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MM03 Version: 1 of 57

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 / director:

Pharmacy & Medicines Management

Approved by: Medicines Policies Group Date approved: 1 April 2011 Endorsement by: Senior Nurse Midwifery Committee / Clinical Directors,

Pharmacy Date endorsed: 1 April 2011

Date activated (live): 1 June 2011 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

Version: 1


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


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


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


BIBLIOGRAPHY 53 RESOURCES 55

Members of the Working Group 56 Consultation / /engagement 56


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 non-medical 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 non-medical prescribing.

• To benefit the patient and provide improved medicines access opportunities within BCUHB.

• To assist in identifying potential candidates and areas for development of non-medical 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;


• 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_guide.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.


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).


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 pharmaco-therapuetic 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.


� 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)


• 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


Unlicensed Medicines From 21st 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 21st 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.


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.


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.


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 non-medical 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_Form.doc http://howis.wales.nhs.uk/sites3/Documents/428/Supplementary_Prescriber_Notification

_Form.doc


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-for-nurse-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.


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.


Currently (2010) the Pharmacy & Medicines Management CPG hosts an evidence-based 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 MeReC o MHRA Drug Safety Update o National Institute for Health and

Clinical Excellence (NICE) o Scottish Medicines Consortium

(SMC) o SIGN o TRIP Database o WeMeReC Bulletins


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…………


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……………


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.


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……………


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.


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……………


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


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……………


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

Yes/No

Read and understood relevant evidence and literature

Yes/No

Been clinically supervised within NMP role and area of prescribing practice

Yes/No

Undertaken an audit around non-medical prescribing

Yes/No

Undertaken CPD around non-medical prescribing

Yes/No


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 Training resource identified and booked

e.g. course, shadowing, reading etc.

1

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)


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.


• 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.


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:


Appendix 3 OBTAINING PRESCRIPTIONS 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 Prescriber WP10SP (pads) WP10SPSS (single sheets for

Computer-generated prescriptions)

• 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


PROCESS FOR REGISTERING AND ORDERING PRESCRIPTION STATIONERY TO PRESCRIBE

Non-medical Prescriber qualifies

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)

The Approved Education Institute sends details to

professional body

Standard hospital stationery utilised to

prescribe within area of practice

BCUHB internal stationery ordering process to be

followed

BSC to place order with

print management supplier*

Prescriptions delivered to BSC

BSC forward to divisional office ordering point

Health Board lead to place order with print

management supplier*

Prescriptions delivered directly to hospital

CPG details stamped by prescriber

Non-medical Prescriber to order via Business Service

Centre (BSC)*

WP10HIP/HSP Hospital outpatients/

Community Case Managers

WP10 prescriptions required

� Primary care

� Hospital outpatients/Community Case Managers

Non-medical Prescriber to register with Health Solutions Wales (HSW)

(12th Floor, Brunel House, 2, Fitzalan Road, Cardiff, CF24 0HA)

http://howis.wales.nhs.uk/sites3/page.cfm?orgid=428&pid=8604

WP10IP/SP Primary Care

Non-medical Prescriber to order via Health

Board lead.

*via the nominated person within the employer organisation


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


Appendix 4

RECORD KEEPING All non-medical prescribers are required to keep accurate, legible, unambiguous contemporaneous records of patient’s care. Ideally, the record of consultation should be on shared patient records; however, if this is not feasible, non-medical prescribers should keep their own records, stored safely and in accordance with Caldicott standards. Details of the assessment, prescription and rationale for prescribing must be entered in patient records, immediately where possible, but no later than 48 hours after the consultation. Appendix 4a may be used if required.


