCT employed Independent Nurse / supplementary Prescribers Nurses should usually hand write on FP10P lilac prescriptions stating the patient s practice code. PCT employed nurses registered to prescribe in one GP practice only may use the green FP10SS computer generated prescription forms which must be overprinted with the words NURSE INDEPENDENT/SUPPLEMENTARY PRESCRIBER with CN in the right hand column and show the prescriber s name, PIN number and contact number and the practice code and PCT address in the prescriber address box. Practice employed Pharmacist Prescribers Pharmacist prescribers registered to prescribe in one GP practice may use the FP10SS computer generated prescriptions which must be overprinted with the words PHARMACIST PRESCRIBER with SP in the right hand column and show the prescriber s name and PIN number and the practice senior partner s name, practice address and practice code in the prescriber address box. PCT employed Pharmacist Prescribers Pharmacists may hand write on FP10P lilac prescriptions stating the patient s practice code. PCT employed pharmacist prescribers registered to prescribe in one GP practice only may use the FP10SS computer generated prescriptions which must be overprinted with the words PHARMACIST PRESCRIBER with SP in the right hand column and show the prescriber s name, PIN number and contact telephone number and the practice code and PCT address in the prescriber address box. PCT employed Community Practitioner Nurse Prescriber Community Practitioner Nurse Prescribers working over several practices must handwrite prescriptions on FP10P lilac pads stating the patients practice code. If community nurses are registered to prescribe in one GP practice only they may use green FP10SS computer generated prescriptions which must be overprinted with the words COMMUNITY PRACTITIONER NURSE PRESCRIBER with CN in the right hand column. Other PCT employed / contracted Independent/ supplementary Prescribers Hospital, clinic or prison healthcare based non medical prescribers may use two methods to prescribe. They may prescribe on the hospital/clinic/hmp prescription form for inpatient and discharge supplies (not prison healthcare) or, where a community pharmacist will dispense the prescription, they will use an FP10P (not prison healthcare ) prescription form as described above. There are services provided by the PCT, whereby medication is supplied directly to the patient e.g. in a Minor Injuries Unit /Sexual Health Clinic. After health assessment, a non medical prescriber may issue stock supplies of medication that have been labelled and dispensed by a pharmacist as an alternative to writing a prescription. 8. ORDERING OF PRESCRIPTION PADS Non medical prescribers should request a new prescription pad when the current stock is unlikely to last for more than two weeks, using the proforma supplied (Appendix) and sent to the General Office at Isaac Maddox House to order their pads. At least 12 working days Page 10 of 26

should be allowed between notifying changes to the PPD and ordering their initial prescriptions. Full details are included in Appendix C. A register will be maintained as a record of issue of prescription pads and for stock control. Details of the serial numbers of prescriptions received and subsequently issued to non medical prescribers will be recorded, along with signatures to confirm delivery. 9. SECURITY OF THE PRESCRIPTION PAD It is the responsibility of both the employer and the non medical prescriber to ensure the security of the prescription forms at all times. It is good practice for each nurse prescriber to keep a record of the serial number of the first and last form in the prescription pad. Under no circumstances should blank prescription forms be pre-signed before use. The prescription pad should only be produced when the need to prescribe has been identified. Prescription pads should never be left unattended or accessible to others. They must never be left on a desk, but placed in a locked drawer. When travelling between patients the prescription pad should not be visible in the car but should be locked in the car boot within the nursing bag. The nursing bag and prescription pad must always be removed from the car when the car is unattended. Prescription pads must be transported in and out of patients homes and from the car to the nurses base etc in the nurse s bag and not routinely carried within a diary or within folders or other papers where they are at risk of falling out. The prescription pad is the legal property of Worcestershire PCT and must be returned by the nurse prescriber on termination of employment with the PCT or a General Practice. This must be done before or on their last day of duty and should be sent to the Medicine management Team. 10. LOSS OR SUSPECTED THEFT OF THE PRESCRIPTION PAD OR FORMS In the event of loss or suspected theft of prescription pads during office hours, the non medical prescriber must report this immediately to their line manager, or General Practitioner for practice employed staff. The line manager is responsible for informing the Local Counter Fraud Team on 01905 760069. Details to be passed on to the Team include the approximate number of prescriptions missing or stolen, their identification numbers and if stolen, when and from where. If the loss or theft occurs out of hours, the loss should be reported directly to their line manager at the earliest opportunity. The Local Counter Fraud Team will arrange for all Community Pharmacists within the PCT and neighbouring PCTs to be notified of any lost or missing pads. The non medical prescriber will be required to order a new pad following the process outlined in Appendix B. Following the loss or theft of a prescription pad, the non medical prescriber will be required to write all prescriptions in red ink for a period of two months. If the missing pads are found, they should be returned to the prescriber s line manager who will arrange for their destruction. Page 11 of 26

