MM03 NON MEDICAL PRESCRIBING GUIDANCE FOR SUPPLEMENTARY AND INDEPENDENT PRESCRIBERS. Version: 1

Version: 1 MM03 NON MEDICAL PRESCRIBING GUIDANCE FOR SUPPLEMENTARY AND INDEPENDENT PRESCRIBERS Date to be reviewed: 1 January 2012 No of pages: 57 Author(s) title: Practice Development Nurse Manager ACoS Nursing, Medicines Management Specialist Nurse, Medicines Management Responsible dept / Pharmacy & Medicines Management director: Approved by: Medicines Policies Group Date approved: 1 April 2011 Endorsement by: Date endorsed: 1 April 2011 Date activated (live): 1 June 2011 Senior Nurse Midwifery Committee / Clinical Directors, Pharmacy Date EQIA completed: October 2010 Documents to be read alongside this policy: Review Purpose of Issue/Description of current changes: To provide Guidance for Non Medical Prescribing at Health Board First operational: 1 June 2011 Previously reviewed: Changes made yes/no: PROPRIETARY INFORMATION This document contains proprietary information belonging to the Betsi Cadwaladr University Health Board. Do not produce all or any part of this document without written permission from the BCUHB MM03 Version: 1 Page 1 of 57

CONTENTS Page Introduction 6 Scope of this Guidance 6 Aims of the Guidance 6 Different Categories of Non-medical Prescriber in Wales 7 Summary of Key Points 8 Prescribing Within Competence 8 Training 9 Eligibility to Become a Non-medical Prescriber 9 Application 10 Registration of the Qualification Upon Completion of Training 10 Local Registration 10 Prescription-only Medicines (local formulary) 11 Unlicensed Medicines 12 Mixing Medicines and Prescribing Medicines for Mixing 12 Off-label Medicines 12 Borderline Substances 12 Appliances and Dressings 12 Types of Prescriptions 13 Quality and Governance Framework and Liability 13 Liability and Responsibilities of the Non-medical Prescriber 14 Liability and Responsibilities of the Employer 14 MM03 Version: 1 Page 2 of 57

Professional Indemnity 14 Employment of New Staff Who Already Hold a Non-medical Prescriber s Qualification 15 Non-medical Prescriber Returning to Work Following a Lengthy Period Of Absence eg Maternity Leave / Sickness 15 Non-medical Prescribing Staff Leaving BCUHB 15 APPENDICES Page Appendix 1 CONTINUING PROFESSIONAL DEVELOPMENT (CPD Introduction 16 Resources 17 Reference List for Evidence-based Therapeutics 18 Alerting Systems 18 Trusted Information Sources for Evidence-based Therapeutics 18 Structured Clinical Examination of Practice (Phase 1-5) 19 Self Certification Process for Ongoing Competence 24 Appendix 2 CATEGORIES OF NON-MEDICAL PRESCRIBERS IN WALES 26 Independent Nurse Prescriber (limited District Nurse / Health Visitor / Community Nurse) 26 Supplementary Prescriber 26 The Clinical Management Plan (CMP) 26 Independent Prescriber 27 Clinical Management Plan Template 28 Appendix 3 OBTAINING PRESCRIPTIONS 29 Process for registering and ordering prescription stationery 30 Detail Required on Stamp for NIP / PIP 31 Storing Prescriptions 31 Stolen Prescription Forms 31 Destruction of Prescriptions When Staff Change 31 Appendix 4 RECORD KEEPING 32 Appendix 4a Prescribing Record Sheet for GP Practice 33 Appendix 5 ADVERSE DRUG REACTION REPORTING 34 Black Triangle Medication 34 MM03 Version: 1 Page 3 of 57

Appendix 6 PRESCRIBING AND ADMINISTRATION OF MEDICINES 35 Prescribing for Self, Friends and Family 35 Appendix 7 GIFTS AND BENEFITS 36 Appendix 8 BUDGET SETTING AND MONITORING 37 Prescribing Costs 37 Appendix 9 DISPENSING OF PRESCRIBED ITEMS 38 Pharmacist Dispensing of Pharmacist Independent Prescriber Prescriptions 38 Dispensing Doctors in Primary Care 38 Dispensing of Items in England, Scotland and Northern Ireland 38 Reimbursement of Prescriptions Dispensed in Primary Care 38 Appendix 10 INDEPENDENT AND PRIVATE CONTRACTORS. (e.g. Practice Nurses employed by GPs) 39 Appendix 11 MONITORING COMPLIANCE TO GUIDANCE 40 Appendix 12 REGISTRATION WITH PROFESSIONAL BODY 41 NMC Register for Nurse Prescribers 41 General Pharmaceutical Council (GPC) Register For Pharmacist Prescribers 41 Health Professions Council (HPC) 42 Appendix 12a LOCAL REGISTRATION AND SPECIMEN SIGNATURE FORM 43 Appendix 13 RISK ASSESSMENT 44 Risk Assessment for implementation of non medical prescribing 45 Non Medical prescribing Risk assessment Worksheet 46 BCUHB Non-medical Prescribing Personal Formulary 48 GLOSSARY 50 MM03 Version: 1 Page 4 of 57

BIBLIOGRAPHY 53 RESOURCES 55 Members of the Working Group 56 Consultation / /engagement 56 MM03 Version: 1 Page 5 of 57

