The Scottish Government

The Scottish Government Chief Nursing Officer Directorate Fiona McQueen, Chief Nursing Officer Dear Colleague Physiotherapist, Podiatrist or Independent Prescribing Services Summary Chiropodist The Scottish Government n - LEGACY 2014 xx COMMONWEALTH GAMES SCOTLAND DL (2015) 15 29 June 2015 Addresses For action 1. Further to CEL(2014) 14 advising of the introduction of Physiotherapist, Podiatrist or Chiropodist Independent Prescribing Services into NHS primary care services this letter details; the administrative and procedural steps required to introduce the service in local Board arrangements; and arrangements for ordering prescription stationery. 2. Annex A details the administrative and procedural steps required. 3. Annex 8 details the prescription ordering arrangements. 4. The NHS (Primary Medical Services Section 17C Agreements) (Scotland) Regulations 2007 and the NHS (General Medical Services Contracts) (Scotland) Regulations 2007 regulate the provision of services from general practitioners under agreements or contracts with NHS Boards. 5. Amendments to the Regulations came into effect on 01 May 2014. These amendments expanded the rules for prescribers in GP practices to include Physiotherapist, Podiatrist or Chiropodist Independent Prescribers Chief Executives, NHS Boards For information Directors of Pharmacy Chief Executive NHS NSS Director of Practitioner Services, NHS NSS General Enquires to: Susan Malcolm Chief Nursing Officer's Directorate Ground Floor East St Andrew's House EDINBURGH EH13DG Tel: 01312442487 email: susan.malcolm@scotland.gsi.gov.uk Prescribing Enquiries to: Shelagh Scott Pharmacy & Medicines Division 1 51 Floor East Rear St Andrew's House EDINBURGH EH13DG Tel: 01312442597 email: Shelagh.Scott@scotland.gsi.gov.uk www.scotland.gov.uk

Action 6. NHS Boards are asked to bring this letter and Annexes to the attention of all staff involved with matters relating to the prescribing and dispensing of NHS prescriptions, in particular: Physiotherapists, Podiatrists or Chiropodists; Community pharmacists; and General medical practitioners. Yours sincerely FIONA MCQUEEN Chief Nursing Officer

Annex A GUIDANCE FOR NHS BOARDS: PHYSIOTHERAPIST, PODIATRIST OR CHIROPODIST INDEPENDENT PRESCRIBERS 1. Independent prescribing by Physiotherapists, Podiatrists or Chiropodists is designed to support: Caring for people in a safe environment and protecting them from avoidable harm; Empowering clinicians to provide the right care, first time and as close to the patients home as possible; Reducing avoidable hospital admissions, especially for frail and elderly patients who following admission are at increased risk of harm from infection and falls; Supporting the increasing number of people living with long-term conditions to self-manage, without unnecessary onward referral or handoffs of care; and Improving the patient experience and reducing inequalities through convenient and timely access to appropriate medicines. 2. Independent prescribing builds on the experience of supplementary prescribing and enables Physiotherapists, Podiatrists or Chiropodists to make autonomous decisions about the treatment of patients. Independent prescribing requires an initial patient assessment, I interpretation of that assessment, a decision on safe and appropriate therapy, and a process for ongoing monitoring of the patient. Physiotherapist, Podiatrist or Chiropodist Independent Prescribers must only work within their own level of professional and clinical competence and must seek advice and make referrals to other healthcare professionals as necessary. Definition of Independent Prescribing 3. The working definition of an independent prescriber is "a practitioner (e.g. doctor, dentist) responsible and accountable for the assessment of patients with undiagnosed or diagnosed conditions and for decisions about the clinical management required, including prescribing." How can Physiotherapists, Podiatrists or Chiropodists become Independent Prescribers? 4. A Physiotherapist, Podiatrist or Chiropodist Independent Prescriber must be a registered Physiotherapist, Podiatrist or Chiropodist whose name is held as a practising prescriber on the register of the Health Care Professions

