Medicines Act 1968 Medical Prescribers: Doctors Dentists Vets
Dr June Crown CBE 2 nd Crown Report: Department of Health. Review of prescribing, supply and administration of medicines: final report. London: DH; 1999
Non Medical Prescribers 1999: 2 nd Crown Report 2005: Supplementary Prescribing by Nurses, Pharmacists, Chiropodists/Podiatrists, Physiotherapists and Radiographers
How and Why of the 2 nd Crown Report Recognised changes on the education and training of other healthcare professional Post graduated education Leading to extended autonomous practice Specialist qualifications Highly trained health professionals using their full range of skills and able to accept clinical responsibility for doing so Within Medicine Development of evidence based practice clinical guidelines and protocols Development of Specialities within medicine Recognised specialist registers by GMC Recognised changes in Professional Relationships Development of the multi- professional team – Advanced healthcare practitioner
2nd Crown Report: Recommendations Overall Objective Any change from current practice should result in improved health outcomes, or else equivalent health outcomes with improved patient convenience or more appropriate professional practice. Any proposed change should be assessed against the following criteria:- health outcomes and patient safety patient choice patient convenience professional appropriateness effective use of resources
IMPROVING HEALTH AND WELL-BEING THROUGH POSITIVE PARTNERSHIPS A STRATEGY FOR THE ALLIED HEALTH PROFESSIONS IN NORTHERN IRELAND 2012 - 2017
“Quotes” “ AHPs will actively enhance people's lives through the planning and delivery of high quality and innovative diagnostic, treatment and rehabilitation services and practices that are safe, timely, effective and focused on the service user.” 4 Strategic Themes: Promoting person-centred practice and care; Delivering safe and effective practice and care; Maximising resources for success; and Supporting and developing the AHP workforce.
Aims of NMP Improve patient care without compromising patient safety Make it easier and quicker for patients to get the medicines they need Increase patient choice in accessing medicines Make better use of the skills of health professionals Contribute to the introduction of more flexible team working across the Health Service
Strategic Theme 4-Supporting and Developing the AHP Workforce : Workforce Planning Workforce Planning – Right people – Right place – Right time – Right outcome Extended roles &Changing work practices Extended Roles Changing Work Practices Skills and Grade Mix – Future skill mix to support strategic shift in how and where care is delivered – Clinical AHP Consultant Grades in Northern Ireland implemented in the next 5 years
Strategic Theme 4-Supporting and Developing the AHP Workforce: Learning & Development AHP Support Staff to Advanced Consultant Practitioners Staff Development – Current Grade – Career progression
Strategic Theme 4-Supporting and Developing the AHP Workforce: Learning & Development Postgraduate Certificate in Prescribing for Allied Health Professionals 2010 11 AHP – 3 radiographers – 2 podiatrists – 6 physiotherapists AHP Prescribing in Northern Ireland :
Non Medical Prescribing for AHP’s : Supplementary Prescribing
Supplementary Prescribing Supplementary prescribing is a voluntary prescribing partnership between an independent prescriber and a supplementary prescriber, to implement an agreed patient-specific clinical management plan with the patient's agreement. The independent prescriber must be a doctor (or dentist).
IP & SP: The Definitions Independent Prescriber professionals who are responsible for the initial assessment of the patient and for devising the broad treatment plan, with the authority to prescribe the medicines required as part of that plan. NMP must only prescribe as IP’s within their scope of practice Supplementary Prescriber professionals who are authorised to prescribe medicines, for patients whose condition has been diagnosed or assessed by an independent prescriber, within an agreed clinical management plan.