Introduction Scope of this Guidance This guidance is based on the Welsh Assembly Government (WAG) document Non Medical Prescribing - A Guide for Implementation (July 2007). The WAG document provides guidance for the implementation of prescribing by non-medical practitioners. This guidance aims to cover supplementary and independent prescribing by nonmedical prescribers (NMPs) employed by Betsi Cadwaladr University Health Board (BCUHB). This document may be used by independent contractors for information and guidance. The document has been written in a generic form to take into account the range of healthcare professionals that will have extension in the form of prescribing to their roles in the future. The introduction of non-medical prescribing in Wales is a dynamic process and this document reflects the current guidance available on its date of publication. Available at: http://www.wales.nhs.uk/sites3/page.cfm?orgid=371&pid=21001 Pharmaceutical Division Welsh Assembly Government Cathays Park Cardiff CF10 3NQ Aims of the Guidance: To define non-medical prescribing practice within BCUHB. To ensure that the development of non-medical prescribing within BCUHB is in line with the organisation s strategic plan. To ensure that prescribing takes place within a clinical governance framework and that NMPs are aware of their legal and professional responsibilities when prescribing. To support appropriate and effective prescribing practice within BCUHB. To inform other health care professionals and patients of the process of nonmedical prescribing. To benefit the patient and provide improved medicines access opportunities within BCUHB. To assist in identifying potential candidates and areas for development of nonmedical prescribing. To encourage personal development and to monitor practice. This document sets out the administrative and procedural steps needed to enable the following healthcare professionals to act as supplementary prescribers: Registered nurses; registered midwives; Registered pharmacists; MM03 Version: 1 Page 6 of 57

Registered chiropodists and podiatrists; Registered physiotherapists; Registered radiographers, diagnostic or therapeutic; Registered optometrists; and the following healthcare professionals to act as independent prescribers: Registered nurses; registered midwives; Registered pharmacists. One of the key recommendations within this guide is that each non-medical prescribing student who is undergoing training, and on completion of training, has to have senior medical staff who will support the student to develop themselves into the role of an NMP. Medical staff have been given the term Designated Supervising Medical Practitioner (DSMP) or Designated Medical Practitioner (DMP). A DSMP/DMP can be a GP, clinical assistant, staff grade or consultant. For more information on the role of a DSMP/DMP, see A guide to help doctors prepare for and carry out the role of designated medical practitioner Available to view on line at: http://www.npc.co.uk/npc_publications/resources/designated_medical_practitioners_gui de.pdf Appropriate Continuing Professional Development (CPD) is a professional obligation for all NMPs (See Appendix 1). Different Categories of Non-medical Prescriber in Wales (See Appendix 2) and factors to consider when adopting prescribing options Supplemetary Prescribers Supplementary prescribing is appropriate for prescribing in the following circumstances: Where patients with long term conditions can be managed by a nurse, pharmacist, physiotherapist, optometrist, chiropodist or radiographer between reviews by the doctor Where there is a close working relationship between the independent prescriber and the supplementary prescriber and both have the same common access to the patient record. It is the most appropriate mechanism for prescribing, for instance, where a prescriber is newly qualified or where a team approach to prescribing is clearly appropriate or where a patient s clinical management plan includes certain Controlled Drugs Where the supplementary prescriber is competent to manage the patient s condition Supplementary prescribing is not suited to emergency, urgent or acute situations because an agreed CMP is required before prescribing can begin. MM03 Version: 1 Page 7 of 57

Independent prescribers Independent non medical prescribing is appropriate in the following circumstances: Where the non medical prescriber works remotely from the doctor, seeing patients independently Where the doctor could see and treat other patients while the non medical prescriber sees some patients Where the non medical prescriber is competent to assess, diagnose and make treatment decisions for patients Prescribers must work within own area of clinical competence It is not appropriate or suitable practice for non-medical prescribers to diagnose and prescribe for several co-morbidities within the same patient. Current legislation places restrictions as to what can and cannot be prescribed by NMPs but this is likely to change; therefore non-medical prescribers are required to keep up to date with legislation and changes applicable to their profession. NMPs are also required to follow BCUHB guidance or policies applicable to medicines management, particularly the Medicines Code and any recommendations on prescribing made by the Health Board Drug & Therapeutics Group. Summary of Key Points Prescribers must only prescribe within their own level of expertise and competence, acting in accordance with their professional code of conduct. There must be a local need for NMPs to prescribe within the post and for this to be included in their job descriptions on completion of training. Eligibility criteria to become an NMP must be met. All staff must be able to demonstrate evidence of appropriate specialist knowledge in the area in which they intend to prescribe. All NMPs have a professional responsibility to keep up to date with best practice in the management of the conditions for which they prescribe. Prescribing Within Competence All nurse and pharmacist independent and supplementary prescribers and allied health professional (AHP) supplementary prescribers must work within their own levels of professional competence and expertise. They must seek advice and make appropriate referrals to other professionals when presented with a situation that is outside their expertise and competence. Nurses, pharmacists and AHPs are accountable for their own actions and must be aware of the limitations of their skills, knowledge and competence. Competency frameworks have been integrated into the Nursing and Midwifery Council (NMC) and Royal Pharmaceutical Society of Great Britain (RPSGB) Standards (see Appendix 1). MM03 Version: 1 Page 8 of 57