Appendix 4a

PRESCRIBING RECORD SHEET FOR GP PRACTICE

This form to be used if a non-medical prescriber is unable to personally update the GP patient record within two working days

Patient name & address: NHS no: D no:

DOB:

Telephone no:

GP name & address: Date prescribed:

1. Name of medication/Item prescribed:

Dosage: Strength:

Frequency: Route: Duration:

2. Name of medication/item prescribed:

Dosage: Strength:

Frequency: Route: Duration:

Reason for prescription: Allergies:

Interactions drug/type of interactions:

Independent Non-medical Prescriber’s name:

Independent Non-medical Prescriber’s signature:

Base:

Telephone no of base:


Appendix 5 ADVERSE DRUG REACTION REPORTING All prescribers are encouraged to report suspected adverse drug reactions using the Yellow Card Reporting Scheme. The Yellow Card Scheme is run by the MHRA and Commission on Human Medicines (CHM). The Scheme is used to collect information from health professionals and patients on suspected adverse drug reactions (ADRs). Yellow Card reports are collected from both health professionals and members of the public on:

• Prescription medicines

• Herbal remedies

• Over-the-counter (OTC) medicines

• Unlicensed medicines, including cosmetic treatments For established medicines, health professionals are requested to report only serious suspected adverse reactions. ▼Black Triangle Medication These are usually newer drugs or vaccines that the Commission on Human Medicines (CHM) and MHRA encourages the reporting of all suspected reactions. They are denoted by an inverted Black Triangle symbol (▼) next to the name of the relevant product in the BNF and SPC. Any adverse event that may be attributable to the given medication should be reported to the Commission on Human Medicines (CHM) using the Yellow Card System. Guidance on its use is available at the back of the BNF or can be accessed via the CHM website www.yellowcard.gov.uk.

Yellow Cards can be obtained from: a) The back of the British National Formulary b) Yellow Card Centre Wales, FREEPOST, Cardiff, CF4 1ZZ c) www.yellowcard.gov.uk

Or can be completed online at the web address above.

Completed Yellow Cards should be sent to:

Yellow Card Centre Wales FREEPOST, Cardiff, CF4 1ZZ.

Patients, parents, carers etc can also report suspected adverse drug reactions using the above methods or the free phone number 0808 100 3352.


Appendix 6

PRESCRIBING AND ADMINISTRATION OF MEDICINES See Chapters 4 & 9 of the BCUHB Medicines Code; and also Guidance on Prescribing (in the current British National Formulary) Non-medical prescribers should separate the functions of prescribing and administration activities whenever possible. In exceptional circumstances, where one individual is involved in both prescribing and administering medication (particularly a controlled drug to a patient), a second suitably competent person should be involved in checking the accuracy of the medicines provided. In the management of substance misuse patients, prescriptions should be written and provided on a daily dispense basis by NIPs/ NPs. Prescribing for Self, Friends and Family Non-medical prescribers must not prescribe any medicine for themselves; neither should they prescribe a medicine for anyone with whom they have a close personal or emotional relationship, other than in an exceptional circumstance.


Appendix 7 GIFTS AND BENEFITS Non-medical prescribers must be aware of the code of conduct and ethics of their professional body: http://www.nmc-uk.org/Documents/Standards/nmcTheCodeStandardsofConductPerformanceAndEthicsForNursesAndMidwives_LargePrintVersion.PDF http://www.pharmacyregulation.org/pdfs/other/gphcstandardsofconductethicsandperflo.pdf http://www.hpc-uk.org/assets/documents/10002367FINALcopyofSCPEJuly2008.pdf The advertising and promotion of medicines is strictly regulated under the Medicines (Advertising) Regulations 1994, and it is important that non-medical prescribers make their choice of medicinal product for their patients on the basis of evidence, clinical suitability and cost effectiveness alone. As part of the promotion of a medicine, or medicines, suppliers may provide inexpensive gifts and benefits; for example pens, diaries or mouse mats. Personal gifts are prohibited, and it is an offence to solicit or accept a prohibited gift or inducement. Companies might offer hospitality at a professional or scientific meeting or at meetings held to promote medicines, but such hospitality should be reasonable in level and subordinate to the main purpose of the meeting. BCUHB has local policies for working with the pharmaceutical industry, which cover gifts and benefits as well as, for example, access to prescribers and sponsorship. Prescribers should familiarise themselves with these policies and are expected to abide by them.