11. GOOD PRACTICE, ETHICS AND COMMON PRESCRIBING ISSUES 11.1 Prescribing decisions A non medical prescriber can only order a medicine for a patient whom he/she has assessed for care. All non medical prescribers using FP10 forms can only write a prescription on a form bearing their name and PIN number. Non medical prescribers may not sign repeat prescriptions originally set up by other prescribers. A non medical prescription should provide treatment for no more than one calendar month, unless direct supply of medication is agreed for a dedicated service or within a GP practice. The non medical prescriber must ensure that the prescription is cost effective, meets the clinical needs of the patient and is within agreed protocols and procedures. Prescribers qualified to prescribe must not issue initial prescriptions on behalf of others who are not qualified to prescribe. However, repeat prescriptions can be issued at the request of those who are not prescribers, where the non medical prescriber was responsible for the initial prescription. Non medical prescribers may issue repeat prescriptions for patients on their own caseload on no more than six occasions or for a maximum period of six months without carrying out a reassessment. In primary care settings, prescriptions should not be written when an item has been administered to a patient using GP surgery or clinic stock items, the cost of these items should be covered from other budgets. 11.2 Who to write prescriptions for Non medical prescribers employed by the PCT may only issue prescriptions for the patients of GP practices within the PCT. In addition, if they are providing services through a Community Nurse Prescribing Contract, they can issue prescriptions for the patients of GP practices covered by the contract and for which a prescribing budget has been agreed. Non medical prescribers working for different practices can use one prescription pad but must complete the relevant Practice Code Number for the individual patient. The Medicines Management Team will supply prescribers with a list of Practice Code numbers. Practice nurse prescribers may only prescribe for patients registered with the practice they are employed by. Nurse prescribers should only prescribe to visiting relatives of patients if they are temporarily registered with the GP/practice concerned. Non medical prescribers can prescribe for travelling families provided that the appropriate residency forms have been completed. Hospital, prison or clinic based non medical prescribers should only prescribe for patients in the clinic, ward or prison in which they are working or for patients in their area of clinical responsibility (e.g. where nurses provide services in the community as part of an outreach team). 11.3 Informing patients Non medical prescribers must ensure that patients and clients are aware of the scope and limits of their prescribing and how the patient or client can obtain other items necessary for their care. Information about treatment should be fully explained to ensure that there is no delay in obtaining supplies. Page 12 of 26

11.4 Prescribing for self, family and friends Non medical prescribers will not prescribe for themselves. It is strongly recommended that (as for doctors and dentists) non medical prescribers should avoid prescribing for close family members, as judgement may be impaired and important clinical examination may be impossible. When the non medical prescriber s family and/or friends are registered with the GP to whom he/she is attached, the nurse must consider whether or not it would be ethical to prescribe and must accept accountability for that decision. 11.5 Completing a prescription form Prescriptions must be written by non medical prescribers in accordance with prescription writing requirements laid down by the Prescription Pricing Division (PPD) of the NHS Business Services Authority as outlined in the Nurse Prescribers Formulary (NPF) and British National Formulary (BNF) and for PCT employed prescribers, the PCT Medicine Policy. The prescriber must complete all details on the prescription form by writing clearly and legibly using an indelible pen (preferably black). Only abbreviations as listed on the inside back cover of the current BNF are permissible. The details must include: - The patient s title, forename, surname and address (including postcode) and if available the patient s NHS number. Age and date of birth should preferably be stated, however, it is a legal requirement to write the patient s age on the prescription when prescribing a Prescription Only Medicine for a child under the age of 12 years. The name of the prescribed item(s), formulation, strength (if any), dose and frequency (in the case of preparations to be taken as required a minimum dose interval should be specified) and quantity to be dispensed. The