Guidance The prescriber, supplementary or independent, must only prescribe if they are competent to do so. Scenarios where a registrant may be expected to assess and prescribe outside their normal field of practice could include, for example, out of hours, walk-in-centres and general practice where a nurse competent to assess and prescribe for adults undertakes a consultation with a child. Prescribers must refer to an appropriate prescriber if they do not fully understand the implications of their prescribing practice in terms of the physiology and pharmacotherapuetic action of medication prescribed even though they may be able to take a thorough and appropriate history which leads to a diagnosis. A non medical prescriber would not be expected to ever prescribe from the whole range of Prescription Only Medicines that they are legally entitled to. (NMC Standards for proficiency for nurse and midwife prescribers, 2006). Training Training for NMPs must take place in an approved education establishment. Consideration in selection of course providers should include: Is course content in line with national and local policy? Does course content include BCUHB medicines management and prescribing priorities? Does the course content include an assessment of the reliability and validity of research material? Does the course provision include appropriate declarations of interest; especially any links/funding from the pharmaceutical industry? Is the course in line with BCUHB policies (e.g. standing financial instructions & Medicines Code)? The course participant must be aware of the above if a course outside BCUHB is attended. Eligibility Criteria to Become a Non-medical Prescriber: Upon completion of training there must be a local need to prescribe within the posts and the opportunity to prescribe within the occupied posts. There must be a clear service and patient benefit. Applicants must have enthusiasm and willingness to study for this course. Applicants must have at least 2 years post-registration experience for pharmacists, or 3 years post-registration clinical nursing experience, the year preceding non medical prescribing training must be in the area in which they wish to prescribe. All staff must have current professional registration. MM03 Version: 1 Page 9 of 57

All staff must be able to demonstrate evidence of appropriate specialist knowledge in the area in which they intend to prescribe. All staff must understand and accept the higher level of clinical responsibility associated with prescribing. All staff must have studied at degree level or equivalent in order to undertake non-medical prescribing training. All staff must have the support of a DSMP/DMP who is able and willing to supervise them through their training and on qualification. A Criminal Records Bureau (CRB) check must have been undertaken for the employee within a timescale sufficient to identify any criminal activity that would put patients at risk. This is particularly important where roles have changed as a result of prescribing qualifications. Application Decisions to train individuals as non-medical independent prescribers (IPs) must be linked to the individual s Knowledge and Skills Framework (KSF) as part of their KSF review. All staff must have access to continuing professional development (CPD) and be prepared to undertake ongoing CPD. Applications to train as an NMP must be supported by the applicant s line manager and be consistent with workforce planning to ensure that time for the course training and supervision to be undertaken is available. Applicants must have the support of their Clinical Programme Group (CPG) Associate Chief of Staff (ACoS) (Nursing), Area Clinical Director (Pharmacy or Therapy) or designated deputy or appropriate CPG lead. All applications should be discussed with BCUHB NMP leads and signed off by the ACoS (Nursing) Pharmacy and Medicines Management CPG or designated deputy. Applications will be referred to the selected higher education institute who will then discuss with the appropriate divisional non-medical prescribing lead. Registration of the Qualification upon Completion of Training The applicant should receive notification from their professional body in order to register their prescribing qualification (see Appendix 11). Local Registration Parameters of practice must be defined to include conditions and medication common to the practitioner s sphere of practice. It is good practice to identify this by means of the personal formulary (Appendix 13c) and personal portfolio All NMPs must complete the following before being entered on the database: BCUHB registration and sample signature form (Appendix 12a). Risk assessment (Appendix 13a) MM03 Version: 1 Page 10 of 57

Personal formulary of commonly prescribed drugs to be used in practice initially, although medications may be added as experience develops throughout the year These documents, once signed by line manager/dsmp as appropriate, together with a copy of the NMP s job description, indicating area of prescribing, must be forwarded to NMP divisional leads: 4 East: Associate Chief of Staff (Nursing) Pharmacy & Medicines Management Clinical Programme Group, Pharmacy, Wrexham Maelor Hospital, Wrexham Central : Medicines Management Specialist Nurse, Pharmacy, Glan Clwyd, Bodelwyddan West: Medicines Management Specialist Nurse, Pharmacy, Ysbyty Gwynedd, Bangor When documentation has been received and checked by NMP leads (as above), the NMP will be included on the BCUHB database and informed of this fact. It is a requirement for employers to maintain an up-to-date register of NMPs working within BCUHB, together with a copy of NMPs signatures. This should be held by the Non-medical Prescribing Lead for the Health Board (ACoS (Nursing) Pharmacy & Medicines Management CPG) and shared with the divisional leads (as above). Applicants must also register with Health Solutions Wales (HSW) as appropriate (see Appendix 3). Applicants must not prescribe until annotation on their professional register is recorded and this had been verified by the appropriate Health Board lead for non-medical prescribing. Prescription-only Medicines (local formulary) BCUHB advises that prescribing should comply with the local formulary and BRAG list agreed by the BCUHB Drugs and Therapeutics Group BCUHB Formulary (http://betsicadwaladruhb.inform.wales.nhs.uk/ ) BRAG List - It should be emphasised that the list is advisory, and appearance of a medicine on the Blue/Red/Amber/Green list does not imply endorsement of use, but rather a recommendation on prescribing responsibilities and whether or not the supply of a particular medicine should be organised through the hospital or primary care pharmacy network. http://howis.wales.nhs.uk/sites3/documents/475/brag%20list%20foreword.pdf http://howis.wales.nhs.uk/sites3/documents/475/rag%20proposed%20list%20current %20April2011.pdf MM03 Version: 1 Page 11 of 57