From BCUHB Draft Medicines Code “6.2.7 Samples of medicines, dressings and devices left by pharmaceutical representatives”

“It is imperative that the Health Board must know what products are being used within its boundaries. Samples of medicines, dressings and devices must not be left in clinical areas, or issued to individual healthcare staff, by pharmaceutical representatives for use within the Health Board. Representatives wishing to discuss supply of samples for use for evaluation of a medicinal product, dressing, or device, must be referred to the pharmacy. “ From: NMC Standards for Nurse and Midwife Prescribers 06.06 Standards http://www.nmc-uk.org/Documents/Standards/nmcStandardsofProficiencyForNurseAndMidwifePrescribers.pdf of proficiency for nurse and midwife prescribers 06.06 Practice standard 21 – Gifts and Benefits 21.1 You must make your choice of medicinal product for the patient/client, based on clinical suitability and cost effectiveness. 21.2 You must maintain a ‘register of interests’ within your own personal portfolio, to be produced on request, if required, for audit purposes. 21.3 You should adhere to local corporate policy when maintaining a ‘register of interests’.


Appendix 8 BUDGET SETTING AND MONITORING Prescribing Costs Non-medical prescribing is, in some instances, substitute prescribing and there should therefore be no additional prescribing costs as a result of nurse prescribing. The National Assembly for Wales in discussion with Health Solution Wales and NHS professionals has agreed the following:

• In primary care the cost of drugs and appliances prescribed by BCUHB Specialist Community Practitioners will remain within the primary care sector.

• Prescribing costs will be allocated to the practice responsible for the patient, for information purposes only, and will not directly affect the practice budget.

In secondary care the prescribing costs will be allocated to the consultant responsible for the patient’s care or the CPG in which the prescriber is employed.


Appendix 9 DISPENSING OF PRESCRIBED ITEMS The dispensing pharmacist or dispensing doctor (in rural communities) must ensure that the prescription meets the legal requirements if an NHS prescription is for a medicine eligible to be prescribed at NHS expense according to the National Health Service England and Wales, Drug Tariff. Pharmacist Dispensing of Pharmacist Independent Prescriber Prescriptions On occasions where a pharmacist is a prescriber and has a dispensing role there should, other than in exceptional circumstances, be separation of prescribing and dispensing roles, in keeping with the principles of safety, clinical and corporate governance. The General Pharmaceutical Council’s standard on prescribing within the Code of Ethics and Standards states that pharmacists should ensure there is separation of prescribing and dispensing, wherever possible. In exceptional circumstances, where a pharmacist is both prescribing and dispensing a patient’s medication, a second suitably-competent person should normally be involved in the checking process. Where the 2 roles do co-exist, another person must carry out a final accuracy check. Where possible, a check for clinical appropriateness should also be carried out. In such exceptional circumstances the same individual can carry out prescribing and dispensing activities provided that:

• Clear accountability arrangements are in place to ensure patient safety and probity.

• There are audit and governance arrangements in place which can track prescribing (the same person/pharmacist prescribing and dispensing should be exceptional).

Dispensing Doctors in Primary Care Where a GP practice is a dispensing practice, prescriptions from non-medical prescribers can be dispensed by the practice but only for the dispensing patients of that practice. Dispensing Doctors cannot dispense prescriptions written by non-medical prescribers for patients of other practices. Dispensing of Items in England, Scotland and Northern Ireland Community pharmacists in England, Scotland and Northern Ireland can dispense prescriptions written by non-medical prescribers practising in Wales. Community pharmacists in Wales can dispense prescriptions written by non-medical prescribers practising in Scotland, England and Northern Ireland. Reimbursement of Prescriptions Dispensed in Primary Care WP10 prescriptions written by non-medical prescribers, i.e. supplementary or independent prescribers, should be sorted according to the prescriber, bundled together and sent to Health Solutions Wales in a similar manner to the way WP10 forms are managed for prescriptions written by GPs.


Appendix 10

INDEPENDENT AND PRIVATE CONTRACTORS (e.g. PRACTICE NURSES EMPLOYED BY GPS) This document may be used as guidance for independent and private contractors. Nurse and pharmacist independent prescribers who are employed by the independent and private sectors, where clinical governance systems may be different or may not be applied in the same way, must ensure they comply with requirements to demonstrate their competence to practise. For example, they must be able to show:

• How they audit their practice.