quantity prescribed should be appropriate to the patient s treatment needs, bearing in mind the interval before the patient s condition is to be reviewed, the need to avoid waste, patient convenience and the avoidance of undue quantities of potentially poisonous substances in the home. It should also comply with the specified pack size in the NPF. The names of medicines should be written clearly, it is recommended to prescribe generically, except where this would not be clinically appropriate or where there is no approved generic name. Where there is more than one item on a form, a line should be inserted between each item for clarity. Unused space at the bottom of the prescription area should be blocked out with, for example, a diagonal line to prevent fraudulent addition of extra items. If any alterations are made, the prescriber must initial them. 11.6 Dispensing and Administration of prescribed items Where a GP practice is a dispensing practice, non medical prescriptions can be dispensed by the practice, but only for the dispensing patients of that practice. Dispensing Doctors Page 13 of 26

cannot dispense prescriptions written by non medical prescribers for patients of other practices. Pharmacists are a very useful source of help and advice to any prescriber. They can advise on pharmacology, drug dosages, product selection and side effects. They will also know the costs, availability and pack sizes of prescribed items. Non medical prescribers should be aware that pharmacists have legal and ethical obligations, which mean they may need to contact the prescriber sometimes urgently to confirm an aspect of the prescription, return it for amendment or even refrain from dispensing it. An up-to-date telephone number should be included (in the address box) on all prescriptions. When a non medical prescriber becomes aware that the patient intends to have a prescription dispensed by an appliance contractor, he/she must ensure that the prescription does not contain medical preparations. Occasionally a prescription may require dispensing out of normal pharmacy opening hours. If a medicine is required urgently and there is no local pharmacy open, the prescription form should be endorsed by the prescriber with the word urgent. The Urgent Primary Care centres hold information on pharmacies that provide an urgent dispensing service. It is unethical for any prescriber to recommend a particular pharmacy to patients. This is a matter of patient choice unless this is in the best interests of patient care or in an emergency situation. There should, wherever possible, be separation of prescribing, administration and dispensing roles, in keeping with the principles of safety, clinical and corporate governance. The NMC standards of proficiency for nurse and midwife prescribers states: You must ensure separation of prescribing and administering activities whenever possible In exceptional circumstances, where a prescriber is both prescribing and dispensing a patient s medication, a second suitably competent person should normally be involved in the checking process. There must be clear accountability arrangements to ensure patient safety and probity, and audit arrangements must allow checking for clinical appropriateness to ensure patient safety and to track prescribing and dispensing by Nurse and Pharmacist Independent Prescribers. 11.7 Verification of prescribing status The Community Pharmacists will need to be sure that the prescriber has qualified as an independent prescriber. The Medicines Management team will hold a list of non medical prescribers, which will be regularly updated that Community Pharmacists can access on request. This will include the identification numbers and contact details. In the case of Community Practitioner Nurse prescriber, the pharmacist will also need to check that the medicines or appliances prescribed are included in the Community Practitioner Prescribers Formulary. Both the Royal Pharmaceutical Society of Great Britain www.rpsgb.org and the Health Professions Council www.hpc-uk.org provide online web access to allow anyone to check the prescriber status of an individual pharmacist or therapist. The Nursing and Midwifery Council www.nmc.org registration database can only be accessed by the employer, using a name and password. Community Pharmacists wishing to verify the prescribing status of an individual nurse prescriber must contact the Medicines Management Team for confirmation. Page 14 of 26

12. RECORD KEEPING All health professionals are required to keep accurate, legible, unambiguous and contemporaneous records of a patient s care. There is no single model or template for a patient record (although for guidance, staff should refer to the standards published by the relevant professional/regulatory body), but a good record is one that provides in a timely manner all professionals involved in a patient s treatment, with the information needed for them to care safely and effectively for that patient. It is a necessary way of promoting communication within the healthcare team and between practitioners and their patients/clients. Good record keeping is, therefore, both the product of effective team working and a pre-requisite for promoting safe and effective care for patients. Please refer to the PCT Record Keeping Policy. Best practice suggests that the details of any prescription, together with other details of the consultation