MILTON KEYNES NON-MEDICAL PRESCRIBING POLICY

Milton Keynes Primary Care Trust MILTON KEYNES NON-MEDICAL PRESCRIBING POLICY We welcome feedback on this policy and the way it operates. We are interested to know of any possible or actual adverse impact that this policy/procedure may have on any groups in respect of gender or marital status, race, disability, sexual orientation, religion or belief, age or other characteristics. Version Date Approved 2 Nov 2006 Last Review March 2008 Review Date October 2011 Equality Impact Assessed Author/Contact Person Approved By: PCT Prescribing Group and Trust Management Team For use in (clinical area) For use by (staff groups) For use for (patients/staff/public) Document Owner: Document Status: Trustwide All staff group Staff/patients Non-Medical Prescribing Steering Group Approved Document ID: Page 1 of 44 Version No: 2

Document History Version Date Author Reason 2 17.10.08 Sue McCready Amendments/additions 3 17.11.10 Sue McCready Amendment to Steering Group Members (page 3) Document ID: Page 2 of 44 Version No: 3

NON-MEDICAL PRESCRIBING STEERING GROUP MEMBERS Sue McCready Helen Chadwick (Chair) Community Nursing Senior Manager Professional Lead for District Nursing Head of GP Consortia Clinical Support/Deputy Chief Pharmacist Michael Ramsden DN Clinical Lead (North)/Community Matron Libby Pell Louise Moran Jayne Skippen Tom Yates Jane Ross Dermatology Specialist Nurse Clinical Nurse Specialist Head of Nursing & Clinical Development, MKUCS Matron, MKUCS Senior Manager, Mental Health Acknowledgements We would like to acknowledge the following Trusts whose policies have contributed to this document: Royal Berkshire and Battle Hospitals NHS Trust Berkshire Healthcare NHS Trust Eastbourne Downs PCT Buckinghamshire Hospitals NHS Trust Brent PCT Buckinghamshire and Oxfordshire Mental Health NHS Trust Western Sussex PCT Document ID: Page 3 of 44 Version No: 3

Contents 1.0 Introduction Page No 1.1 Policy Statement and Aim 5 1.2 Definition of NMP and Background 5 2.0 Scope 6 3.0 Objectives 6 4.0 Academic Preparation 7 4.1 Training and Competency Requirement for Non-Medical 7 Precribers 4.2 Risk Assessment and Management including Consent 9 4.3 Legal and Clinical Liability 10 4.4 Eligibility Criteria and Application Process 11 4.5 Supplementary Prescribing and The Clinical 15 Management Plan 4.6 BNF and Drug Tariff 17 4.7 Safety and Security 17 4.8 Communication and Record Keeping 22 5.0 Roles and Responsibilities 23 5.1 Chief Executive 23 5.2 Non-Medical Prescribing Lead and NMP Steering Group 23 5.3 Authors of Documents 23 5.4 Line Managers 24 5.5 All staff 24 6.0 Audit 24 7.0 Equality Impact Assessment 24 8.0 Healthcare Standards 25 9.0 Dissemination 25 10.0 Overall responsibility for the document/appraisal 25 process 11.0 Attachments Appendix 1 Non-Medical Prescibing Application Criteria Appendix 2 CMP Templates Appendix 3 Form for Obtaining SHA Funding in Thames Valley for Pharmacist and AHP Supplementary Prescribing Training Appendix 4 Equality Impact Assessment Screening Template 26 34 36 43 Document ID: Page 4 of 44 Version No: 3

1.0 Introduction 1.1 Policy Statement and Aim 1.2 Definition of NMP and Background This policy provides guidance on the introduction and development of non-medical prescribing (NMP) within Milton Keynes Primary Care Trust. Definition of Non-medical and Supplementary Prescribing Non-medical prescribing is the term used to describe any prescribing done by a healthcare professional other than a doctor or dentist. Supplementary prescribing is defined as a voluntary partnership between an independent prescriber (currently a doctor or dentist) and a supplementary prescriber to implement an agreed patient specific clinical management plan (CMP) with the patient s agreement. Two important features of this definition are that the partnership is voluntary and that there is significant involvement of the patient. In practice this will follow a sequence involving: the diagnosis by the doctor/dentist agreement by the patient to be managed by the prescribing partnership preparation of a CMP (by either the supplementary prescriber or the independent prescriber) The management by the supplementary prescriber within the terms of the CMP. Supplementary prescribing involves a regular clinical review of the arrangement by the independent prescriber. Nurses, Pharmacists, Radiographers, Physiotherapists, Podiatrists and Optometrists are entitled to undertake training to become supplementary prescribers. This group of practitioners can prescribe any medicine, including controlled drugs, which have been agreed with a doctor and are listed in a Clinical Management Plan. Independent prescribers are able to prescribe any licensed medicine for any medical condition they are competent to treat (except controlled drugs). Nurses can prescribe some controlled drugs but only for certain medical conditions. Pharmacists are not able to prescribe controlled drugs but this could change in the future. Pharmacists and Nurse Independent Prescribers may not prescribe unlicensed medicines but they may prescribe a licensed medicine for an unlicensed indication. However, they could prescribe as a supplementary prescriber within the context of an agreed clinical management plan. Document ID: Page 5 of 44 Version No: 3