Legal Requirements for Supplementary Prescribing: doctor the independent prescriber must be a doctor (or dentist) the supplementary prescriber must be an eligible AHP, pharmacist, optometrist or nurse or agreed there must be a written or electronic clinical management plan agreed by all parties including the patient must be able to access the common patient record the independent prescriber and the supplementary prescriber must be able to access the common patient record
Supplementary Prescribing: The Prescribing Partnership CMP Patient Supplementary Prescriber Doctor
CMP hinges on the Doctor/AHP Prescribing Partnership IP is responsible for determining conditions the CMP covers, special considerations inrealtion to the individual patient and the limits of the SP’s SP is autonomously responsible for clinical assessment and personally accountable for prescribing decisions (i.e. drug choice, and dose ) within the limits of the CMP
CMP Must be Must be Patient Specific – Take into account the patients medical history and any other conditions they may have. Allergies or sensitivities the patient has Not a blanket authority to prescribe medicines May not be suitable for all patients Must clearly state the limits of prescribing i.e. when referral back to IP should take placeHowever Clinical Management Plans (CMPs) have to be relatively simple and quick to complete – or supplementary prescribing will simply not be worth the effort. They should not duplicate a lot of information that is already recorded in the shared record.
Regulations specify that the CMP must include the following: the name of the patient to whom the plan relates; the illness or conditions which may be treated by the supplementary prescriber; the date on which the plan is to take effect, and when it is to be reviewed by the doctor or dentist who is party to the plan; reference to the class or description of medicines or types of appliances which may be prescribed or administered under the plan; any restrictions or limitations as to the strength or dose of any medicine which may be prescribed or administered under the plan, and any period of administration or use of any medicine or appliance which may be prescribed or administered under the plan; [NB The CMP may include a reference to published national or local guidelines. However these must clearly identify the range of the relevant medicinal products to be used in the treatment of the patient, and the CMP should draw attention to the relevant part of the guideline. Any guideline referred to also needs to be easily accessible] relevant warnings about known sensitivities of the patient to, or known difficulties of the patient with, particular medicines or appliances; the arrangements for notification of:- a) suspected or known reactions to any medicine which may be prescribed or administered under the plan, and suspected or known adverse reactions to any other medicine taken at the same time as any medicine prescribed or administered under the plan, and b) incidents occurring with the appliance which might lead, might have led or has led to the death or serious deterioration of state of health of the patient the circumstances in which the supplementary prescriber should refer to, or seek the advice of, the doctor or dentist who is party to the plan.
Clinical Management Plan: CMP Departmental Protocol Protocol for Lung Cancer Clinical Specialist Radiographer Review for Patients with Lung Cancer Agreed by Lung Team Clinical Oncologists, Radiotherapy Lead Clinician, Clinical Director & Professional Lead
Shared Patient record Hardcopy & ‘COIS’ electronic case notes Gained user rights to input prescribing information electronically Meets statutorily requirements – Automatically available for IP and other clinicians – Meets the trust’s NMP policy requirement s – Governance CMP hardcopy inserted to patient notes at the end of treatment Potential of Electronic Version of CMP BHSCT: NMP Policy Prescriber details, Date, Drug, Quantity, Dose, Frequency, Treatment duration
Scope of Supplementary Prescribing: (NPC 2010) No restrictions on the clinical conditions SP may treat as CMP in place. Primarily used to treat chronic conditions or patients with who require long term care. This includes cancer. All general sales list (GSL) medicines, pharmacy (P) medicines, appliances and devices, foods and other borderline substances approved by the Advisory Committee on Borderline Substances. Medicines for use outside of their licensed indications (i.e. ‘off label’ prescribing), ‘black triangle’ drugs, and drugs marked ‘less suitable for prescribing’ in the 'British National Formulary' (BNF). Controlled Drugs except those listed in schedule 1 of the 2001 Regulations. These drugs are not for use in humans.
Supplementary Prescribing Let the confusion begin!
INDEPENDENT PRESCRIBER SUPPLEMENTARY & INDEPENDENT PRESCRIBER The Prescribing Umbrella Non-Medical Prescriber Medical Prescriber
Non Medical Prescribers Nurses Pharmacists Radiographers Physiotherapists Chiropodists/ Podiatrists Optometrists
Non Medical Prescribers INDEPENDENT PRESCRIBER SUPPLEMENTARY PRESCRIBER
The BHSCT AHP Supplementary Prescribing Experience.