with the patient, should be entered onto the shared patient record immediately, or failing that, as soon as possible after the consultation. Only in very exceptional circumstances (e.g. the intervention of a weekend or public holiday) should this period exceed 48 hours from the time of writing the prescription. This information should also be entered at the same time onto the patient record and onto the nursing or pharmacy patient record (where a separate record exists). It is recommended that the record indicates clearly: The date of the prescription; The name of the prescriber (and that they are acting as a Nurse or Pharmacist Independent Prescriber); The name of the item prescribed, together with the quantity (or dose, frequency and treatment duration). To aid safe administration of medicines, the record should include: The name of the item prescribed, the strength (if any) of the preparation, the dosing schedule and route of administration, e.g. paracetamol oral suspension 120mg/5mls to be taken every four hours by mouth as required for pain, maximum of 20mls in any 24 hours. In the case of topical medicines the name of the prescribed item, the strength (if any), the quantity to be applied and the frequency of the application should be indicated. For dressings and appliances, details of how they are to be applied and how frequently changed, are useful. It is recommended that any advice given on General Sales List and Pharmacy medicines provided over the counter is also recorded. In some circumstances, in the clinical judgement of the prescriber, it may be necessary to advise the GP or consultant immediately about the prescription. This action should be recorded in the common patient record. Where a prescriber is acting in the absence of another, the original prescriber should be notified as soon as possible that a prescription has been issued. Page 15 of 26

13. ADVERSE REACTION REPORTING If a patient suffers a suspected adverse reaction to a prescribed, over-the-counter (Pharmacy or General Sales List) or herbal medicine, the adverse reaction should be reported via the Yellow Card Scheme. The Yellow Card Scheme is a voluntary scheme through which healthcare professionals (including nurses and midwives) notify the Medicines and Healthcare Products Regulatory Agency (MHRA)/Committee on Safety of Medicines (CSM) of suspected adverse drug reactions. The MHRA/CSM encourage the reporting of all suspected adverse drug reactions to newly licensed medicines that are under intensive monitoring (identified by an inverted black triangle both on the product information for the drug and in the BNF and MIMS) and all serious suspected adverse drug reactions to all other established drugs. Serious reactions include those that are fatal; life threatening, disabling, incapacitating or which result in, or prolong hospitalisation and/or are medically significant. The new electronic Yellow Card provides a simple and fast way to report suspected adverse reactions. The electronic Yellow Card, together with instructions on how to use it, is available on the MHRA website (www.mhra.gov.uk). Health professionals are encouraged to report all suspected adverse drug reactions using this method, although hard copy Yellow Cards are also acceptable. (Yellow forms can be found at the back of the British National Formulary and Nurse Prescribers Formulary). The adverse reaction should be reported to the GP and documented by the nurse prescriber, in red, on nursing and practice records and on Safe Code documentation. An entry on to the GP clinical system is strongly recommended. A supplementary prescriber should inform the independent prescriber of any reported ADRs. Should a health professional other than the non medical prescriber detect the adverse reaction, he/she should report the incident to the prescriber, make a record in the notes and the GP must be informed. If a patient suffers harm due to an adverse incident involving medicines; or if harm could have been caused to the patient by the medicine (a near miss), the incident or near miss should be reported by the non medical prescriber as described in the PCT s Incident Reporting Policy. Community pharmacy contractors are required to have an approved incident reporting system. The NPSA s confidential National Reporting and Learning System is available to them. 14. LEGAL & CLINICAL LIABILITY 14.1 Liability of prescriber/professional indemnity Prescribers are accountable for all aspects of their prescribing decisions. They should therefore 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. All prescribers should ensure that they have sufficient professional indemnity insurance, for instance by means of membership of a professional organisation or trade union which provides this cover. Page 16 of 26