Independent non-medical prescribers are able to independently prescribe any licensed medicine for any medical condition, with the exception of many controlled drugs. Independent Nurse Prescribers are not authorised to prescribe a mixture of licensed medication for administration via, for example, a syringe driver. Whilst the medications they are prescribing are individually licensed for administration, if they require mixing, this alters the properties of the medication and renders it an unlicensed one. Regulations allow independent prescribing of any licensed medicine for any medical condition within a NMP's competence including, for nurses, some controlled drugs from 1 May 2006. Independent Prescriber refers to those practitioners (eg. Doctor, Dentist, Nurse, Pharmacist) who are responsible for the assessment of patients with diagnosed or undiagnosed conditions and for decisions about the clinical management required, including prescribing. An independent prescriber is responsible for their own prescribing decisions. 2.0 Scope This policy applies to all strategies, policies, procedures, protocols and guidelines produced for use within the Trust and wherever Trust staff carry out their responsibilities as employees of the Trust. It applies to documents intended for distribution and use on a Trust wide basis or within individual Directorates, Departments, Service Areas and by all Professionals. This policy will take effect from the date of its approval, all documents will be standardised as and when they come up for review. 3.0 Objectives The Policy must ensure that Service Managers are required to complete a detailed service development proposal document that demonstrates the need for a nonmedical prescribing service: Non-medical prescribing must offer improved patient care, this is defined as improved quality of care, quicker and better access to treatment Proposals should demonstrate that all the elements covered in this policy have been considered in detail with confirmation that these will be implemented where appropriate. Proposals should indicate which prescribing budget will be used for paying the non-medical prescribing costs. Details of the current prescribing budget should also be provided (annual spend and whether increasing or decreasing). There is no additional funding for implementation of non-medical prescribing. It is anticipated that non-medical prescribing implementation will be through service redesign. Document ID: Page 6 of 44 Version No: 3

4.0 Academic Preparation 4.1 Training and Competency requirements for Non- medical prescribers Non-medical prescribing courses must be approved by SHA and appropriate professional body. This course includes: For Nurses At least 26 taught days on an NMC validated programme of preparation at a Higher Educational Institute (HEI). Some programmes are now available via a distance-learning route (eg Winchester) An additional 12 days (12 x 6.5 hours excluding breaks) learning in practice with a designated supervising medical practitioner. A commitment to self directed study It is important that those attending the course recognize that the course is very demanding of time. Successful completion of the course will lead to a V300 annotation to the NMC professional register For Pharmacists 26 days training at a HEI either face to face or by open learning 12 days(12 x 6.5 hours excluding breaks) learning in practice with a designated medical practitioner. A commitment to self directed study Successful completion of the course will lead to independent prescriber annotation to the Register of Pharmaceutical Chemists. They will also be able to practice as a supplementary prescriber. For AHPs 26 days training at a HEI either face to face or by open learning 12 days (12 x 6.5 hours excluding breaks) learning in practice with a designated medical practitioner. A commitment to self directed study Successful completion of the course will lead to supplementary prescriber annotation on the Health Professional Council Register. (a) Re-validation The NMP Steering Group will facilitate practitioners to identify CPD needs annually through discussion forums Document ID: Page 7 of 44 Version No: 3

The NMP Steering Group will maintain a CPD monitoring role Audit of CPD will be developed annually and inform SHA NMPs should understand that they are responsible for maintaining their own CPD (b) CPD and maintaining competency The following is an extract from Standards of proficiency for Nurse and Midwife prescribing, but is equally applicable to all professions: Under new legislation prescribers must have sufficient knowledge and competence to: Assess a patient/client's clinical condition Undertake a thorough history, including medical history and medication history, and diagnose where necessary, including over the counter medicines and complementary therapies. Decide on management of prescribing condition and whether or not to prescribe. Identify appropriate products if medication is required. Advise the patient/client on effects and risks. Prescribe if the patient/client agrees. Monitor response to medication and lifestyle advice. Central to an individual maintaining and developing prescribing competence is the pertinent provision of CPD and clinical supervision. All practitioners have the professional responsibility to keep themselves abreast of clinical and professional developments. Prescribers will be expected to keep up-to-date with best practice in the management of conditions for which they may prescribe, and in the use of drugs, dressing and appliances. Nurses may use the learning from this activity as part of their Post Registration Education and Practice (PREP). Pharmacists may use this as part of their CPD record. Prescribing should be discussed at appraisal and personal development planning and any training needs identified through CPD. NPC Competency Framework will form the basis of CPD. It will then be the responsibility of the service manager and non-medical prescriber to ensure the non-medical prescribing policy is followed. (c) Non-medical prescribers are expected to maintain a CPD portfolio, including a review of prescribing related critical incidents and learning from them, although critical incidents may be recorded in a separate log. This log should be included within the annual development review process and used to provide evidence for the non-medical prescribing role within their KSF outline. Document ID: Page 8 of 44 Version No: 3

(The Department of Health commissioned the National Prescribing Centre (NPC) to provide CPD support by means of the document Maintaining Competency in Prescribing an outline framework to help nurse/pharmacist/allied health professional prescribers. This document is available from the NPC s website. nww.npc.ppa.nhs.uk It is a tool to be used to reflect on prescribing practice, to identify gaps and learning needs and should be used to form the basis of personal development plans.) It is recommended that the non-medical prescriber accesses ongoing education offered and be self directed in meeting learning and development needs. Attend non-medical prescribing forum as per policy Attend relevant CPD updates and training. Ensure that prescribing is in line with up-to-date, best practice in the management of conditions that are being treated and in line with local PCT prescribing policy Use the NPC Competency Framework as a working tool to reflect on prescribing practice Non-medical prescribing will be discussed at appraisal and any training needs identified through PDP It is recommended that a recognised tool such as the NIPEC tool is used for performance review Access regular Clinical Supervision If a non-medical prescriber has not prescribed for over one year (this may be due to a changing role or the need for support) or failed to attend the prescribing forum for over one year (except in special circumstances) prescribing may temporarily cease to be part of their professional duties, following discussion with the line manager and professional lead. This should be reported to the Non-medical Prescribing Steering Group. On returning to practice following a break in prescribing of over one year (or less, if felt needed by the prescriber) support will be facilitated by the nonmedical prescriber s manager. Once qualified, it is the responsibility of their line manager, in conjunction with the budget holder and the professional lead for the service (eg Consultant Psychiatrist, Clinical Director), to agree to the areas in which they are able to prescribe as part of their professional duties. In the case of supplementary prescribing the therapeutic area/s must be agreed. Should the prescriber wish to expand on these areas, the line manager should explore any further clinical training or experience that may be required and this must be provided before this new area can be included in their professional duties. 4.2 Risk assessment and management 4.2.1 Non-medical prescribing should be included in clinical risk management (including root cause analysis), patient safety (including NPSA national reporting and learning scheme), confidentiality, handling complaints and controls assurance programmes. 4.2.2 A statement on non-medical prescribing will be entered in PCT service areas' risk registers. Document ID: Page 9 of 44 Version No: 3