Unlicensed Medicines From 21 st December 2009 legislation changed to allow pharmacist (PIPs) and nurse independent prescribers (NIPs) to prescribe unlicensed medicines in all clinical areas, for use by his/her individual patient on his/her personal responsibility. Mixing Medicines and Prescribing Medicines for Mixing From 21 st December 2009 legislation changed to allow PIPs and NIPs to mix medicines to produce an unlicensed medicine, where the mixing of medicines means the combining of two or more medicinal products together for the purposes of administering them to meet the needs of a particular patient. A supplementary prescriber can mix medicines to produce an unlicensed medicine but only where the mixing of medicines forms part of the clinical management plan for an individual patient. Off-label Medicines Off-label medicines are licensed medicines for unlicensed uses. PIPs and NIPs may prescribe medicines 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. Where possible, the prescriber should explain the situation to the patient/guardian 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 follow BCUHB Guidance on Off-Label medicines (See Chapter 12 BCUHB Medicines Code) Borderline Substances 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 (http://www.ppa.org.uk/ppa/edt_intro.htm). Although this is a non-mandatory list, PIPs and NIPs should normally restrict their prescribing of borderline substances to items on the ACBS approved list. Appliances and Dressings PIPs and NIPs may prescribe any appliance and dressing listed in Part IX of the Drug Tariff. Prescribing nurses and pharmacists should take into account any local formulary policies and the implications for primary care. MM03 Version: 1 Page 12 of 57

Types of Prescriptions The type of prescription used depends on where the prescription will be dispensed e.g. hospital or primary care sector. 1. Prescribing within the hospital setting for dispensing by a hospital pharmacy: Internal hospital prescriptions will be used, which can only be dispensed within the hospital service. 2. Prescribing from an acute or community setting: For dispensing in community, usually by a community pharmacist, WP10HIP/WP10HSP will be used (HIP indicating independent prescriber; HSP indicating supplementary prescriber). The prescribing costs arising from WP10HP prescriptions will be charged to BCUHB, usually at CPG level. 3. Working in a primary care setting: WP10IP/WP10SP will be used. Registration with HSW will be necessary for groups 2 & 3 (See Appendix 3). All communications concerning a patient s treatment from an NMP should state the NMP s qualification. The NMP should mark each prescription as follows: SP for Supplementary Prescribers NIP for Nurse Independent Prescriber PIP for Pharmacist Independent Prescriber Quality & Governance Framework / Liability A robust system must be in place to centrally co-ordinate all non-medical prescribing applications and ensure an up-to-date database of NMPs is maintained. CPGs must include non-medical prescribing within their overall quality and governance frameworks to ensure nurses, pharmacists and AHPs practice safely and competently in relation to quality and safety. A system must be in place for CPGs to monitor NMPs performance in relation to prescribing practice. Regular audit should be conducted in relation to appropriate and cost- effective prescribing. It is recommended that a supervisor is sought from either the medical profession or identified from within the Non Medical Prescriber s team. A system must be in place for CPGs to identify poor professional performance (PDR, Competence & Supervision Policy) A system must be in place for CPGs to inform NMP leads when an NMP leaves the Health Board. MM03 Version: 1 Page 13 of 57

Where an NMP works across boundaries and has not worked in the field previously then the NMP must evidence their competence in assessment and diagnosis of conditions within the new field of practice. As with all new and developing roles, a dedicated competency based framework should be produced and agreed by the NMP s line manager and medical supervisor. The framework must ensure that the practitioner has significant exposure to the conditions and the medicines that will be regularly prescribed and deemed competent by the medical supervisor. It is recommended that a minimum of 72 working hours is spent in the new field of practice followed by an assessment similar to the SCEP (structured clinical examination of practice) performed during training (Appendix 1). Previous experience may be APELed when considering this timeframe. Individual risk assessments, signed by the line manager, must be carried out on an annual basis. Liability and Responsibilities of the Non-medical Prescriber NMPs are accountable for all aspects of their prescribing decisions. They should therefore only prescribe within their area of competence and for 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. patients, colleagues, or from the pharmaceutical industry) that might result in inappropriate prescribing. Where NMPs are trained and qualified to practice only as a supplementary prescriber, they must work to an approved clinical management plan (Appendix 2). Liability and Responsibilities of the Employer Where NMPs are appropriately trained and qualified, and prescribe as part of their professional duties, with the consent of their employer, the employer is held vicariously liable for their actions. Both the employer/contractor and employee should ensure: The employee is qualified and competent to prescribe in the area of practice identified. The employee s job description (or contractor s agreed arrangements) includes a clear statement that prescribing is required as part of the duties of that post or service. The employee and employer undertake regular appraisal and review (annually as a minimum). Professional Indemnity All NMPs should ensure they have sufficient indemnity insurance with their own professional bodies. MM03 Version: 1 Page 14 of 57

In the absence of the employee holding their own professional liability insurance (PLI), the employee could be personally liable for any costs should the employer attempt to claim back any payout from the employee. Employment of New Staff Who Already Hold an Non-medical Prescriber s Qualification This qualification will be recognised once usual employment/recruitment checks have been made by the candidate s line manager. The candidate will be eligible to practice as an NMP if all the following criteria are met: Evidence of a numeracy assessment must be produced if the candidate has qualified outside Wales; otherwise this must be assessed in line with WAG guidance. There is an appropriate member of senior medical staff who can act as clinical support. There is a requirement in the job description to undertake non-medical prescribing. The member of staff needs to register locally (see Local Registration, Appendix 12). Non-medical Prescriber Returning to Work Following a Lengthy Period of Absence (E.g. maternity leave / sickness of equal or greater than 6 months) When a non-medical prescriber returns to work following a lengthy period of absence, it is advisable that they work under the supervision of their DMP who should agree their competence after a minimum period of 2 months following their return. The NMP should be able to demonstrate evidence of continued competence by means of professional portfolio. The NMP should submit a reviewed risk assessment to the nonmedical prescribing lead for their area. Non-medical Prescribing Staff Leaving BCUHB If an NMP, who has previously worked as a prescriber, changes role, leaves the organisation or employer, or ceases to have prescribing responsibilities, they must return any remaining unused prescriptions to the employer. The employer should inform HSW of the change, if appropriate, by completing the appropriate forms and submitting to HSW. Health Solutions Wales Prescribing Services Standard forms library - http://howis.wales.nhs.uk/sites3/documents/428/independent_prescriber_notification_f orm.doc http://howis.wales.nhs.uk/sites3/documents/428/supplementary_prescriber_notification _Form.doc MM03 Version: 1 Page 15 of 57