• How they keep up to date with current guidance, and

• How they safeguard the patients in their care. Nurse and pharmacist independent prescribers who have dual roles within the NHS and in the private sector must not use WP10 NHS prescription stationery when practising in the private sector. Nurse and pharmacist independent prescribers working in the private sector should seek guidance from their relevant professional bodies. Nurse and pharmacist independent prescribers who are employed by the independent and private sectors should be added to the BCUHB database in order to receive information regarding updates/forums etc and to meet organisational and professional requirements. The requirement to complete a sample signature form, and submit authorisation to prescribe, in the form of a copy of the prescriber’s job description, remains the same as a BCUHB employee.


Appendix 11 MONITORING COMPLIANCE TO GUIDANCE Audits of non-medical prescribing practice will be carried out regularly by the CPG in which the non-medical prescriber works. The aim of the audits will be to look at:

• The number of prescriptions being generated.

• The type of prescribing – independent/supplementary.

• If supplementary prescriber, check if a CMP is in the patient’s notes.

• Does the prescription tally with the CMP/formulary?

• Is there evidence, e.g. in the personal portfolio / personal formulary that the practitioner has been prescribing with competence?


Appendix 12 REGISTRATION WITH PROFESSIONAL BODY NMC Register for Nurse Prescribers Through the normal reporting processes, the Approved Education Institute (AEI) will provide the Nursing and Midwifery Council (NMC) with details of those students who have passed the relevant prescribing course. This process will not be necessary for nurses undertaking the ‘Conversion Course’ as the nurse will already be recorded on the NMC register as V300 following registration as a supplementary prescriber. This annotation on the register is recognised by the NMC for supplementary and independent prescribers. Nurses should not practise until they have been notified by the NMC that their registration entry has been annotated. Nurses with queries about the registration process can contact the NMC registration department:

NMC 23 Portland Place London W1B 1PZ Tel: 020 7333 9333

General Pharmaceutical Council (GPC) Register for Pharmacist Prescribers Through the normal reporting processes, the approved education institute (AEI) will provide the GPC (formerly the Royal Pharmaceutical Society of Great Britain (RPSGB)) with details of students who have passed the relevant prescribing course. The pharmacist must individually apply to the GPC for registration. The GPC will write to each pharmacist who successfully completes a prescribing course accredited by the GPC, enclosing an application for annotation form. Application forms are available on the GPC website: www.pharmacyregulation.org Formerly: www.rpsgb.org.uk Applications for annotation of the register must be submitted to the GPC within 6 months of the date of award of the practice certificate. Completed applications should be submitted to the GPC’s registration section. A registration fee is payable; details of fee payments are available from the GPC. The registration process may take 7 to 14 days after the GPC has received the list from AEI’s and the registration form from the pharmacist. Pharmacist prescribers should not practice as prescribers until they have been notified by the registration department at the GPC that their registration entry has been annotated. The GPC provides an on-line search facility so that any other pharmacists can check whether a pharmacist is annotated as a supplementary prescriber or independent prescriber: www.pharmacyregulation.org


Pharmacists with queries about the registration process can contact the GPC/RPSGB Registration Dept:

The Royal Pharmaceutical Society of Great Britain 1 Lambeth High Street London SE1 7JN Tel: 020 7572 2322

Health Professions Council (HPC) The prescriber, on completion of the course, must inform the HPC in order to amend their registration details http://www.hpc-uk.org/aboutregistration/professions


Appendix…12a

LOCAL REGISTRATION AND SPECIMEN SIGNATURE FORM

NON-MEDICAL PRESCRIBER AUTHORISED TO PRESCRIBE

Mr / Mrs / Miss / Ms (print name):

Work address:

Contact tel no:

Tick appropriate box:

V300 Supplementary Prescriber

V300 Independent/Supplementary Prescriber

If Supplementary Prescriber, name of doctor/s acting as IP

Title: Speciality/Department

Area of practice (e.g. diabetes, CHD):

Name of Line Manager: …………………………………………………………………

Signature of Line Manager: ……………………………………………………………..