4.2.3 Service managers, non-medical prescribers and independent prescribers must ensure appropriate risk assessments are carried out at each stage of implementation of the non-medical prescribing project in their service. It is important to let the new service bed down and to ensure the new nonmedical prescriber is not pressurised to work in positions outside their competence. Teams are reminded of the Trust whistle-blowing policy. 4.2.4 Non-medical prescribers are encouraged to complete incident forms for any incident or near miss. Milton Keynes PCT has a no blame culture and encourages learning from incidents. It is particularly important, especially in the developmental stages that near misses are also reported on the Trust incident form. 4.2.5 The Pharmaceutical Advisers provide advice/support to individuals or services as appropriate. Consent Prescribing involves a voluntary relationship between the prescriber and the patient. It must only be carried out with informed patient consent, or relative/guardian consent, as defined by the trust s consent policy, and this consent must be recorded in the medical notes. If informed consent is not given then prescribing cannot be undertaken. For supplementary prescribing once consent is obtained the CMP must be signed by both the independent and supplementary prescriber. As a good practice point the service user should be given the opportunity to sign the CMP but this is not legally required. 4.3 Legal and Clinical Liability 4.3.1 Where a nurse, allied health professional or pharmacist 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 all prescribers are individually and professionally accountable to their professional bodies for this aspect of their practice and must act at all times in accordance with their professional codes of conduct. 4.3.2 Due to the extended role in patient care represented by prescribing the likelihood of personal negligence actions are increased and therefore the government, professional bodies and Trust recommend that all prescribers ensure that they also have suitable professional indemnity insurance, for instance by means of membership of a professional organisation and trade union. 4.3.3 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 (eg. From the pharmaceutical industry, patients or colleagues) that might result in inappropriate prescribing. Document ID: Page 10 of 44 Version No: 3

4.3.4 Where a NMP is both prescribing and administering, a second, suitably qualified person should normally be involved in the checking process. Where this is not possible, the NMP should adopt a personal process whereby they step back from the process and then perform a double check before administering. 4.4 Eligibility Criteria and Application Process Eligibility Criteria Applicants must meet the entry criteria for the non-medical prescribing course Based on the DoH 2006 and NMC 2006 criteria: - be a 1st level nurse, midwife and/or Specialist Community Public Health Nurse on the Nursing and Midwifery Council (NMC) professional register; OR - a Pharmacist registered with the Royal Pharmaceutical Society of Great Britain (RPSGB); OR - An Optometrist registered with the General Optical Council; OR - A Podiatrist, Physiotherapist or Radiographer registered with the Health Professionals Council (HPC) Will have the specified period of relevant professional post qualification experience depending on professional background. Will have the relevant prior experience in the proposed area of practice. For example for NMC (nursing) registrants the year preceding the application should be in the clinical field in which they intend to prescribe and for pharmacists the practitioner should have up to date clinical, pharmacological and pharmaceutical knowledge relevant to the area of intended prescribing. Have written support from employer/manager which includes an appraisal of their suitability to prescribe, identified opportunities within the service area to prescribe, and approval from the prescribing budget holder to access the resources. The Manager is required to undertake an appraisal of the applicant's suitability to prescribe before they apply for a training place. Managers must ensure that the necessary clinical governance infrastructure is in place to enable the applicant to prescribe once they are qualified to do so. By approving this application the Manager is confirming that: 1. The applicant has been assessed as competent to take a history, undertake a clinical assessment, and diagnose. Document ID: Page 11 of 44 Version No: 3

2. There is clinical need within the applicant's role to justify prescribing. 3. The applicant ha sufficient knowledge to apply prescribing principles taught on the programme of preparation to their own area and field of practice. 4. The applicant can demonstrate appropriate numeracy skills. Managers should not put applicants forward if they haven't demonstrated the above competencies. The above may be confirmed through the applicant undertaking a module to prepare them in diagnosis and physical assessment or through Continuing Professional Development (CPD) reviews in the workplace. Have the support of a designated supervising medical practitioner who will provide the student with supervision, support and opportunities to develop competence in prescribing practice. Guidance on Designated Medical Practitioner (DMP) Supervisors for Non-medical Prescribing (NMP) Course A Designated Medical Practitioner (DMP) must provide support to students on an independent/ supplementary prescribers programme of preparation. Eligibility of DMO must be sufficiently impartial to the outcome for the student and wherever possible should not be the same person sponsoring the student to undertake the programme. The role and responsibilities of the Designated Medical Practitioner The curricula for preparing nurse and pharmacist prescribers includes no less that 12 days of learning in practice. The curricula to prepare allied health professionals (initially chiropodists/ podiatrists, radiographers and physiotherapists) and optometrists as supplementary prescribers will include similar requirements. This period of learning in practice is to be directed by a DMP who will also be responsible for assessing whether the learning outcomes have been met and whether the trainee has acquired certain competencies. Normally, these outcomes and competencies will be identified by the HEI running individual courses. The DMP must have the knowledge, skills and expertise to provide appropriate support to students in their field of practice. Learning opportunities must be identified with the student with offers of support and guidance to enable students in their prescribing role. This involves: Establishing a learning contract with the trainee Planning a learning programme which will provide the opportunity for the trainee to meet their learning objectives and gain competency in prescribing Facilitating learning by encouraging critical thinking and reflection Document ID: Page 12 of 44 Version No: 3