Appendix 1 CONTINUING PROFESSIONAL DEVELOPMENT 1. Introduction Appropriate Continuing Professional Development (CPD) is a professional obligation for all NMPs. CPD is an integral part of the clinical governance process, alongside: ensuring clear lines of responsibility and accountability for overall quality of clinical care; development of identified quality improvement programmes, including clinical audit; supporting evidence-based practice; implementation of clinical standards; monitoring of clinical care; workforce planning and development; and identification and effective management of risk. It is recommended that staff use the outline framework Maintaining Competency in Prescribing produced by the National Prescribing Centre (NPC) (www.npc.co.uk) to help inform their CPD needs, taking into account their profession and area of prescribing practice. Competency framework examples for nurses, pharmacists and AHPs are available from: http://www.npc.co.uk/prescribers/resources/maint_comp_prescribing_nurs.pdf http://www.npc.co.uk/prescribers/resources/nurse_update_framework.pdf http://www.npc.co.uk/prescribers/resources/competency_framework_oct_2006.pdf http://www.npc.co.uk/prescribers/resources/maintain_comp_prescribing.pdf http://www.npc.co.uk/prescribers/resources/competency_framework_optometrist.pdf http://www.nmc-uk.org/educators/standards-for-education/standards-of-proficiency-fornurse-and-midwife-prescribers/ 2. At Entry to the Prescribing Course Decisions to train individuals as non-medical independent prescribers (IPs) must be linked to the individual s Knowledge and Skills Framework (KSF) as part of their KSF review. Applicants to be NMPs must be able to demonstrate evidence of appropriate specialist knowledge in the area in which they intend to prescribe. They must understand and accept the higher level of clinical responsibility associated with prescribing. 3. Following Successful Completion of Non-medical Prescribing Course The CPD needs of NMPs should be identified as part of their PDP and, for BCUHB employees, should be linked to the staff development/ksf process. MM03 Version: 1 Page 16 of 57

The NMP should be able to demonstrate evidence of continued competence. This should be done by the use of a professional portfolio, identifying any new medications and the conditions for which they have been prescribed, outside the normal sphere of practice. Using the form at Appendix 1, evidence of ongoing CPD should be forwarded to the NMP Divisional Lead on a yearly basis, to be annotated on the database. A personal prescribing formulary, (appendix 13c) signed by the appropriate supervising medical practitioner should be considered by the NMP and the line manager to support prescribing in practice. The personal formulary should be amended to show changes in prescribing practice during the year. NMPs must identify their individual training needs with their line manager. These should be included in their Personal Development Plan and recorded within the KSF. It is the responsibility of the NMP to ensure they remain up to date on therapeutics in the field of their prescribing practice and on changes in national and local prescribing policy. All NMPs should maintain their own knowledge though literature, professional networks and clinical supervision. All NMPs are advised to join the Non-medical Prescribers Forums where they can discuss their CPD needs. NMPs are also encouraged to develop networks with other non-medical prescribers who are prescribing in the same speciality 4. Continuing Professional Development may include: Course provision. BCUHB Medicines Management Team. NPC tutors/evidence based CPD providers. Local universities (School of Healthcare Sciences, Faculty of Health, Bangor University/ Glyndwr University, Wrexham) Self-directed learning linked with appropriate bodies e.g. Welsh Medicines Resource Centre (WeMeReC), National Prescribing Centre (NPC), and NPCi 5. Resources Applicants should participate in clinical supervision. Clinical support forums: Local forums will be provided and are an excellent method of facilitating networking, updating, and continuing professional development. A nominated representative from the forum will be invited as a member to represent NMPs on the BCUHB NMP Steering Group. MM03 Version: 1 Page 17 of 57

Currently (2010) the Pharmacy & Medicines Management CPG hosts an evidencebased therapeutics trainer accredited by the National Prescribing Centre (NPC). Regular courses are organised for the Primary Care Prescribing Teams and ad hoc for NMPs. 7. Reference List for Evidence-Based Therapeutics NMPs should follow the principles of Information Mastery. A useful introduction is: http://www.npci.org.uk/therapeutics/mastery/mast1/workshops/workshop_60minute_ elearn_event1.php ALERTING SYSTEMS All prescribers should have a system of being alerted to important new, relevant, valid information when it is published. Drug Safety Update from the Medicines and Healthcare Regulatory Authority (MHRA) An essential monthly update relating to drug safety in the UK; all prescribers should be aware of these updates: http://www.mhra.gov.uk/publications/safetyguidance/drugsafetyupdate/index.htm NPC Ecab - is a daily or weekly alerting email system for therapeutics and medicines news.http://www.npc.co.uk/rss/news_rss.htm Trusted Information Sources for Evidence-based Therapeutics Welsh Medicines Resource Centre wemerec http://www.wemerec.org/ National Prescribing Centre & NPCi (interactive) http://www.npc.co.uk/, http://www.npci.org.uk/ Trusted Sources of Evidence o British National Formulary (BNF) o Clinical Evidence (BMJ) o Clinical Knowledge Summaries (aka Prodigy) o Cochrane o Drug and Therapeutics Bulletin o Electronic Medicines Compendium (EMC) o Evidence Based Medicine Journal o o o o o o o MeReC MHRA Drug Safety Update National Institute for Health and Clinical Excellence (NICE) Scottish Medicines Consortium (SMC) SIGN TRIP Database WeMeReC Bulletins MM03 Version: 1 Page 18 of 57