Tel No of Line Manager: ………………………………….

Start Date:

Specimen Signature: …………………………………………………………………….

Professional Registration Number (NMC/RPSGB): ………………………………………….

Please return form to: West: Medicines Management Specialist Nurse

Pharmacy Department, Ysbyty Gwynedd, Bangor LL57 2PW

Central: Medicines Management Specialist Nurse Pharmacy Department, Ysbyty Glan Clwyd, Bodelwyddan

East: Associate Chief of Staff (Nursing), Pharmacy and Medicines Management CPG Wrexham Maelor Hospital, Wrexham


Appendix 13

• 13a RISK ASSESSMENT FOR IMPLEMENTATION OF NON-MEDICAL PRESCRIBING - This form must be completed before prescribing can take place in the clinical area

• 13b NON-MEDICAL PRESCRIBING RISK ASSESSMENT WORKSHEET

• 13c BCUHB NON-MEDICAL PRESCRIBING PERSONAL FORMULARY It is accepted good practice that most routine prescribing should be from a limited formulary. As NMP is a relatively new development, BCUHB strongly encourages all NMPs to follow this principle. A personal formulary in this instance is a list of the most routine medicines or groups of medicines prescribed by that NMP. Usually this will be drawn up by the NMP with other clinicians within that CPG. Medicines and dressings should be used in accordance with the BCUHB Formulary. On occasion a NMP may need to prescribe outside of his/her personal formulary; this should involve a risk assessment and appropriate CPD Routine review of an NMP’s personal formulary could take place as part of the clinical governance process.


Appendix 13a RISK ASSESSMENT FOR IMPLEMENTATION OF NON-MEDICAL PRESCRIBING

This form must be completed before prescribing can take place in the clinical area

NAME: ……………………………………….. Prof. Body: NMC / GPC / HPC Prof. Reg. No: ………………………………` Contact details: ……………………………

Non-medical prescribing check list (for use by the non-medical prescriber)

One copy to be submitted to the appropriate Associate Chief of Staff (Nursing) for the Clinical Programme Group CPG. Plus one copy to be submitted with prescriber’s job description and Appendix 12a to the divisional Health Board lead for NMPs: West: Medicines Management Specialist Nurse

Pharmacy, Ysbyty Gwynedd, Bangor

Central: Medicines Management Specialist Nurse Pharmacy, Glan Clwyd, Bodelwyddan East: Associate Chief of Staff (Nursing), Pharmacy and Medicines Management CPG

Pharmacy, Wrexham Maelor Hospital

Risk No

Description of Risk Y – Yes N – No

U - Uncertain

Current Position Review Date

Comments

Y N U 1 Are you certain that you are registered as a non-

medical prescriber with your professional body?

2 Have you completed:

• A local registration & sample signature form

• Risk assessment form

• Personal formulary (if applicable)

3 Have you submitted the above (signed by your line manager) to the divisional NMP lead?

4 Is the need for prescribing documented in your job description?

5 Have you sent a copy of your job description to the divisional NMP lead?

6 Do you know the name of your divisional prescribing lead?

7 Do you know how to order your specific prescription pads and use them?

8 What arrangements do you have in place to store your pads/report loss of pads?

9 Do you have details of your local prescribing formulary?

10 Do you meet or have contact with the practice Pharmacist Advisor/ Non- medical Prescribing Group?

11 Do you feel you have adequate support from your DMP?

12 Do you have access to the internet? 13 Can you access WeMeRec/NPC? 14 Are you sure you have indemnity insurance?


NON-MEDICAL PRESCRIBING RISK ASSESSMENT WORKSHEET Appendix 13b

This form must be signed and dated overleaf

Department/CPG:

Assessor (Non Medical Prescriber):

Element: Direct Patient Care Risks Health and Safety Risks Business and Market Risks

Date:

Hazard Risk Associated Who Will Be Harmed? (how many)

Existing Control Measures Risk level: Low Medium High

Action Required Risk level: Low Medium High


Hazard Risk Associated Who Will Be Harmed (how many)?

