Practical Prescribing for Musculoskeletal Practitioners 2/e

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Chapter 1

Non-medical prescribing: the law and accountability

1.1 Prescribing law

Nurses and pharmacists who are suitably qualified independent prescribers may now prescribe from the full British National Formulary (BNF). Radiographers and optometrists may undertake supplementary prescribing. However, it has taken several years to get to this point.

From 1 May 2006, the nurse prescribers’ extended formulary was discontinued and qualified nurse independent prescribers (formerly known as extended formulary nurse prescribers) automatically became entitled to prescribe any licensed medicine for any medical condition within their competence.

From 23 April 2012, changes to the Misuse of Drugs Regulations 2001 relating to nurse and pharmacist independent prescribing of controlled drugs (Misuse of Drugs (Amendment No. 2) (England, Wales and Scotland) Regulations 2012 (Statutory Instrument 2012/973)) came into force.

See: www.legislation.gov.uk/uksi/2012/973/pdfs/uksi_20120973_en.pdf

Since then, both nurse independent prescribers and pharmacist independent prescribers have been able to prescribe any controlled drug listed in schedules 2–5 for any medical condition within their competence (except diamorphine, cocaine and dipipanone for addiction).

Physiotherapists and podiatrists have been able to undertake supplementary prescribing since 2005. In August 2013 the government passed legislation allowing appropriately trained physiotherapists and podiatrists in England to act as independent prescribers. Secondary legislation is due to follow in Scotland, Wales and Northern Ireland.

As a result of this, appropriately qualified and annotated physiotherapists and podiatrists will be able to prescribe any licensed medicine, provided it falls within their individual area of competence and respective scopes of practice, which are defined as follows:

A physiotherapist independent prescriber may prescribe any licensed medication within national and local guidelines for any condition within their area of expertise and competence within the overarching framework of human movement, performance and function.

A podiatrist independent prescriber can prescribe only those medicines which are relevant to the treatment of disorders affecting the foot, ankle and associated structures, in line with current practice and consistent with published professional guidance.

Education programmes to deliver training in independent prescribing for physiotherapy and podiatry practitioners are anticipated to begin in January 2014. Podiatrists and physiotherapists who are currently supplementary prescribers will be required to undertake a conversion course to become independent prescribers.

1.2 Guidance and standards

Guidance and standards exist and apply for all health professionals as detailed below.

The Nursing and Midwifery Council (NMC) has produced new standards of proficiency for nurse and midwife prescribers (NMC June 2006).

See: www.nmc-uk.org/Documents/NMC-Publications/NMC-Standards-proficiency-nurse-and-midwife-prescribers.pdf

The Department of Health (DH) has produced guidance entitled ‘Improving Patients’ Access to Medicines – A Guide to Implementing Nursing and Pharmacist Independent Prescribing within the NHS in England’ (DH 2006).

See: http://www.prescribingforsuccess.co.uk/document_uploads/About/DHGuideApril06.pdf

The regulatory body for the General Pharmaceutical Council is responsible for standards of conduct, ethics and performance and for the registration of Independent pharmacist prescribers.

See: http://www.pharmacyregulation.org/standards/conduct-ethics-and-performance

Pharmacists must prescribe in accordance with ‘Medicines, Ethics and Practice’ published by the Royal Pharmaceutical Society of Great Britain (RPSGB).

See: www.rpharms.com/mep/download-the-mep.asp

Allied health professionals must act in accordance with the Health and Care Professions Council (HCPC) ‘Standards of conduct, performance and ethics (2012)’.

See: www.hpc-uk.org/assets/documents/10003B6EStandardsofconduct, performanceandethics.pdf

The HCPC has developed new standards for prescribing which reflect recent changes in legislation (August 2013). The standards apply to chiropodists/podiatrists and physiotherapists who are trained either as supplementary prescribers or as supplementary and independent prescribers. They also apply to radiographers who have completed training to become supplementary prescribers. They set out expectations of education providers delivering training in prescribing and outline the knowledge, understanding and skills expected of a prescriber. The standards can be found on the following link:

http://www.hpc-uk.org/assets/documents/10004160Standardsforprescribing.pdf

The National Prescribing Centre has developed a single generic competency framework for non-medical prescribers, to be used by clinicians as a source of information and as a tool to reflect on practice and identify continuing professional development (CPD) needs.

See: www.npc.co.uk/improving_safety/improving_quality/resources/single_comp_framework.pdf

1.3 Non-medical prescribing definitions

There are two methods of prescribing:

1. Independent prescribing

2. Supplementary prescribing

Definition of independent prescribing

With independent prescribing, the non-medical prescriber takes responsibility for the clinical assessment of the patient, establishing a diagnosis and the clinical management required. The non-medical practitioner also takes responsibility for prescribing (where necessary) and the appropriateness of any prescription.