Structured Clinical Examination of Practice for extension of parameters of prescribing Phase One: Consultation and History Taking Scenario: This patient/client is new to your caseload. Conduct an initial consultation and take a history. Expected Skills: Demonstrate competence in the initial assessment of the patient through effective consultation and history taking Assessment criteria Pass Refer Comments Greets patient in an appropriate and friendly manner and introduces self Clarifies reason for the client s/patient s visit and his/her expectations Is skilful at acquiring information about the patient, allowing patient to express own ideas and concerns Uses good listening techniques eye contact, open attentive posture Is sensitive to patient s needs and feelings, e.g. privacy Ascertains history of present problem/illness Ascertains general medical history Ascertains any relevant allergies Ascertains family and social history Ascertains lifestyle information Questioning indicates that prescriber is approaching the situation systematically covering the body systems (as appropriate) Cardio- vascular Respiratory Gastrointestinal Endocrine Neurological Musculoskeletal Genitourinary Other( please specific) Questioning indicates that prescriber is beginning to formulate the possible causes of the problem/illness Discusses and agrees the need for a further examination with the patient Appropriately documents findings Instructions to examiner: Tick the appropriate box during interaction or just afterwards. Please state whether the student has passed or been referred PASS REFER Please circle the appropriate criteria above. Signature of Designed Medical Practitioner: Date of Assessment MM03 Version: 1 Page 19 of 57

Structured Clinical Examination of Practice for extension of parameters of prescribing Phase Two: Clinical Assessment & Working/Differential Diagnosis Scenario: The patient requires a physical examination: This is undertaken to explore a reported symptom. The student needs to conduct an appropriate physical examination to inform a working diagnosis. Expected Skills: Demonstrate competence in relevant clinical assessment skills & methodology to inform a working diagnosis Assessment criteria Pass Refer Comments Undertakes an appropriate clinical examination applying a systematic approach and observes patient for signs of discomfort throughout Conducts the examination selectively and thoroughly reflecting the history established Identify presenting problems and related pathophysiology Applies a systematic approach to gathering further information Requests and interprets relevant diagnostic tests Assesses the relationship between multiple pathologies Correctly identifies key information Develops a correct working/differential diagnosis Knows how and when to refer/ consult and seek guidance Appropriately documents findings Appropriate closure of the examination process Instructions to examiner: Tick the appropriate box during interaction or just afterwards. Please state whether the student has passed or been referred PASS REFER Please circle the appropriate criteria above. Signature of Designed Medical Practitioner: Date of Assessment MM03 Version: 1 Page 20 of 57

Structured Clinical Examination of Practice for extension of parameters of prescribing Phase Three: Development of a treatment management plan Scenario: Having developed a working diagnosis, a treatment management plan is devised. Assessment criteria Pass Refer Comments Reviews differential diagnosis, rechecks doubtful findings and modifies treatment as appropriate Identifies any legal or ethical issues relevant to the treatment planned. Recognizes the potential outcomes of prescribing more than one medication (if applicable) Appropriately explains the treatment plan to the patient and negotiates an agreed course of action Prescribes according to local formulary, national guidelines etc Advises patient on management of common side effects Outlines appropriate plans to monitor the effects of medications using appropriate investigations Indicates appropriate plans to observe and respond to drug interactions, adverse reactions and use appropriate reporting mechanisms Document all actions appropriately After consultation: Was the diagnosis correct Yes/No After consultation: Prescriber is fully able to justify actions Instructions to examiner: Tick the appropriate box during interaction or just afterwards. Please state whether the student has passed or been referred PASS REFER Please circle the appropriate criteria above Signature of Designed Medical Practitioner: Date of Assessment MM03 Version: 1 Page 21 of 57

Structured Clinical Examination of Practice for extension of parameters of prescribing Phase Four: Counsel the Patient regarding their Medication Scenario Counsel the patient on the medication. Assessment criteria Pass Refer Comments Explains what the medication is for Explains dose and frequency Explains how to take medicines/use device e.g. after food etc Explains what to do if misses dose or takes too many Informs the patient the duration of treatment Informs the patient when the medication is likely to start working Informs the patient the likely side effects Advises on what to do about side effects. Explains about the monitoring that is required for medication e.g. LFTs, FBC BP etc Advises the patient on how to obtain further supplies Asks the patient if there any questions Answers question clearly, avoiding jargon Provides written information The prescriber checks the patients understanding Explores the need of compliance aid Ensures the patient knows when to have their next appointment Informs the patient who and how to contact people outside the next appointment schedule, if necessary The prescriber included the carer/relative if necessary Prioritised order of information Documents appropriately Instructions to examiner: Tick the appropriate box during interaction or just afterwards. Please state whether the student has passed or been referrer PASS REFER Please circle the appropriate criteria above Signature of Designed Medical Practitioner: Date of Assessment MM03 Version: 1 Page 22 of 57