Existing Control Measures Risk level: Low Medium High

Action Required Risk level: Low Medium High

Assessor Name: ………………….……………………….. Signature: ……………………………………………….… Date: …………………… Line Manager Name: …………………………………………… Signature: ………………….……………………………… Date: …………………… Evaluation of Risk Likelihood of Occurrence Major: Loss of life or disability Financial instability Significant loss of reputation Low: Annually Serious: Fractures or lacerations Fraud Adverse effect on local reputation Medium: Monthly Slight: Graze or bruises Bad press locally Pilfering or uncovered debt High: Daily/Weekly


BCUHB Non-medical Prescribing Personal Formulary Appendix 13c

NAME: …………………………………………………… Date: …………………………. Designation: ……………………………………………...

MEDICINES FOR PERSONAL FORMULARY MUST BE IN THE BCUHB FORMULARY

Medicine / Medicine Group

Indications Dose Route(√) Guidelines Available? e.g.

NICE, Local Guidelines

BNF Page No &

Section

Remarks Review Date

Oral S/C I/M I.V. Other


Supervising Medical Practitioner Name: …………………………………….……… Signature: ………………………………… Date: ……………………… Non-medical Prescriber Name: …………………………………….……. Signature: ………………………………… Date: ………………………


GLOSSARY ♦ AWMSG - All Wales Medicines Strategy Group The All Wales Medicines Strategy Group (AWMSG) provides advice to the Minister for Health & Social Services in an effective, efficient and transparent manner on strategic medicines management and prescribing. http://www.wales.nhs.uk/sites3/page.cfm?orgid=371&pid=14547 ♦ Black Triangle Drugs▼ The black triangle denotes a new drug. All suspected reactions to black triangle drugs should be reported (including those considered not to be serious). An adverse reaction should be reported even if it is not certain that the drug has caused it, or if other drugs have been given at the same time. ♦ CASPA - Comparative Analysis System for Prescribing Audit A prescribing analysis system provided by Health Solutions Wales. ♦ CMP - Clinical Management Plan A document relating to a specific patient and agreed by the supplementary prescriber and independent prescriber, describing how the patient is to be managed and which medicines the supplementary prescriber can prescribe. ♦ CD - Controlled Drug A controlled drug is one designated as such in The Misuse of Drugs Act 1971. There are five categories of controlled drug: Schedules 1, 2, 3, 4 and 5. Please note that the law on the prescribing of controlled drugs by non-medical prescribers may change following consultations by the Home Office (2009-2010). ♦ DSMP/DMP - Designated Supervising Medical Practitioner/Designated Medical Practitioner The doctor who supports and supervises the non-medical prescriber during the days of the ‘learning in practice’ element of the training course. ♦ First Level Registered Nurse A person registered as a first level nurse on the nursing part of the Nursing and Midwifery Council professional register. ♦ GPC - General Pharmaceutical Council From 27 September 2010 a new regulator for pharmacy, the General Pharmaceutical Council (GPC) will replace the RPSGB as the regulator for pharmacists, pharmacy technicians and pharmacy premises. ♦ HIW - Health Inspectorate Wales On behalf of the NMC, HIW conducts all approvals, re-approvals and monitoring of courses in Wales that lead to registration or recording on the NMC professional register, amongst many other activities.