Providing dedicated time and opportunities for the trainee to observe how the DMP conducts a consultation/interview with patients/clients and/or parents/carers and the development of a management plan Allowing opportunities for the trainee to carry out consultations and suggest clinical management and prescribing options, which are then discussed with the DMP Helping ensure that the trainees integrate theory with practice Taking opportunities to allow in-depth discussion and analysis of clinical management using a random case analysis approach, when patient/client care and prescribing behaviour can be examined further Assessing and verifying that, by the end of the course, the trainee is competent to assume the prescribing role. Where possible an experienced non-medical prescriber should work alongside the student and DMP to provide support and guidance as appropriate. DMP commitments: 1. To meet with the student at the start of the course, the midway point and at the end of the course in order to: Discuss identified learning needs and the student's progress in meeting these Discuss the student's log of practice activities. 2. To observe a minimum of four patient consultations undertaken by the student, providing constructive feedback as needed. 3. To contact a member of the course management team with any queries about the course requirements. 4. To contact a member of the course management team with any queries about the student's progress. 5. To complete the verification of practice form. 6. To sign each prescribing episode in the student's portfolio as representing safe and appropriate prescribing for the patient. Ref. Nursing and Midwifery Council (2006) Ref. National Prescribing Centre (2005) Training and preparation for prescribing Nurses training to become a prescriber will undertake a specific programme of preparation at degree level. This programme comprises 26 taught days at a Higher Education Institution plus 12 days 'learning in practice' during which a designated supervising medical practitioner will provide the student with supervision, support and opportunities to develop competence in prescribing Document ID: Page 13 of 44 Version No: 3

practice. The programme of training and preparation may be spread over a period of 3-6 months. Nurses will qualify to prescribe independently and on a supplementary prescribing basis. The nurse will also need to undertake an element of self directed study. Pharmacists training to become a prescriber will undertake a specific programme of preparation at QAA level three (ie. degree level). This programme comprises 26 taught days which could be a combination of deskbased learning, open learning or distance learning. However, it is important there is some desk-based learning where there is the opportunity to learn from and support peers at a Higher Education Institution, which could be a school of pharmacy, plus 12 days 'learning in practice' during which a designated supervising medical practitioner will provide the student with supervision, support and opportunities to develop competence in prescribing practice. Pharmacists will qualify to prescribe independently and on a supplementary prescribing basis. AHPs training to become a supplementary prescriber will undertake a specific programme of preparation at least at degree level. This programme comprises 26 taught days at a Higher Education Institution (normally over a period of 3-6 months) plus 12 days 'learning in practice' during which a designated supervising medical practitioner will provide the student with supervision, support and opportunities to develop competence in prescribing practice. The following are some of the universities that offer prescribing courses Reading University contact Sue Topper 0118 378 5838 s.topper@reading.ac.uk Oxford Brookes University Marion Waite - 01865 488112 University of Hertfordshire Denise White 01707 284943 University of Winchester (E learning) Joan Burgess 01962 827494 University of Luton 01582 743048 Funding Funding for prescribing courses for staff in this Trust is currently provided by South Central Strategic Health Authority and includes course fees. This funding is not guaranteed long term. The student can undertake the course at universities within the post registration training contract (currently Bedforshire and Oxford Brookes Universities). For further information on non-medical prescribing please access www.southcentral.nhs.uk Or contact Nurse Prescribing Lead 01908 230525 Deputy Chief Pharmacist 01908 243655 Document ID: Page 14 of 44 Version No: 3

Process for application for non-medical prescribing course Consider if a patient group direction may be more appropriate than nonmedical prescribing. Link http://www.portal.nelm.nhs.uk/pgd/viewrecord.aspx?recordid=422 If wishing to use supplementary prescribing, read and understand the framework of a clinical management plan and consider how this mechanism allows you to potentially prescribe in your intended areas of prescribing. Those wishing to use independent prescribing also need to examine the permitted medicines and conditions (particularly CDs) and consider the appropriateness of this for their practice. Arrange a meeting with your manager to discuss appropriateness of nonmedical prescribing for your area of clinical practice Discuss your proposal with the NMP lead for your professional group. Identify a medical practitioner who could potentially be a designated medical practitioner (DMP) to support and assess you throughout your course. Provide the doctor or dentist you are considering asking to be your DMP with the attached information sheet in this pack. Ask them to read it carefully before agreeing to be your DMP. Obtain information and application form from chosen university. Complete PCT application form and discuss with your manager (Appendix A). Complete study leave application process to university of choice. For pharmacy and AHP applicants there is an additional funding form that needs to be completed and sent to the SHA. Your application will be reviewed by the Trust non-medical prescribing Lead. Once you have had confirmation that your application has internal approval you may submit your application to your chosen university. This will then need to be signed by the Trust NMP lead. 4.5 Supplementary Prescribing and The Clinical Management Plan The Clinical Management Plan is the foundation stone of supplementary prescribing. Before supplementary prescribing can take place, it is obligatory for an agreed CMP to be in place (written or electronic) relating to a named patient and to Document ID: Page 15 of 44 Version No: 3

that patient's specific condition(s) to be managed by the supplementary prescriber. This should be included in the patient record. Regulations specify that the CMP must include the following: the name of the patient to whom the plan relates; the illness or conditions which may be treated by the supplementary prescriber; the date on which the plan is to take effect, and when it is to be reviewed by the doctor or dentist who is party to the plan; reference to the class or description of medicines or types of appliances which may be prescribed or administered under the plan; any restrictions or limitations as to the strength or dose of any medicine which may be prescribed or administered under the plan, and any period of administration or use of any medicine or appliance which may be prescribed or administered under the plan; [NB The CMP may include a reference to published national or local guidelines. However these must clearly identify the range of the relevant medicinal products to be used in the treatment of the patient, and the CMP should draw attention to the relevant part of the guideline. Any guideline referred to also needs to be easily accessible] relevant warnings about known sensitivities of the patient to, or known difficulties of the patient with, particular medicines or appliances; the arrangements for notification of:- a) suspected or known reactions to any medicine which may be prescribed or administered under the plan, and suspected or known adverse reactions to any other medicine taken at the same time as any medicine prescribed or administered under the plan, and b) incidents occurring with the appliance which might lead, might have led or has led to the death or serious deterioration of state of health of the patient the circumstances in which the supplementary prescriber should refer to, or seek the advice of, the doctor or dentist who is party to the plan. Following diagnosis by the independent prescriber, the independent and supplementary prescriber will probably need to discuss the CMP before the document itself is prepared. Either the independent or supplementary prescriber may draft the CMP; however, both must formally agree to the CMP before supplementary prescribing can begin. It is for the independent prescriber to determine the extent of the responsibility he or she wishes to give to the supplementary prescriber under the CMP. The independent prescriber will clearly need to take account of the experience and areas of expertise of the supplementary prescriber and the professional relationship between the independent and supplementary prescribers when coming to this decision. The CMP comes to an end: At any time at the discretion of the independent prescriber At the request of the supplementary prescriber or patient At the time specified for the review of the patient (unless it is renewed by both prescribers at that time) Document ID: Page 16 of 44 Version No: 3