The RPSGB Code of Ethics states that all pharmacists who own a pharmacy, superintendent pharmacists, and pharmacist managers should ensure that all professional activities undertaken by them or under their control are covered by adequate professional indemnity insurance. The standard for prescribing also says that pharmacists must only prescribe within the limits of their registration and must comply with statutory requirements applicable to their prescribing. The NMC recommends that every nurse/midwife prescriber should ensure he/she has professional indemnity insurance, by means of a professional organisation or trade union body. Prescribers must also be aware of the level of indemnity insurance offered by their insurer to determine whether it is sufficient for purpose. Both the employer and employee (or contractor) should jointly agree the individual prescribing practice that includes a clear statement on scope of prescribing and areas of competence required as part of the duties of the prescriber. 14.2 Liability of employer Where a nurse, midwife, pharmacist or therapist is appropriately trained and qualified and prescribes as part of their professional duties with the consent of their employer, the employer is held vicariously liable for their actions. In addition, non medical prescribers are individually professionally accountable to their own professional body for this aspect of their practice, as for any other, and must act at all times in accordance with Codes of Professional Conduct. 15. BUDGET SETTING AND MONITORING Prescribing expenditure incurred by community non medical prescribers is charged to the GP practice or service on whose behalf he/she prescribes. Prescriptions issued by practice nurse prescribers are charged to the employing practice. Prescribing in community hospitals. Clinics and the prison service is charged to the PCT Provider Services budgets. Primary care prescribers are required to add the GP practice/service code onto the prescription form at the time of issuing the prescription. All expenditure is then coded to the appropriate practice. It is therefore extremely important that the code is clearly stated on the form. On a monthly basis, the Medicines Management Team will review the prescribing expenditure by non medical prescribers, including any uncoded prescribing. Areas of significance will be closely monitored and the prescriber s manager informed if necessary. This includes practice nurses prescribing. On a quarterly basis, reports will be prepared, as directed by the Pharmaceutical Advisers and sent to individual prescribers and their managers. These will include: Individual prescriber reports for all practice and non-practice prescribers. These will include details of all the prescriptions issued by the prescriber in that quarter. A summary of total prescribing expenditure by each PCT employed prescriber in that quarter for the Locality Associate Directors of Provider Services. The PCT Medicine Management Team reserve the right to challenge prescribers to justify their prescribing in terms of overall costs, drug choice and clinical appropriateness. In addition to the central and local systems for monitoring the number and cost of items prescribed by non medical prescribers, each prescriber is responsible for his/her own Page 17 of 26

individual practice, and must carry out regular reviews of his/her prescribing practice and take part in clinical governance activities of their employing organisation. 16. CLINICAL GOVERNANCE IN INDEPENDENT PRESCRIBING Clinical governance is the system through which NHS organisations are accountable for continuously improving the quality of their services and safeguarding high standards of care, by creating an environment in which clinical excellence will flourish. Chief executives are legally accountable for the quality of care that patients receive and for securing patient safety. The parameters of an individual s prescribing must be agreed between the prescriber, their manager or local professional lead (e.g. the PCT Head of Medicines Management & Pharmacy in the case of a community pharmacist), and their employer. Prescribers should use clinical supervision arrangements or equivalent as an opportunity for reflection on prescribing, as well as other aspects of practice. The model of clinical supervision should be agreed at local level, taking account of other staff support mechanisms and resources. 16.1 Continuing Professional Development 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. This is no less true for prescribing. Non medical prescribers will be expected to keep up to date with evidence and best practice in the management of the conditions for which they prescribe, and in the use of the relevant medicines. Non medical prescribers may use the learning from this activity as part of their Continuing Professional Development. The PCT will ensure that the practitioner has access to relevant education and training provision and will support non medical prescribers in pursuing self-directed study. Details of additional training and updating will need to be incorporated by the individual into their personal professional profile, in order to renew their registration. 16.2 Non medical Prescribing and the BNF/Drug Tariff Independent and supplementary prescribers will receive a centrally funded copy of the BNF every six months and Children s BNF every year. Community Practitioner Nurse Prescribers will receive a copy of the Community Practitioners Formulary every two years. Prescribers are able to access the Drug Tariff through the PPA website www.ppa.nhs.uk 17. MONITORING All non medical prescribers, when first registering with the PCT as a prescriber will be asked to confirm their awareness and understanding of this policy. FP10 prescribing will be monitored via the NHS Business Services and hospital prescribing by the visiting clinical pharmacists. A report will be taken to the Provider Medicine Management Committee and the Professional Executive Committee twice a year. Page 18 of 26