♦ HSW - Health Solutions Wales HSW is an NHS Wales organisation. The Prescribing Services Unit provides data entry and pricing services relating to prescriptions dispensed within Wales. It is also responsible for the provision of prescribing information and information systems to enable drug expenditure to be monitored ♦ Licensed Medicine The Medicines and Healthcare Products Regulatory Agency (MHRA) operates a system of licensing before the marketing of medicines. Medicines which meet the standards of safety, quality and efficacy are granted a marketing authorisation (previously a product licence) which is normally necessary before they can be prescribed or sold. This authorisation covers all the main activities associated with the marketing of a medicinal product. ♦ MeReC Bulletins Evidence Based Medicines Bulletins produced by the NPC ♦ MHRA - Medicines and Healthcare Regulatory Authority The MHRA is responsible for the regulation of medicines and medical devices and equipment used in healthcare and the investigation of harmful incidents. The MHRA also looks after blood and blood products, working with UK blood services, healthcare providers, and other relevant organisations to improve blood quality and safety. ♦ NMC - Nursing and Midwifery Council The UK regulatory and professional regulatory body for nurses and midwives. The NMC holds a professional register with three parts: Nursing, Midwifery and Specialist Community Public Health Nursing. ♦ NMP – Non-medical prescriber. ♦ NPC – National Prescribing Centre A health service organisation, formed in April 1996 by the Department of Health (England) to support evidence based use of Medicines. NHS Wales has a contract with NPC via The Welsh Assembly Government. ♦ NPCi The NPC virtual learning environment, it covers around fifty clinical conditions commonly encountered by front line healthcare professionals ♦ ‘Off-label’ Medicine A medicine which is prescribed outside of the terms of the marketing. ♦ OSCE - Objective Structured Clinical Examination A form of examination where the student is observed by the examiner in practice or simulated practice. ♦ Registered Midwife A person registered as a midwife on the midwifery part of the Nursing and Midwifery Council professional register.


♦ Registered Nurse A person registered as a nurse on the nursing part of the Nursing and Midwifery Council professional register. ♦ Registered Specialist Community Public Health Nurse A person registered as a specialist community public health nurse, including health visitors, school nurses, occupational health nurses, family nurses (Scotland), and sexual health nurses, on the specialist community public health nursing part of the Nursing and Midwifery Council professional register. ♦ RPS – Royal Pharmaceutical Society The professional leadership body for pharmacists in England and Wales. The RPSGB was, until 2010 also the regulatory body for pharmacists in England, Scotland and Wales ♦ RPSGB - Royal Pharmaceutical Society of Great Britain (RPSGB) The former regulatory and professional regulatory body for pharmacists in England, Scotland and Wales. ♦ SIGN Scottish Intercollegiate Guidelines Network ♦ Supplementary Prescriber A suitably qualified nurse, pharmacist or allied health professional working in partnership with an independent prescriber who may prescribe in accordance with an agreed clinical management plan. ♦ Unlicensed Medicine An unlicensed medicine does not have a marketing authorisation issued by the Medicines and Healthcare Products Regulatory Agency. Products that are not licensed in the UK include:

i) An imported product licensed in another member state or third country but not in the UK.

ii) Unlicensed products manufactured in the UK to the specification of a prescriber, to meet the special needs of his/her individual patients, where no UK licensed medicine is available to meet those special needs.

♦ WeMeReC - Welsh Medicines Resource Centre An organisation in Wales which provides educational resources to multi-disciplinary professionals to influence safe and effective prescribing.


RESOURCES / BIBLIOGRAPHY DoH (2000) The NHS Plan: A plan for investment. A plan for reform. Department of Health. Cm4818-I. Available at: http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/@ps/documents/digitalasset/dh_118522.pdf DoH (2004) Extending Independent Nurse Prescribing within the NHS in England: A guide for implementation. (2nd Edition) Department of Health, London http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_4072177.pdf DoH (2006) Improving patients’ Access to medicines: A Guide to Implementing Nurse and Pharmacist Independent Prescribing within the NHS in England. Department of Health, London (Gateway Reference: 6429) DoH (2008) Health and Social Care Act. Department of Health, London Home Office (1968) Medicines Act 1968. London. Available at: http://www.legislation.gov.uk/ukpga/1968/67/introduction Home Office (1971) Misuse of Drugs Act, London Home Office (1997) The Prescription only Medicines (Human use) Order. London Home Office (2003) Misuse of Drugs (Amendment No3) Regulations, London Joint Formulary Committee. British National Formulary (BNF), British Medical Association & Royal Pharmaceutical Society of Great Britain, London. Current Edition available at: www.bnf.org.uk MHRA (2005) MLX 320: Consultation on options for the future of independent prescribing by extended formulary nurse prescribers. Medicines and Healthcare products Regulatory Agency, London MHRA (2005) MLX 321: Consultation on proposals to introduce independent prescribing by pharmacists. Medicines and Healthcare products Regulatory Agency, London National Prescribing Centre (2003) Maintaining Competency in Prescribing: An outline framework to help nurse supplementary prescribers. NPC, Liverpool Nursing and Midwifery Council (2006) Standards of proficiency for nurse and midwife Prescribers. NMC, London Nursing and Midwifery Council (2007) Standards for Medicines Management. NMC, London Nursing and Midwifery Council (2008) The Code: Standards of conduct, performance and ethics for nurses and midwives. NMC, London