Structured Clinical Examination of Practice for extension of parameters of prescribing Phase Five: Write a Prescription Scenario Write the prescription for the initial/new medication Assessment criteria Pass Refer Comments Name & address Date of birth & age preferably, legally for under 12 years Legibility in ink Dated Signed in ink by prescriber Drug prescribed (generically where appropriate) Names of drugs in full Dose and frequency specified; if prn a minimal dose interval Avoid use of decimal points if possible Use appropriate units to express the dose e.g. micrograms Avoid abbreviations for units Quantity either as number of days in box or total amount stated Adequate quantities prescribed Space at end of items to be deleted If CDs, appropriate legal requirements (see BNF/MEP) Record appropriately To successfully pass Phase Five, the prescription must be able to be dispensed by the pharmacist i.e. all appropriate sections must be completed. Instructions to examiner: Tick the appropriate box during interaction or just afterwards. Please state whether the student has passed or been referred PASS REFER Please circle the appropriate criteria above Signature of Designed Medical Practitioner: Date of Assessment MM03 Version: 1 Page 23 of 57

Annual declaration for Ongoing Competence The CPG will need to inform the Divisional Lead. Name of NMP: Occupation: Work Address: Work Telephone: E-mail Address: PiN/Registration Number: Type of Prescriber: V300 SP V300 SP/IP Date of Registered Qualification: Area of Prescribing Practice e.g. COPD, Asthma, Diabetes: Any expansion in areas of prescribing since last review? Yes / No If yes, please specify: I have undertaken the following activities: Area to self certify Response If No, your intended actions Read updates on prescribing Yes/No Read and understood relevant NICE guidelines Read and understood relevant evidence and literature Been clinically supervised within NMP role and area of prescribing practice Undertaken an audit around non-medical prescribing Undertaken CPD around nonmedical prescribing Yes/No Yes/No Yes/No Yes/No Yes/No MM03 Version: 1 Page 24 of 57

CPD evidence: Where can your CPD evidence be found? Case studies/reflection/evidence of competence in prescribing decisions (identify and attach) If you have identified training needs during your PDP (professional development plan) or annual review (appraisal) in relation to non-medical prescribing please state what they are and how they will be addressed. Training need identified 1 Training resource identified and booked e.g. course, shadowing, reading etc. 2 3 Have there been any specific circumstances impacting upon your prescribing practice over the past year, i.e. long term sickness etc? I declare that I am competent in the area where I am currently prescribing. Signed.Date.. Line Manager s signature..date.. This form to be completed in line with your PDR/appraisal. A copy kept in your personal file by your manager, and a copy sent to the Divisional Lead for Non-Medical Prescribing (see page 8) MM03 Version: 1 Page 25 of 57

Appendix 2 CATEGORIES OF NON-MEDICAL PRESCRIBERS IN WALES Independent Nurse Prescriber (limited) (V100/V150) (INP) (District Nurse/Health Visitor/Community Nurse) This category of nurse in Wales represents district nurses, community nurses and health visitors, enabling prescribing independently from a limited formulary known as the Nurse Prescribers Formulary (in Wales District Nurses and Health Visitors). This became known as District Nurse/Health Visitor Prescribing or First Phase Nurse Prescribing. This category of nurse prescriber continues to prescribe from the Nurse Prescribers Formulary for Community Practitioners; this consists of mainly dressings, creams and P and limited POM medicines. Supplementary Prescriber (V300) Currently nurses, midwives, pharmacists, optometrists, physiotherapists, radiographers; chiropodists/podiatrists are able to train as supplementary prescribers. Supplementary prescribing is defined as: a voluntary prescribing partnership between an independent prescriber (doctor or dentist) and a supplementary prescriber, to implement an agreed patient-specific clinical management plan (CMP) with the patient s agreement. Following agreement of the CMP the supplementary prescriber may prescribe any medicine for the patient within the CMP until the next review date. There are no restrictions on medical conditions that can be managed via supplementary prescribing. An agreed CMP is a legal requirement before supplementary prescribing can take place. The doctor, or dentist, is responsible for the diagnosis and setting the parameters of the CMP. There is no specific formulary for supplementary prescribing and, provided they are included in the CMP, non-medical prescribers are able to prescribe within the constraints of the BCUHB Medicines Code: o All prescription-only medicines (POM s), including controlled drugs. o Medicines for use outside their licensed indications (off label prescribing), black triangle drugs and those marked less suitable for prescribing in the BNF. o Unlicensed drugs. The Clinical Management Plan (CMP) Where a CMP is to be used, a senior clinical pharmacist (divisional) could be consulted for advice if appropriate. o The supplementary prescriber must never make amendments to any CMP without the agreement of the DSMP/DMP named on the plan. o All amendments must be recorded on the CMP and signed by the DSMP/DMP o The CMP must be agreed by DSMP/DMP, supplementary prescriber and the patient. o The current CMP must be clearly visible within the patient s records. o The CMP must be reviewed annually, or if there is a change in the patient s condition, and is valid for a12 month period. MM03 Version: 1 Page 26 of 57

Independent Prescriber (V300) (e.g. NIP/PIP) Independent prescribers (currently NIPs/PIPs) may prescribe for any medical condition within their area of competence. NIPs may prescribe some controlled drugs as per current BNF - Nurse Prescribers Formulary. PIPs cannot prescribe controlled drugs as an independent prescriber but may do so as a supplementary prescriber with a clinical management plan. A NMP must only ever prescribe within their area of competence and expertise if they move to another area of practice they must consider the requirements of their new role and only ever prescribe within their area of competence and expertise. MM03 Version: 1 Page 27 of 57