Where there is a sole independent prescriber and he or she is replaced for whatever reason. In these circumstances the CMP must be reviewed by their successor. Template CMPs are available in Appendix 2 4.6 The BNF & Drug Tariff These publications are essential to the prescriber. Nurses All nurse prescribers receive a copy of the Nurse Prescribers Formulary, which is published biennially. Nurses who are qualified as nurse independent prescribers should also receive six monthly copies of the British National Formulary, except for those occasions when publication of the BNF coincides with that of the Nurse Prescribers Formulary (NPF) when they will receive only the NPF. The Business Services Agency (formerly the Prescription Pricing Authority) also sends all nurse prescribers six-monthly copies of the Drug Tariff usually the May and November editions. Copies of all of these publications are distributed through the central NMP contact point in the PCT. Pharmacists All pharmacists already receive a copy of BNF every six months and a copy of the Drug Tariff monthly either direct or through their Trust/NMP Lead. AHPs AHP prescribers will receive copies of the BNF and Drug Tariff via the central NMP contact point in the PCT. Copies of both the BNF and Drug Tarriff are available online: www.ppa.org.uk/index (select drug tarriff) www.bnf.org 4.7 Safety and Security A. PRESCRIPTION PADS The Prescription Pad The prescription pad for non-medical prescribers (NMP) is coloured differently for easy identification by pharmacists and the Prescription Pricing Division (PPD). The pad is marked FP10(CN). Prescription pads for new prescribers will be supplied by The Stationery Office and will arrive ready personalised with the prescriber's details. The prescription forms will be serially numbered and produced on specially printed, anti-fraud paper with a total of one hundred forms on each pad. Document ID: Page 17 of 44 Version No: 3

Prescription pads are controlled stationery and are ordered by the Prescribing Lead PA, direct from The Stationery Office. Tel 01908 230525. The Prescription Form Prescribers working across different GP practices can use one pad, but must complete the relevant practice code for the client. Prescribers will be provided with a laminated card that will list practices with the corresponding practice codes. This card must be kept securely. Prescribers must complete all details on the prescription form by writing clearly and legibly using permanent black ink. The essentials for the proper completion of the FP10(CN) (FP10P) are included in the sections marked 'Record Keeping' and 'Prescribing'. The content of the prescription stamp has been agreed by the NHS Executive and the Prescription Pricing Division and will be used by The Stationery Office in the printing of the pads with each prescriber's details. This will include: The full name of the Trust The name of the NMP The NMP s Personal Identification Number (PIN) The contract code for Milton Keynes Primary Care Trust (a unique identifier developed and supplied by the PPD). On the prescription form prescribers must enter: The practice code at which the client is registered The telephone number of the NMP s base The client's details Prescriber's signature and the date Items prescribed as specified in section 'Prescribing' B. ELECTRONIC PRESCRIBING Non-medical prescribers who work out of a GP practice will be able to computer prescribe as soon as their surgery's prescribing system has been accredited. They will be able to use FP10SS prescription forms, as opposed to hand-written FP10P forms (lilac). This will be quicker and will allow patient records to be updated at the same time as prescribing takes place. FP10SS forms are green, computer single sheet prescription forms. The computer prescribing system will print the prescription, prescriber s name and address etc. Software configuration changes are required to ensure correct prescriber details are correctly printed by GP systems. Required details for non-medical prescribers are: A "prescriber identifier" e.g. EFNP/Nurse Supplementary Prescriber the appropriate professional PIN number Document ID: Page 18 of 44 Version No: 3

address details, using an agreed format (includes printing the appropriate practice/ surgery code (for prescribing cost allocation purposes)). Security of Paperwork Prescribing has legal and professional obligations and responsibilities. It is the responsibility of the prescriber to ensure the security of the pad at all times. The first and last serial number of the current prescription pad should be recorded and kept in a safe place. Minimal stocks of forms only will be held. Under no circumstances should blank prescription forms be signed before use. The prescription pad should only be produced when needed and never left unattended. A car is not a secure place, prescription pads must always be removed from the car. When travelling the prescription pad should not be visible in the car. Prescription pads must be kept in a lockable drawer. The prescription pad is the property of Milton Keynes Primary Care Trust. When a prescriber leaves employment, the prescription pad must be handed personally to the Prescribing lead to be destroyed before or on the last day of employment. An Annex A1 form must be completed and sent to the PPD Procedure for Loss or Suspected Theft of FP10 (FP10P) Forms Prescriber Responsibility Loss or suspected theft must be reported immediately to: Police (giving details of the approximate number of prescription forms involved, date, time and venue of loss) Thames Valley Primary Care Agency by telephone (0118 918 3376/3369 Contracts Team) Pharmaceutical Adviser at PCT Headquarters on 01908 243655 Pharmaceutical Adviser to record and inform NMP Admin Office (Neath Hill HC 01908 230525) If the loss occurs at a weekend or bank holiday Thames Valley Primary Care Agency and Pharmaceutical Adviser must be informed on the first working day. The police must still be informed at the time the loss is noted. A Security Incident Form must be completed this is available from Finance Department, Trust Headquarters and returned to Human Resources in Trust Headquarters. Document ID: Page 19 of 44 Version No: 3