BCH AHPISP’s Linda Young Lung Cancer Specialist Jenny Keane Head & Neck Cancer Specialist Helen Vennard Breast and Gynae Specialist.
CSR Clinical specialist radiographers – Principle Radiographers 6-8 years in current posts Work in disease specific teams MSc level Postgraduate Education modules Expert knowledge in the clinical management and treatment of cancer relevant to our specialist disease site
Patient Centered Care Levels Matched Against Current Roles And Responsibilities. Level 1 Providing appropriate specialist information and knowledge to patients and careers. Giving guidance and support around the diagnosis and treatment options. Ensuring seamless transfer from diagnosis to treatment and onward referral where appropriate. Level 2 Core Member of the MDT. Functioning as a member of the multidisciplinary team, where decisions about the optimum treatment options to offer to each patient. Provide specialist knowledge to the lung cancer multi-professional team meeting. Participate at Lung Cancer Regional Network level. Play a lead role in development of radio-therapeutic practice pertaining to the treatment of lung cancers. Level 3 Responsibility for the co-ordination of care across the radiotherapy pathway. Responsible for managing treatment related toxicities. CSR On-treatment and post treatment review The NHS Cancer Plan and the New NHS: Providing a patient centered service (2004), DH
Lung Cancer Team Clinical Navigation Radial intent Palliative intent Managing treatment related toxicity Gaining optimum control of symptoms of disease Appropriate onward referral Clinical Oncologists Lung Cancer Nurse Lung Cancer Radiographer Medical Oncologists
THE POSTGRADUATE CERTIFICATE IN PRESCRIBING FOR ALLIED HEALTH PROFESSIONALS FEB 2010
Portfiolo……it was unending!!!!!!! Postgraduate Certificate Prescribing Portfolio of Prescribing Competencies
Postgraduate Certificate Semester 2 February 2010 Pharmacotherapeutics in Prescribing Semester 1 October 2010 Prescribing in Practice Jan 2011 Results Feb 2011 Semester 3 June 2010 Clinical Experience & Case Study “Scouting” Register with HPC April 2011 Graduate June 2011 Paperwork July 2011 September 2011 Clinical Protocols in place ??????? Legislation in Place October application to Register January 2010 AHPISP
Lessons learnt in the first week at UU All drugs are poison! DR MARK CROSS Drug Drug Interactions Importance of Drug Historys & Allergies Co-morbidities, e.g renal disease Patients don’t tell the truth about taking their medication! THE BROWN BAG PHENOMEN!
CSR links to the Patient’s Journey MDT New patient Clinic Radiotherapy Planning Clinic Radiotherapy On Treatment Review (urgent & weekly for duration of treatment Radiotherapy Follow-up Clinic
CSR links to the Patient’s Journey MDT New patient Clinic Radiotherapy Planning Clinic Radiotherapy On Treatment Review (urgent & weekly for duration of treatment Radiotherapy Follow-up Clinic CMP
Radical NCSCL 66Gy in 33 fractions SUCRALFATE 1g PO TDS from start of treatment until for 4 weeks post +/- PPI Oramorph 2.5mg PO 4-6 hrs PRN Fluconazole 50mg PO 14 days Case 1 Normal Grade 2 Grade 3 with candidiasis
ALL DRUGS ARE POISONS!!! FLUCONAZOLE: – Caution in patients with renal impairment EGFR <50 reduce dose by half after 1 st dose Rare cases of hepatic failure! As a causal relationship with fluconazole cannot be excluded, patients who develop abnormal liver function tests during fluconazole therapy should be monitored for the development of more serious hepatic injury. Fluconazole should be discontinued if clinical signs or symptoms consistent with liver disease develop during treatment with fluconazole. Cautions!!!!!!!