Definition of supplementary prescribing

Supplementary prescribing is defined as a voluntary partnership between an independent prescriber (a doctor or dentist) and a supplementary prescriber, to implement an agreed patient-specific clinical management plan (CMP), with the patient’s agreement.

Supplementary prescribing allows nurses, pharmacists and allied health professionals who have completed the relevant training, with their employers’ approval, to prescribe in a supplementary prescribing partnership.

Following assessment and diagnosis by the independent prescriber and an agreement on the CMP, the supplementary prescriber may prescribe any medicine for the patient that is referred to in a patient-specific CMP, until the next review by the independent prescriber. There is no formulary for supplementary prescribing and no restrictions on the medical conditions that can be managed under these arrangements.

Supplementary prescribing is also a useful mechanism to enable new independent nurse, pharmacist and allied health professional prescribers to develop their expertise and confidence in prescribing or where a team approach to prescribing is clearly appropriate.

Health professionals acting as supplementary prescribers can prescribe any medicines that can be prescribed by an NHS doctor, including controlled drugs and unlicensed medicines, as agreed in the CMP.

Off-licence medicines

Independent prescribers must take full responsibility for their prescribing, and should only prescribe ‘off-licence’ (i.e. outside the licensed indication) when it is considered best practice to do so.

1.4 Accountability

Accountability is the professional term for responsibility and is defined for non-medical prescribers in the NMC Standards of Proficiency for Nurse and Midwife Prescribers (May 2006). The NMC may take disciplinary action when a nurse fails to follow guidelines for professional accountability.

Practice Standard 1

This standard is set out in NMC Standards of Proficiency for Nurse and Midwife Prescribers (May 2006):

You may only prescribe once you have successfully completed an NMC-approved programme and recorded this on the NMC register.

You may only prescribe from the formulary linked to your recorded qualification and must comply with statutory requirements applicable to your prescribing practice.

The ability to prescribe is a privilege granted to you by legislation and your employer and should be seen in this light.

Practice Standard 2

This standard is set out in NMC Standards of Proficiency for Nurse and Midwife Prescribers (May 2006):

You are professionally accountable for your prescribing decisions, including actions and omissions, and cannot delegate this accountability to any other person.

You must only ever prescribe within your level of experience and competence, acting in accordance with Clause 6 of the NMC Code of Professional Conduct, Standards for Conduct, Performance and Ethics.

If you move to another area of practice you must consider the requirements of your new role and only ever prescribe within your level of experience and competence.

In order to prescribe for a patient or client, you must satisfy yourself that you have undertaken a full assessment, including a thorough history, and where possible accessing a full clinical record.

You are accountable for your decision to prescribe and must prescribe only where you have relevant knowledge of the patient’s health and medical history.

You must ensure a risk assessment has been undertaken in respect of the patient’s other current medication and any potential for confusion with other medicines.

The regulatory body for the General Pharmaceutical Council is responsible for standards of conduct, ethics and performance and for the registration of Independent pharmacist prescribers.

See: http://www.pharmacyregulation.org/standards/conduct-ethics-and-performance

Physiotherapists and podiatrists will be required to comply with the necessary standards of prescribing practice once published by the HCPC.

Continuing professional development (CPD)

Prescribers are expected to recognise the importance of (and their responsibility to) maintain up-to-date knowledge of prescribing. Prescribers must comply with their registering body’s CPD requirements.

1.5 Vicarious liability

Liability is the legal term for responsibility. If, for example, a practitioner breaches legislation setting out what they can do within their role, this may be deemed a criminal act. Vicarious liability, where the employer takes legal responsibility for the actions of its staff, provides protection for non-medical prescribers (Caulfield 2004). Non-medical prescribing practitioners prescribing in a self-employed capacity must have personal insurance cover, as vicarious liability would not be applicable in this instance/setting.

It is important to read and be aware of your employer’s (NHS Trust’s) prescribing policy. For example, in some acute Trusts prescribing policies exclude nurses from prescribing cytotoxics. If a nurse were to act outside the boundaries agreed with their employer by prescribing cytotoxics, they would therefore not be covered by vicarious liability and the employer’s insurance policy would not pay out. Professional indemnity cover, as provided through Royal College of Nursing (RCN) membership for example, is vital for nurses in extended roles.

Physiotherapists must also be aware of the principle of vicarious liability, whereby an employer is liable for the acts and omissions of an employee. Employers