Thames Valley Primary Care Agency Following the loss of prescription pads, Thames Valley Primary Care Agency will: Inform the prescriber to write and sign all prescription forms in a specified colour for a period of two months Inform all pharmacies in the relevant area. Trust's Responsibilty The NMP Steering Group must ensure the following: A current list of all prescribers, together with their signatures, is kept centrally That a record of the first and last serial numbers on prescription forms issued to NMPs are recorded and kept centrally, as well as by individual NMP That the Prescription Pricing Division is notified of the details of all NMPs eligible to prescribe. The PPA is notified immediately if: - A prescriber stops prescribing - A prescriber changes his/her name That no further prescription pads are ordered for a prescriber who has left employment or who has been suspended from prescribing duties and any remaining prescription pads are destroyed That prescribers have access to a secure place to keep prescription pads That NMPs are registered with the appropriate professional body by obtaining a copy of the NMPs Statement and maintaining this in their personal files Prescribing Prescriptions should be written in keeping with the recommendations in the BNF. NMPs can write prescriptions only on a prescription pad bearing their name and Registration Number. Prescribers qualified to prescribe cannot issue prescriptions: On behalf of a practitioner who is not a prescriber For a client they have not assessed for the current condition for which they are prescribing Each practitioner should be aware of the Practice Guidelines for Prescribing where the client is registered. Where prescribers prescribe for Travellers/Asylum Seekers who are not registered with a GP, a Temporary Registration Form, registering the client at the NMP s own practice, must be completed prior to prescribing. The practice should then be Document ID: Page 20 of 44 Version No: 3

informed of the Temporary Registration, and the prescribed medication entered on the computer and/or temporary medical records bearing the client's details. The prescriber must keep a record of the serial number of prescriptions in a safe and accessible place. All the details on the Prescription Form must be completed in permanent black ink. The quantity prescribed should be appropriate to the client's needs. Some medicines are available only in special packs and containers and the quantity contained should be prescribed provided this is clinically and economically appropriate. The item prescribed should be written clearly using approved generic titles as specified in the BNF and should not be abbreviated. The only exception to this rule is the prescribing of dressings and appliances, or where branded prescribing is recognised as good practice. Where there is more than one item on a prescription form a line should be inserted between each item for clarity. Unused space in the prescription area of the prescription form should be blocked out using a 'Z' line. Details of the item prescribed must include: The name of the item The quantity and strength where applicable The dosage and frequency The name of the prescriber and signature Full directions. Use of the terms 'as directed' or 'as before' must be avoided Only abbreviations that appear on the back page of the BNF are acceptable Alterations must be made by scoring out with a single line Other forms of erasure must never be used. Care & Control of Medicines All NMPs should follow the guidance on prescribing and medicines management as set out in MKPCT Care and Control of Medicine Policy and the medicine policies of Milton Keynes PCT. This includes adherence to the Milton Keynes Primary Care Trust Prescribing Strategy, the Milton Keynes Joint Trusts Formulary and procedures for the introduction of new drugs. The NMP shall not prescribe drugs, medicines or appliances whose cost or quantity, in relation to any patient, is, by reason of the character of the drug, medicine or appliance in question, in excess of that which was reasonably necessary for the proper treatment of that patient. Document ID: Page 21 of 44 Version No: 3

Prescribers are expected to follow guidance set out by NICE, MKPCT and within NSFs 4.8 Communication and Record Keeping Standards of proficiency for nurse and midwife prescribers (NMC 2006) "Records should include the prescription details, together with relevant details of the consultation with the patient/client. The maximum time allowed between writing the prescription and entering the details into the general record is for local negotiation. However, only in exceptional circumstances should this exceed 48 hours." To ensure good communication, the non-medical prescriber should enter into the patient held records at the time of issuing the prescription and the General Practice Computerised patient records (if applicable), within 48 hours the following details: - indication for prescribing - the date of prescribing - the name, dosage, route of administration and quantity of the item prescribed - the name of the prescriber and signature (electronic signature is acceptable) - if the date of the entry does not coincide with the date of the contact with the patient then the date of entry, actual time of visit and the date of the contact must be recorded. A record of any medication prescribed must be entered on the: Patient records at the time of issuing the prescription Clinic held records within 48 hours of the prescription being generated Personal Child Health Record, where relevant (to prevent 'clinic hopping'). Client's GP held medical records Computer held at the GP surgery where agreed with the practice within two working days of the prescription being generated. This can be done either personally or by fax to the named person at the surgery If the independent prescriber is covering for a prescribing colleague and writes a prescription for a patient from another practice this information must also be sent to the prescriber attached to that practice Supplementary prescribers must ensure there is a copy of the current clinical management plan filed in the patient's notes and that this updated as necessary Any adverse incidents MUST be recorded on an adverse incident form. Adverse Drug Reactions must be reported to the MHRA on a Yellow Card. The information entered should indicate: The name of the item prescribed The quantity prescribed, dose and frequency The date the item was prescribed Document ID: Page 22 of 44 Version No: 3