Council (HCPC) with an annotation signifying that s/he has successfully completed an education and training programme accredited by the HCPC. 5. In addition to fulfilling the legal criteria for eligibility to prescribe, physiotherapists, podiatrists and chiropodists who wish to train as independent prescribers must have experience practising in the clinical environment where they will prescribe and be annotated with the Health and Care Professions Council (HCPC) either as independent and/or supplementary prescribers. 6. The outline curricula for Physiotherapist, Podiatrist or Chiropodist independent prescribing training and for the conversion of Physiotherapist, Podiatrist or Ch iropodist supplementary prescribers to independent prescribers can be accessed on the HCPC website. 1 Selection Criteria for Training 7. The selection of Physiotherapists, Podiatrists or Chiropodists who may train as NHS independent prescribers is a matter for NHS Boards who are best placed to assess local service and patient needs. In selecting Physiotherapists, Podiatrists or Chiropodists, whether they work in primary care or in secondary care, NHS Boards should confirm that: the post is one in which the Physiotherapist, Podiatrist or Chiropodist has the need and the opportunity to act as an independent prescriber immediately after qualifying. In this regard, the therapeutic area in which the Physiotherapist, Podiatrist or Chiropodist will prescribe should also have been identified before they begin training; they have access to the relevant budget to meet the cost of their prescriptions; a designated medical practitioner agrees to support and supervise the non medical prescribers 12 days (78hours) "learning in practice" element of the training; they will support Physiotherapist, Podiatrist or Chiropodist Independent Prescribers during their training, allow some flexibility for self-directed study and provide access to Continuing Professional Development (CPO) on completion of their training course; and Physiotherapist, Podiatrist or Chiropodist Independent Prescribers work within a robust clinical governance framework. Legislative Requirements 8. Boards may only enter into arrangements for the provision of a Physiotherapist, Podiatrist or Chiropodist Independent Prescribing Service with an appropriately trained and registered Physiotherapist, Podiatrist or 1 www.hpc-uk.org

Chiropodist who is on the non medical presciber register maintained by the Board and will provide the service as part of their Physiotherapist, Podiatrist or Chiropodist role. 9. NHS Boards can also directly employ or engage Physiotherapist, Podiatrist or Chiropodist Independent Prescribers to provide a Physiotherapist, Podiatrist or Chiropodist Independent Prescribing Service. Funding for Physiotherapist, Podic;ltrist or Chiropodist Independent Prescribing Training Courses 10. Central funding is currently made available through the Scottish Government Health Directorates to support the direct costs of NHS Physiotherapist, Podiatrist or Chiropodist Independent prescribing training. It is also open to NHS employers to pay for the training of Physiotherapists, Podiatrists or Chiropodists through other sources of funding. Medicines Prescribable Under Physiotherapist, Podiatrist or Chiropodist Independent Prescribing Arrangements 11. Physiotherapist, Podiatrist or Chiropodist Independent Prescribers are able to prescribe licensed medicines with the current exception of Controlled Drugs. Physiotherapist, Podiatrist or Chiropodist Independent Prescribers providing a Physiotherapist, Podiatrist or Chiropodist Independent Prescribing Service in primary care may not prescribe drugs, medicines and other substances listed in Schedule 1 to the "Directions as to the Drugs, Medicines and Other Substances which may, or may not, be ordered for patients in the provision of Primary Medical Services under a General Medical Services Contract. The only exception to this is if they are using a supplementary prescribing arrangement within an agreed clinical management plan. 12. Medicines legislation allows Physiotherapist, Podiatrist or Chiropodist Independent Prescribers to prescribe medicines off-label - i.e. outside their licensed indication(s) but if they do so they must accept professional, clinical and legal responsibility for such prescribing, and should only prescribe "offlabel" where it is accepted clinical practice. If medicines are to be used 'offlabel', where possible the prescriber Ishould explain the situation to the patient/guardian. Where a patient is unable to agree to such treatment the prescriber should act in accordance with their professional ethics, best practice available for the given situation and within any policy guidance from the NHS Board. 13. The Advisory Committee on Borderline Substances (ACBS) advises as to which substances may be regarded as drugs - the ACBS approved list can 2 be found in the British National Formulary (BNF). Physiotherapist, Podiatrist or Chiropodist Independent Prescribers can prescribe borderline substances, but the prescription must be endorsed 'ACBS'. Although the ACBS list is non- 2 https:llwww.medicinescomplete.com/mc/bnf/curnentl