Royal Pharmaceutical Society of Great Britain (2006) Curriculum for the education and training of pharmacist supplementary prescribers to become independent prescribers. RPSGB, London Scottish Executive Health Department. (2006) Non Medical Prescribing in Scotland: Guidance for Nurse Independent Prescribers and for Community Practitioner Nurse Prescribers in Scotland: A Guide for Implementation Scottish Executive, Edinburgh. WAG (2005) Designed for Life: Creating World Class Health and Social Care for Wales in the 21st Century. Welsh Assembly Government, Cardiff WAG (2007) Non Medical Prescribing - A Guide for Implementation. Welsh Assembly Government, Cardiff – available at http://www.wales.nhs.uk/sites3/page.cfm?orgid=371&pid=21001


RESOURCES British National Formulary: www.bnf.org

Department of Health: www.dh.gov.uk

Drug Information zone: www.druginfozone.org

Drug Tariff: www.drugtariff.com/

Health Professions Council: http://www.hpc-uk.org/

Information for multidisciplinary prescribers: www.prescriber-support.co.uk

Medicines and Health Care products Regulatory Agency: www.mhra.gov.uk

National Patient Safety Agency: www.npsa.nhs.uk

National Prescribing Centre: www.npc.co.uk

Nurse Prescriber: www.nurse-prescriber.co.uk

Nursing and Midwifery Council: www.nmc-uk.org

Prodigy: www.prodigy.nhs.uk

Royal Pharmaceutical Society: http://www.rpsgb.org.uk/


TITLE OF WORKING GROUP: NON MEDICAL PRESCRIBING STEERING GROUP Members of the Working Group:

Name Title ACoS Pharmacy & Medicines Management CPG Medicines Management Specialist Nurse Medicines Management Specialist Nurse

Allied health professional representative Practice Development nurse Manager

Non-medical prescriber representative from forum (West)

Pharmacist representative (pharmacist independent prescriber)

Pharmacist independent prescriber/NPC trainer Education representative Practice nurse representative

Non-medical prescribers from primary & secondary care

Consultation/Engagement has taken place with:

Name Title / CPG Approved

yes/no Comments

Director of Nursing, Midwifery and Patient Services

Yes

Assistant Director of Nursing Yes Assistant Director of Nursing Yes Assistant Director of Nursing Yes CoS Pharmacy and Medicines

Management CPG Yes

ACoS (Nursing) Cancer, Palliative Medicines and Clinical Haematology CPG

Yes

ACoS (Nursing) Anaesthetics, Critical Care & Pain Management CPG

Yes

ACoS (Nursing) Primary Community and Specialist Medicine CPG

Yes Comments received and guidance amended

ACoS (Nursing) Women’s and Maternal Care CPG

Yes

ACoS (Nursing) Therapies & Clinical Support CPG

Yes

ACoS (Paediatric Nursing) Children and Young People CPG

Yes

ACoS (Nursing) Emergency, Specialist Surgery and Dental CPG

No Comments noted


ACoS (Nursing) Mental Health and Learning Disabilities CPG

Yes

Senior Lecturer, Health Studies, Glyndwr University

Yes Comments noted

Senior Lecturer, Health Studies, Bangor University

Yes Comments noted

Chief of Staff, Pharmacy & Medicines Management CPG

Yes

Director of Pharmacy/Chief Pharmacist, Ysbyty Glan Clwyd - Central Division

Clinical Director Pharmacy & Medicines Management (East)

Yes

Director of Pharmacy/Chief Pharmacist, Ysbyty Gwynedd - West Division

Yes