The prescriber (with name and qualification clearly printed) must sign the entry. The entry must be recorded on the patient notes/patient held records/on the same day on which the prescription was written. It should be recorded as soon as possible on the GP records/computer. In some circumstances, in the clinical judgement of the prescriber, it may be necessary to advise the GP immediately of the prescription. 5.0 Roles and Responsibilities 5.1 Chief Executive The Chief Executive has overall responsibility for ensuring the Trust has appropriate strategies, policies, protocols, procedures and guidelines in place and that the Trust works to best practice and complies with all relevant legislation. Final accountability for corporate policies, procedures, protocols and guidelines will reside with the Chief Executive of the Trust. He/She will ensure that responsibility for specific areas is allocated to the appropriate Accountable Director. Although responsibility for production may be delegated to others, ultimate accountability remains with the Chief Executive and Accountable Directors. 5.2 Non-Medical Prescribing Lead and NMP Steering Group Overall responsibility for overseeing the development and approval process of documents in line with this policy Placing approved documents on Medicines Management Intranet site Ensuring all obsolete documents are archived centrally Maintaining a record of Equality Impact Assessment outcomes related to this document 5.3 Authors of Documents It is the responsibility of the author of a document to:- Ensure that the above documents are implemented appropriately and, where necessary, audit the compliance with those documents. Ensure appropriate review of the documents, either in line with the review timescale set at the time of approval, or as a result of changes in practice, organisational structure or legislation. Ensure appropriate consultation has taken place with the relevant individuals and groups. Ensure route for dissemination of policy is clearly defined. Ensure guidance provided in this Policy is followed. Ensure the necessary Equality Impact Assessment has been carried out prior to the document entering the approval process. Document ID: Page 23 of 44 Version No: 3

5.4 Line Managers All line managers are responsible for:- Ensuring all approved documents are accessible for all their staff Ensure staff have read and understood the relevant documents Ensure systems exist to identify staff training needs on the implementation of new and updated documents. 5.5 All staff 6.0 Audit All staff must ensure that their practice is in line with current documents in use across the Trust and specific to their area of work. Incidents resulting from a failure to comply with a document must be reported to the Line Manager and the incident reporting system used where appropriate. Audits are to be maintained in line with recommendations from MKPCT. Each nonmedical prescriber is responsible for his/her individual practice, and must carry out regular reviews of his/her prescribing practice. Assistance with identifying audit methodologies and interpreting findings are available through MKPCT s normal clinical governance mechanisms. Individual non-medical prescriber PACT data is only available on request to the Pharmaceutical Advisers (Telephone 01908 243655). Competency Standards Competency Frameworks for all prescribers can be found on the National Prescribing Centre Website: http://www.npc.nhs.uk/non_medical/competency_frameworks.htm Standards of Proficiency for Nurse and Midwife Prescribers http://www.nmc-uk.org/aframedisplay.aspx?documentid=1645 The Clinical Governance Framework for Pharmacist Prescribers http://www.rpsgb.org/pdfs/clincgovframeworkpharm.pdf 7.0 Equality Impact Assessment This document has been Equality Impact Assessed prior to approval. Document ID: Page 24 of 44 Version No: 3

8.0 Healthcare Standards This document addresses the criteria outlined in the Healthcare Standards for PCTs under the following domains. Domain Evidence Safety Patient Focus This policy is designed to ensure that Non-Medical Prescribers are competent to practice. The aim of the policy is to ensure safe prescribing practice. This policy ensure that patients have prompt and effective access to Non-Medical Prescribing 9.0 Dissemination This policy will be placed on the Trust's central database. It will be placed onto the Trust's intranet site. 10.0 Overall responsibility for the document/appraisal Process The Non-Medical Prescribing Lead and Steering Group has overall responsibility for the review and update of this policy. This policy will be approved by PCT Prescribing Group Trust Management Team and Clinical Governance Committee. Document ID: Page 25 of 44 Version No: 3

APPENDIX 1 NHS NON-MEDICAL PRESCRIBING SOUTH CENTRAL STRATEGIC HEALTH AUTHORITY APPLICATION CRITERIA CANDIDATE AGREEMENT ORGANISATIONAL AGREEMENT SUPERVISION SUPPORT AGREEMENT Please return to SUE McCREADY, PRESCRIBING LEAD, NEATH HILL HEALTH CENTRE NB: Short meeting will be required with Sue to establish course eligibility. Document ID: Page 26 of 44 Version No: 3

NON-MEDICAL PRESCRIBERS (NMP) APPLICATION Funding for Non-Medical Prescribing is obtained through this application to Non- Medical Prescribing Leads who access funding through the Strategic Health Authority. All parts MUST be completed Name and Address of Candidate Name: Address: Job Title: Signature: Date: Name and Address of Employing Organisation Prescribing Lead: Sue McCready Address: Neath Hill Health Centre 1 Tower Crescent Neath Hill Milton Keynes MK14 6JY Signature: Date: Name & address of Medical Prescriber practice supporter Signature: Date Line Manager agreement to release from practice for taught theory and medical supervision Name (please print): Tel no: Signature: Date: NAME OF UNIVERSITY: Start Date: Document ID: Page 27 of 44 Version No: 3

NHS NON-MEDICAL PRESCRIBING (NMP) APPLICATION CRITERIA CANDIDATES AGREEMENT Name:. Designation: NMC Pin No:.. Expiry Date: Registration No:. Address:.... Which area(s) are you currently caring for patients for whom you are likely to prescribe for: Minor Injuries Minor Ailments Health Promotion Palliative Care If other, please indicate:... Please indicate your qualifications and dates you qualified:.. Date:... Date:... Date:... Date:. Are you a 1 st level Registered Nurse or Registered Midwife? Yes No If yes, which part of the Register are you on:... Are you a Pharmacist? Yes No Are you a AHP? Yes No Are you capable of study at level 3? Yes No Describe what support networks are available to you:.. Document ID: Page 28 of 44 Version No: 3

Please demonstrate the need within your service/client group for non-medical prescribing skills including level of client contacts (relate to key areas, etc) (Please complete prescribing situation A form): Document ID: Page 29 of 44 Version No: 3