ALL DRUGS ARE POISONS!!! SUCRALFATE: – Bezoars (an insoluble mass formed with the gastric lumen) – Caution in patients with renal impairment due to increased aluminium absorption – Concomitant administration may reduce the bioavailability of certain drugs including tetracycline, ciprofloxacin, norfloxacin, ketoconazole, digoxin, warfarin, phenytoin, theophylline, thyroxine, quinidine and H 2 antagonists. The bioavailability of these agents may be restored by separating the administration of these agents from SUCRALFATE by two hours. Cautions!!!!!!!
Radical NCSCL 64Gy in 32 fractions 3 rd fraction described Pain in the left thorax Open and close surgery No brachial plexus neuropathy No clinical indication for pain Described Pain with neuropathic element Case 2
Radical NCSCL 64Gy in 32 fractions 2 nd Week Nausea – METOCHLOPRAMIDE – CYCLIZINE – ONDANSETRON – Added in Steroid Friday night at 5pm Nausea and vomiting ? Admission – LEVOMAPROMAZINE 6mg Nocte Case 2 DRUG DRUG INTERACTION! LEVO with Amitriptylline
Contacted GP who after discussion felt that the drug combination was justified and she took responsibility for the prescription GP issued the script to local pharmacy Patient collected on way home Nausea and vomiting was resolved by Monday. Pain remained controlled. Case 2 DRUG DRUG INTERACTION! LEVO with Amitriptylline
Did this meet the aims of NMP No inpatient bed stay
Do we consider SP to be of value? Patient’s: Yes! “I get the same care, the same medicines, I just don’t have to wait so long to get them.” Doctors: Definate Yes “Can I head off to planning now? sure you can mange the clinic this morning, give me a shout if you need me. Any problems, I’ll come down asap. “
Why has Supplementary Prescribing appeared to fail in Nursing Models ?
The reasons! Available for Nurses since 1999 Over 50% of the nurses surveyed could use NMP in their area of practice. Due to difficulties implementing NMP in practice only 22.7% were prescribing in practice. unavailability of prescription pads awaiting prescribing code impracticalities due to trust-wide remit not working in an area of practice that lends itself to extended independent or supplementary nurse prescribing GRIBBEN, L., 2004. Meeting The Educational Needs of Independent and Supplementary Nurse Prescribers – An Interim Evaluation. MSc Learning & Teaching. University of Ulster Jordanstown At a local level NMP uptake was initially high within Northern Ireland however it is reported that within the Belfast Trust only 25% of nurses trained as non- medical prescribers actually practice. V Hall Consultant Nurse. Pharmacist NMP’s only 47% of them were actively prescribing BISSEL, P., COOPER,R., GUILLAUME, L., ANDERSON, C., AVERY, A., HUTCHINSON, A., JAMES, V., LYMN, J., MARSDEN, E., MURPHY, E., RATCLIFFE, J., WARD, P., and WOOLSEY, L., 2008. Nurse and Pharmacist Supplementary Prescribing in the UK - a systematic Review of the Literature. London: DH
CAUTION!!!!! AHP’s Will Follow The Same Path If Candidates Are Not Able To Meaningfully Prescribe In Practice
Why has implementing supplementary prescribing worked for us?
How supplementary prescribing will work your you! A Trustwide Non Medical Prescribing policy reflects the prescribing rites of your profession Departmental Prescribing Policy/ AHP role specific clinical protocol Appropriate identification of applicant Right person Right place Right time Right outcome
How supplementary prescribing will work your you! AGREED Core Formulary: Which Which reflects Prescribers level of clinical management, skill and knowledge of medicine will be reflected in the classes of medication listed in the SP’s core formulary and referral back to IP trigger points. Close team working built on a mutual trust and respect for each prescribers role Access to the shared patient record A WORKABLE SYSTEM for implementing the CMP!