mandatory, Physiotherapist, Podiatrist or Chiropodist Independent Prescribers should normally restrict their prescribing of borderline substances to the items listed and they should work within any guidance issued by the NHS Board. 14. Physiotherapist, Podiatrist or Chiropodist Independent Prescribers in primary care can prescribe any appliances/dressings listed in the Scottish Drug 3 Tariff. Physiotherapists, Podiatrists or Chiropodists prescribing in secondary care are not restricted to prescribing from the Tariff list but, when prescribing, should take into account local formulary policies and the implications for primary care. 15. The Home Office/Department of Health has consulted on proposals to enable Physiotherapist, Podiatrist or Chiropodist Independent Prescribers to prescribe Controlled Drugs. Home Office Ministers have confirmed that they will aim to implement the legislative changes by June 2015. Physiotherapist, Podiatry or Chiropody Independent Prescribers: Dispensing Prescriptions in Hospital 16. A register of Physiotherapist, Podiatry or Chiropody Independent Prescribers currently employed by a Health Board should be kept by the Non- Medical Prescribing (NMP) lead. Pharmacy staff should be able to check the prescriber against the register. 17. The HCPC has an on-line web portal which provides a list of Physiotherapists, Podiatrists or Chiropodists registered either by name or registration number. Dispensing Doctors: Dispensing Physiotherapist, Podiatry or Chiropody Independent Prescriber Prescriptions 18. Physiotherapist, Podiatrist or Chiropodist Independent Prescriber prescriptions can be dispensed by a GP dispensing practice, but only for the patients of that practice. Patient Records: Access and Updating 19. All health professionals must keep accurate, legible, unambiguous and contemporaneous records of a patient's care. Information on prescribing and any other relevant details resulting from a patient consultation with a Physiotherapist, Podiatry or Chiropody Independent Prescriber must be entered into the shared patient record immediately, or as soon as possible. Only in exceptional circumstances e.g. over a weekend or public holiday, should th is period exceed 48 hours from the time of writing the prescription. It is recommended that, as a minimum, the record should indicate the date, name of the prescriber, item prescribed, quantity prescribed (or dose, frequency and treatment duration). In the case of topical medicines, the name of the item, strength (if any) and the frequency of application. For appliances/dressings, details of how they are to be applied and how frequently changed. It is also 3 http://www. isdscotland. org/health-t opics/prescribinb-and-med icines/scottish-drug-t ariffl

useful to record any advice given on General Sales List and Pharmacy medicines. Prescribing information should also be entered onto any other separate record(s) which may exist for that patient e.g. nursing or pharmacy record. Suspected Adverse Reactions to Medicines 20. If a patient suffers a clinically significant suspected adverse reaction to a medicine, the. adverse reaction should be reported via the Yellow Card Scheme. Information about the Scheme can be found on the Medicines and Healthcare products Regulatory Agency (MHRA) website 4.(or by completing the yellow form available at the back of hard copies of the BNF) 21. "Drug Safety Update" is a monthly electronic bulletin issued by the MHRA which contains information and clinical advice about the safe use of medicines and includes regular updates on the Yellow Card Scheme. The Drug Safety Update can be accessed on the MHRA website. Legal and Clinical Liability 22. Prescribers are accountable for all aspects of their prescribing decisions. They should only prescribe those medicines they know are safe and effective for the patient and the condition being treated. 23. Physiotherapist, Podiatrist or Chiropodist Independent Prescribers should ensure that they have sufficient professional indemnity insurance, for instance by means of membership of a ~rofessional organisation or trade union or through vicarious liability arrangements with their employer. For further information Physiotherapists, Podiatrists or Chiropodists should refer to the HCPC website and to their Code of Ethics and Standards. 24. Where a prescriber 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. Clinical Governance 25. 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. 26. The HCPC has developed a GB-wide clinical governance framework both f~r ~h~siotherapist: ~od.iatri~t or Chi l~opodist.prescrib~rs. and orga~isations commissioning or participating In PhYSiotherapist, Podiatrist or Chiropodist prescribing. NHS Boards should refer to this framework, which is available on the Society's website. 4 https:llwww.gov.uk/governmentlorganisations/medicines-and-healthcare-products-regulatoryagency