NHS NON-MEDICAL PRESCRIBING (NMP) MANAGER STATEMENT OF COMMITMENT TO UNDERTAKE THE PREPARATION FOR NON-MEDICAL PRESCRIBING NB. Managers should not put applicants forward if they have not demonstrated the competencies below. By approving this application the Manager is confirming that: 1. The applicant has been assessed as competent to take a history, undertake a clinical assessment and diagnose. Tick 2. There is a clinical need within the applicant's role to justify prescribing. Tick 3. The applicant has sufficient knowledge to apply prescribing principles taught on the course to their own area of practice. Tick 4. The applicant can demonstrate appropriate numeracy skills. Tick ORGANISATIONAL STATEMENT: (To be completed by Line Manager) I agree to release the applicant for study related to the Non-Medical Prescribing Name:.. Signature:.... Date:... I agree to support and release the applicant to use prescribing Skills Name:.. Signature:.... Date:... APPLICANT STATEMENT: I agree to complete the Non-Medical Prescribing Preparation Programme and to use my newly acquired skills to benefit the users of my service Name:.. Signature:.... Date:... (Competencies can be confirmed through the applicant undertaking a module to prepare them in diagnosis and physical assessment through CPD reviews.) Based on Standards of Proficiency for Nurse and Midwife Prescribers NMC 2006 Document ID: Page 30 of 44 Version No: 3

NHS NON-MEDICAL PRESCRIBING (NMP) AGREEMENT WITH SUPERVISION IN PRACTICE SUPPORTER Proforma for Approval of Non-Medical Prescribing Training Practice/Department Name of Medical Assessor:... Qualifications:.. Address: Contact Telephone Number:. Could you please supply the following information to assist in making sure the Department of Health criteria for the supervision in practice for nurse and midwife prescribers by medical assessors are being met. Please tick the appropriate boxes. DoH (Nov 2001) Criteria. Are you a registered medical practitioner who: (i) and (ii) and (iii) and (iv) has normally had at least 3 years medical, treatment and prescribing responsibility for a group of patient/clents in the relevant field of practice? Yes No (a) is within a GP practice and is either vocationally trained or is in possession of a certificate of equivalent experience from the Joint ofr Post-Graduate Training in General Practice? Yes No (b) is a specialist registrar, clinical assistant or a consultant within a NHS Trust or other NHS employer? Yes No has the support of the employing organisation or GP practice to act as the designated medical practitioner who will provide supervision, support and opportunities to develop competence in prescribing practice? Yes No has some experience or training in teaching and/or supervision in practice? Yes No If not an Approved Training Practice/Institution, then please outline your experience of teaching, supervision and assessment of students:......... I confirm that I have agreed to provide for a total of 12 days of the programme the training opportunities, supervision, support and assessment for (student) to enable her/him to undertake the Non-Medical Prescribing course. Signature:. Date:. For office use only Approved for funding Yes/No Signed Date Document ID: Page 31 of 44 Version No: 3

Non-Medical Prescribing Course DPMP Agreement Form This form must be signed within the first two weeks of a student starting the course. DPMP commitments: 1. To meet with the student at the start of the course, the midway point and at the end of the course in order to: Discuss identified learning needs and the student's progress in meeting these. Discuss the student's log of practice activities. 2. To observe a minimum of four patient consultations undertaken by the student, providing constructive feedback as needed. 3. To contact a member of the course management team with any queries about the course requirements. 4. To contact a member of the course management team with any concerns about the student's progress. 5. To complete the verification of practice form. 6. To sign each prescribing episode in the student's portfolio as representing safe and appropriate prescribing for the patient. Name of DPMP:... Name of Student Signature of DPMP:.. Signature of Student.. Date:. Date: Document ID: Page 32 of 44 Version No: 3

FORM A Prescribing situation NMP Candidate Job Title (Compliments of Royal Berkshire and Battle NHS Hospitals Trust) Please describe a situation where you believe non-medical prescribing, within the current legal framework, would benefit a patient you have recently cared for Type of prescription EP or SP please state How would the medicines you wish to prescribe now be provided for the patient? Are there any particular implications that follow for this patient? Please describe here Please describe here Please describe here Patient Please describe the benefits if you could have prescribed in this situation to the: Organisation You How often do you think the situation you described above would occur? DAILY WEEKLY MONTHLY As a non-medical prescriber applicant do you perceive any barriers to being able to prescribe? Please state below: 33

APPENDIX 2 TEMPLATE CMP 1 (Blank): for teams that have full co-terminus access to patient records 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 34

TEMPLATE CMP 2 (Blank): for teams where the SP does not have co-terminus access to the medical record Name of Patient: Patient medication sensitivities/allergies: Patient identification e.g. ID number, date of birth: Current medication: Medical history: Independent Prescriber(s): Supplementary prescriber(s): Contact details: [tel/email/address] Contact details: [tel/email/address] Condition(s) to be treated: Aim of treatment: Medicines that my 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 35

APPENDIX 3 Form for Obtaining SHA Funding in Thames Valley, for Pharmacist and AHP Supplementary Prescribing Training. Process of application for NHS funding for Supplementary prescribing courses for Pharmacists & AHP s This form has been adapted from that used by the London WDCs Please read the following notes carefully. Each applicant working in the Thames Valley area who wishes to obtain NHS funding, will need to complete one of these forms. Funding will cover the cost of the training course. Please complete the form and return a paper copy to Elaine Bowden Education Commissioning Manager, NHS Education South Central (NESC),1 st Floor Rivergate House, Newbury Business Park, London Road, Newbury, Berkshire, RG14 2PZ It is important that funding decisions are made as early as possible so please complete and return this form even if you are not yet clear which university courses are available or which you might wish to attend. All applications will be considered by a meeting of the TV non-medical prescribing steering group and you will be notified of the funding decision by e-mail. Incomplete forms will be returned to the applicant. Successful applicants will be funded as individuals supported by a named NHS organisation. If an individual moves to another organisation or the organisation wishes to support another individual, a separate funding application must be made. Please note: Each applicant must also apply separately to the education provider that you wish to attend for training e.g. the university. Forms are available directly from the university and once completed, must be returned to the university. When the names of the universities are available they will be listed in Appendix B. The university will notify its applicants of their decisions. University places cannot be accepted without funding and the SHA will be working closely with the course providers to match funding with places. Availability of forms Copies of this form are available on the Thames Valley Strategic Health Authority web site www.tvsha.nhs.uk Completion of form The form must be completed as follows: Section 1 and Section 5 must be completed by the applicant. 36