Head & Neck CSR Core Formulary 5 Infections Antimicrobials: 5.1Antibacterial drugs 6 Endocine system 9 Nutrition and blood 9.1 Agents used for anemias and some other blood disorders 9.2 Fluids and electrolytes 9.5 Minerals 9.6 Vitamins 10 Musculoskeletal and joint disease 10.1.1 Non-steroidal anti- inflammatory drugs 11 Eye 11.8 Tear deficiency, ocular lubricants, and astrigents 12 Ear, Nose and oropharynx 12.2 Drugs acting on the nose 12.3 Drugs acting on the oropharynx 13 Skin 13.2 Emollent and barrier preparations 13.4 Local anaesthesia 15 Anaesthesia: 15.2 Local anaesthesia Controlled Drugs schedule 2,3 & 4: BUPRENORPHINE CODIENE PHOSPHATE FENTANYL MORPHINE SALTS: SEVREDOL MST CONTINUOUS OXYCODONE HYDROCHLORIDE OXYNORM OXYCONTIN TARGINACT TRAMADOL HYDROCHLORIDE Off Label drugs OXCETACAINE in ANTACID: LEVOMEPROMAZINE: 1Gastro-intestinal system 1.1Agents for dyspepsia and gastro- oesophageal reflux disease 1.2Antispasmodics and other drugs and mucosal protectants 1.3Antisecretory drugs and mucosal protectants 1.4 Acute diarrhoea 1.6 Laxatives 1.7 Local preparations for anal and rectal disorders 3.Respiratory system 3.6 Oxygen 3.9 Cough preparations 3.10 Systemic nasal decongestants 4 Central nervous system 4.1 Hypnotics and anxiolytics 4.6 Drugs used in nausea and vertigo 4.7Analgesics controlled drugs listed below
Head & Neck CSR Core Formulary 5 Infections Antimicrobials: 5.1Antibacterial drugs 6 Endocine system 9 Nutrition and blood 9.1 Agents used for anemias and some other blood disorders 9.2 Fluids and electrolytes 9.5 Minerals 9.6 Vitamins 10 Musculoskeletal and joint disease 10.1.1 Non-steroidal anti- inflammatory drugs 11 Eye 11.8 Tear deficiency, ocular lubricants, and astrigents 12 Ear, Nose and oropharynx 12.2 Drugs acting on the nose 12.3 Drugs acting on the oropharynx 13 Skin 13.2 Emollent and barrier preparations 13.4 Local anaesthesia 15 Anaesthesia: 15.2 Local anaesthesia Controlled Drugs schedule 2,3 & 4: BUPRENORPHINE CODIENE PHOSPHATE FENTANYL MORPHINE SALTS: SEVREDOL MST CONTINUOUS OXYCODONE HYDROCHLORIDE OXYNORM OXYCONTIN TARGINACT TRAMADOL HYDROCHLORIDE Off Label drugs OXCETACAINE in ANTACID: LEVOMEPROMAZINE: 1Gastro-intestinal system 1.1Agents for dyspepsia and gastro- oesophageal reflux disease 1.2Antispasmodics and other drugs and mucosal protectants 1.3Antisecretory drugs and mucosal protectants 1.4 Acute diarrhoea 1.6 Laxatives 1.7 Local preparations for anal and rectal disorders 3.Respiratory system 3.6 Oxygen 3.9 Cough preparations 3.10 Systemic nasal decongestants 4 Central nervous system 4.1 Hypnotics and anxiolytics 4.6 Drugs used in nausea and vertigo 4.7Analgesics with the exceptions of controlled drugs listed below
How supplementary prescribing will work REGIONALLY! Have some ACTIVE prescribers as members of committees at strategic level to inform at regional level!
How AHP strategy will be implemented REGIONALLY! Commissioners, don’t be a stranger! Commissioners, don’t be a stranger!