CLINICAL MANAGEMENT PLAN Name of patient: Identification of patient (e.g. hospital number, date of birth): Patient medication sensitivities/allergies: Independent Prescriber(s): Supplementary Prescriber(s): Condition(s) to be treated: Aim of treatment: Medicines that may be prescribed/adjusted by supplementary prescriber: Preparation: Indication: Dose schedule: Specific indications for referral back to the independent prescriber: Guidelines or protocols supporting Clinical Management Plan: Frequency of review and monitoring by: Supplementary Prescriber: Supplementary Prescriber and Independent Prescriber: Process for reporting adverse drug reactions: Shared record to be used by supplementary prescriber and independent prescriber: Agreed by Independent Prescriber(s): Date: Agreed by Supplementary Prescriber(s): Date: Date agreed with patient/carer: MM03 Version: 1 Page 28 of 57

OBTAINING PRESCRIPTIONS Appendix 3 An NMP, employed by BCUHB within primary or secondary care / from primary care contractor, whose prescriptions will be dispensed at NHS expense in a community pharmacy, will require one or more of the following WP10 prescriptions: NHS Prescription WP10SP (pads) WP10SPSS (single sheets for Computer-generated prescriptions) Prescriber Supplementary Prescriber WP10IP (pads) WP10IPSS (single sheets for computer generated prescriptions) Independent Prescriber WP10HSP (pads) Supplementary Prescriber (issued in hospital for dispensing in community pharmacy) WP10HIP (pads) Independent Prescriber (issued in hospital for dispensing in community pharmacy) The prescribing costs arising from WP10HP prescriptions will be charged to BCUHB, usually at CPG level. For Independent Prescriber registration form: http://howis.wales.nhs.uk/sites3/docopen.cfm?orgid=428&id=89077 For Supplementary Prescriber registration form http://howis.wales.nhs.uk/sites3/docopen.cfm?orgid=428&id=44897 MM03 Version: 1 Page 29 of 57

PROCESS FOR REGISTERING AND ORDERING PRESCRIPTION STATIONERY TO PRESCRIBE Non-medical Prescriber qualifies The Approved Education Institute sends details to professional body WP10 prescriptions required Primary care Hospital outpatients/community Case Managers Non-medical Prescriber to register with Health Solutions Wales (HSW) (12 th Floor, Brunel House, 2, Fitzalan Road, Cardiff, CF24 0HA) http://howis.wales.nhs.uk/sites3/page.cfm?orgid=428&pid=8604 Non-medical Prescriber to register with professional body and local Non-medical Prescribing Lead Complete registration and sample signature form (Appendix 12a) Submit to NMP local lead with a copy of job description and completed risk assessment (Appendix 12b) Standard hospital stationery utilised to prescribe within area of practice WP10IP/SP Primary Care Non-medical Prescriber to order via Business Service Centre (BSC)* BSC to place order with print management supplier* Prescriptions delivered to BSC BSC forward to divisional office ordering point WP10HIP/HSP Hospital outpatients/ Community Case Managers Non-medical Prescriber to order via Health Board lead. Health Board lead to place order with print management supplier* Prescriptions delivered directly to hospital CPG details stamped by prescriber BCUHB internal stationery ordering process to be followed *via the nominated person within the employer organisation MM03 Version: 1 Page 30 of 57

Detail Required on Stamp/Sticker for NIPs/PIPs using Unprinted WP10: Prescriber s name and NMC/GPC number Contact address and phone number V Number (cost code) Stickers may be available through Pharmacy for applying to each prescription Storing Prescriptions Prescribers are responsible for their prescription pads, and all reasonable precautions to prevent loss and inappropriate use should be taken. Blank prescription forms should not be pre-signed before use. Prescriptions are controlled stationery and should be securely stored. A record of the first and last serial number of prescriptions in the pad issued to the prescriber should be made. It is considered good practice to record the serial number of the first remaining prescription form at the end of each working day. This would help identification if any are lost or stolen overnight. Stolen Prescription Forms In the event of loss or suspected theft of prescriptions, the non-medical prescriber must complete an incident report form and report the loss immediately to their line manager who should inform the police, BSC, HSW and ACoS (Nursing) Pharmacy and Medicines Management CPG. The non-medical prescriber will report details of the approximate number of scripts missing, plus where they went missing from, or last time they were seen. The line manager will investigate the incident and report the investigation findings to the ACoS (Nursing) for the appropriate CPG who will report the findings of the investigation to the Associate Chief of Staff (Nursing) Pharmacy and Medicines Management CPG. It is important that the manager s investigation determines the circumstances, as the police will also be investigating. The ACoS (Nursing) Pharmacy and Medicines Management CPG will be required to inform the Risk Manager of the incident. Prescribers will be asked to sign the prescription in red ink for a period of 2 months. Destruction of Prescriptions When Staff Change If a non-medical prescriber who has previously worked as a prescriber changes role, leaves the organisation, or employer, or ceases to have prescribing responsibilities, they must return any remaining unused prescriptions to the employer for either re-distribution to another non-medical prescriber (in the case of blank WP10s), or destruction. The employer should inform Health Solution Wales of the change via either of the following forms: http://howis.wales.nhs.uk/sites3/docopen.cfm?orgid=428&id=89077 for independent prescriber registration form http://howis.wales.nhs.uk/sites3/docopen.cfm?orgid=428&id=44897 for supplementary prescriber registration form MM03 Version: 1 Page 31 of 57