6 July 2011
The ‘Evaluation of Nurse and Pharmacist Independent Prescribing’ was commissioned by the Department of Health to help inform planning for current and future non-medical prescribers. The study, conducted over two years, looked at many different aspects of nurse and pharmacist independent prescribing and addressed seven research questions:
- What is the scope and scale of independent prescribing (IP) by nurses and pharmacists?
- What is the quality of, how safe is, and how clinically appropriate is IP by nurses and pharmacists?
- Are the operational arrangements for clinical governance and risk management for IP by nurses and pharmacists adequate and sufficiently robust to ensure patient safety?
- What are the prescribing models in current practice, their associated resources, and patient utility?
- Is IP by nurses and pharmacists acceptable to patients, and what are patients’ experiences of the impact of IP on choice, access, and clinical outcomes?
- Do any changes need to be made to existing educational programmes for nurse and pharmacist independent prescribers?
- What is the response of other health professionals to nurse and pharmacist IP?
The study was conducted in three phases:
- Phase one was a national overview. It included surveys of 1184 nurse and pharmacist independent prescribers and 87 non-medical prescribing (NMP) trust leads. Focus groups with 23 representatives from higher education institutes (HEIs), including NMP programme leads and designated medical practitioners, were also conducted. National safety datasets were analysed by representatives from regulators, professional indemnity insurers and NHS organisations.
- Phase two looked at case studies of practice over ten case study sites, including general practice, outpatients, a walk-in-centre and out of hours, and included an analysis of the clinical appropriateness of 100 consultations. A case record audit was conducted, evaluating practice against national prescribing standards. 321 records were audited from eight prescribers in eight of the case study sites. 273 patient surveys were analysed and interviews with the main non-medical prescriber at each study site completed.
- Phase three involved a multi-stakeholder workshop to consider and prioritise the study findings and implications. Forty-three of the 60 invited individuals participated. Among those represented were the NPC; SHA and trust NMP leads; patients and the public; the Department of Health; professional bodies; professional regulators; and HEIs.
This was a large study with many findings of which only a few are considered in this rapid review.
Quality and safety
Overall the study results indicate that nurse and pharmacist independent prescribing is both safe and clinically appropriate. Analysis of a sample of transcriptions of audio-recorded non-medical prescriber’s consultations showed that nurse independent prescribers (NIPs) and pharmacist independent prescribers (PIPs) are prescribing appropriately across a range of prescribing indicators. The indicator question ‘Is this drug the least expensive alternative compared to others of equal utility?’ received a lower rating compared to more clinical questions of appropriateness. Raters made positive comments on the safety and effectiveness of the prescribing episodes, a quarter of consultations however attracted comments regarding potential for improvements in history-taking, assessment and diagnostic skills.
Non-medical prescribers’ performance and adherence to NICE/SIGN guidance in four areas: asthma, lipid modification (secondary prevention), type 2 diabetes (oral blood glucose lowering therapy) and lower urinary tract infection, was assessed by audit of patient records. The audits showed that recommendations on cost-effective prescribing, dosage and treatment length were not always followed. In the initial treatment of cardiovascular disease, the NICE guidelines of prescribing simvastatin 40mg, unless there is potential interaction or contraindication, was not followed in 61% of cases. In these cases either simvastatin was prescribed at sub-therapeutic levels or alternative statins were prescribed. The audit of diabetes management found that initial treatment was appropriate in all cases and follow up was adherent to guidelines in 87%. The authors stated that overall there was some evidence that practice level prescribing influences may be overriding national guideline recommendations.
Based on the findings of this study, further work needs to be done to implement NICE guidelines into the practice of non-medical prescribers. No evidence was found of the use of the information produced by NICE for patients and carers, and along with the consultation analysis, it has been shown that some additional work is needed to help non-medical prescribers make their consultations more concordant and to improve their skills of giving information to patients.
Following the completion of the research, stakeholder workshops were held to discuss the findings and their implications. Five top priorities were identified:
- A common quality assurance framework for all prescribers
- An organisational strategy for NMP
- Demonstrating the value of non-medical prescribing
- Greater patient and public involvement
- More planning and support for newly-qualified NMPs
In view of the findings that non-medical prescribers were sometimes not following latest evidence and guidelines, non-medical prescribers should ensure that they remain up to date on available treatment options and current national guidelines. They should also maintain their assessment, diagnostic and prescribing skills to ensure that they remain competent to prescribe.
How does this relate to NPC publications and resources?
The NPC is about to begin to produce a single prescribing competency framework, which will replace the current competency frameworks for different groups of non-medical prescribers and will also include medical prescribing. This piece of work will assist in addressing the first action point above, of having a common quality assurance framework for all prescribers.
A comprehensive range of e-learning resources are available on the NPC website to keep prescribers updated on specific therapeutic topics, general prescribing skills and other areas of medicines management. Specifically, e-learning resources are available on the therapeutic areas covered in the study: asthma, cardiovascular disease – lipids, type 2 diabetes and UTI.
The NPC has also produced e-learning resources on concordance and adherence to treatment, including consultation skills, to support the guidance on adherence from NICE.
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