Role of NHS National Services Scotland (NSS) 27. Physiotherapist, Podiatrist or Chiropodist Independent Prescribers in primary care need to be registered with NSS before prescription forms can be ordered. 28. Information about registration and other details can be found on the Information Services Division website 5 29. Each Physiotherapist, Podiatrist or Chiropodist Independent Prescriber will be issued with a unique prescriber code, and the NMP Lead wi ll order a supply of prescription stationery for the Physiotherapist, Podiatrist or Chiropodist Independent Prescriber using form PSD7 (for Physiotherapist, Podiatrist or Chiropodist Independent Prescribers in primary care) and form HBP (for hospital-based Physiotherapist, Podiatrist or Chiropodist Independent Prescribers). 30. These forms can be downloaded from the Practitioner Services Division website 6 31. Completed forms should be sent to Practitioner Services, 3 Bain Square, Kirkton Campus, Livingston EH54 700. 32. Information Services Division of NSS will provide the NHS Boards with Physiotherapist, Podiatrist or Chiropodist independent prescribing data for monitoring purposes. Security & Safe Handling of Prescription Stationery: Good Practice 33. The security of prescription stationery is the responsibility of the NHS/employing organisation and the practitioner. It is good practice to record the number of the next unused form at the end of the working day. This will help to identify quickly any forms that are lost or stolen. Blank forms must never be pre-signed or left unattended. 34. Practitioners should report a suspected loss or theft of any prescription stationery to the local NHS Board as soon as the loss/theft is discovered. They should report the number of prescription/requisition forms 10sUstolen, their serial numbers and where and when they were 10sUstolen. The Board should notify the Fraud Liaison Officer, who is responsible for informing local pharmacists and NHSScotland Counter Fraud Services and for deciding jointly with the NHS Board and NHSScotland Counter Fraud Services on the action to be taken. Further information on Counter Fraud Services can be found at www.nhs.cfs.scot.nhs.uk 5 http://www. isdscotland. org/health-t opics/prescribing-and-med icines 6 http://www. isdscotland. org/hea Ith-T opics/prescribing-and-med icines/prescriber -Codes

ANNEX B APPLICATIONS FOR REGISTRATION OF NON MEDICAL PRESCRIBERS TO PRESCRIBE ON GP10NMP PRESCRIBING STATIONERY (prescribers in secondary care can prescribe on medicines charts without going through this process but will be registered to prescribe on the healthboards register) Prescriber Requests form ISD(NMP)1 from local NHS Board, or download from http://www.isdscotland. org/health- T obics/prescribing-and- Medicines/Prescriber-Codes/ Sends completed form to local NHS Board. NHS Board Authenticates information provided. Approves application. I Authorises use of NHS prescriber code (if available). Sends completed form to NSS Evadis Team - nss.evadis@nhs.net 1 NSS Allocates prescriber code (if necessary). Confirms registration. Registers prescriber on EVADIS. NHS Board Sends to NSS Practitioner Services (PSD) form PSD GP10NMP http://www.psd.scot.nhs.ukjprofessionals/pharmacy/prescription forms/gp10nmp ord er form Sep14 OOO.doc Request supply of prescription pads. Order and delivery timetable is available at: http://www.psd.scot. nhs. ukjprofessionals/pharmacy/prescription-order -Forms. htm I PSD Arranges printing of prescription pads. NHS Board Receives prescription pads GP1 O(NMP) Forwards pads to prescriber.

PSD 7 NON MEDICAL PRESCRIBER: ORDER FORM for GPIONMP for PODIATRISTS, RADIOGRAPHERS & PHYSIOTHERAPISTS Form to be completed by Authorised Signatory and returned to: Practitioner Services, Kirkton Campus, 3 Bain Square, Livingston, EH54 7DQ Tel : 01506 705 100 Fax: 01506 705 191 e-mail: NSS.psd-pscriber-statnry@nhs.net 1.1.1 Prescriber Code (If Part Printed Board Cipher only) HCPC ;Registration No Health Surname:........................... Radiographer Independent Prescriber Supplementary Prescriber Physiotherapist Independent Prescriber Supplementary Prescriber Podiatrist Independent Prescriber Supplementary Prescriber Initial:..... Please tick Please tick Please tick I Part Printed Pads Principal Address (for pre-printing on pads) Post Code........... Contact Telephone Number... Quantity (Minimum quantity 5 pads) D Address for delivery of pads: (NHS organisation stores or pharmacy depaltment/ ordirect to the prescriber' s address where agreed with PSD by NI IS Board's Finance Manager): Post Code:...................... Signed:....................................... (Authorised Signatory) Date:......... Print Name:................... Telephone Number:...............