It started with district nurses and health visitors independently prescribing a very small range of products. Then in 2002 came the introduction of the extended formulary for nurse prescribers, which enabled appropriately trained nurses to prescribe for a much wider range of conditions.
By 2005, over 6,000 extended nurse prescribers were signing prescriptions and, this month, extended formulary nurse prescribers across England can prescribe every medicine in the formulary for any medical conditions - with the exception of some controlled drugs.
In a practice with an extended formulary nurse prescriber, GPs are less likely to find a nurse waiting outside the consulting room waiting for a scrip to be signed before the next patient comes in.
The practice will also be better placed to run flu and other clinics and to smooth the management of chronic disease by using such nurses.
Nurse prescribing might improve patient concordance with treatment, because the prescriber is the same person who is monitoring the patient.
There is also potential benefit in out-of-hours patient management. If nurses can handle the needs of patients with chronic disease or those requiring palliative care, GPs are free to tackle real emergencies.
Many believe that extended nurse prescribing is simply an acknowledgement of what is already widely happening in practice. Many nurses already write prescriptions for patients in clinics or the community.
One concern for both GPs and nurses is the responsibility. GPs are responsible to their patients for what they prescribe, as are nurses. Yet, as the employer of a nurse, a GP might be vicariously responsible.
This is particularly relevant for the prescription of controlled drugs and whether nurse prescribing increases the risk to the patient.
This highlights the importance of appropriate training and systems. This includes contemporaneous record keeping of all actions in relation to a patient's care, and the availability of appropriate training on the use of controlled drugs in a palliative care setting.
Dame Janet Smith, in the conclusions to her Shipman Inquiry report, stated that the government should not be deterred from extending nurse prescribing to include controlled drugs.
Nurses caring for terminally ill patients need to have an appropriate range of drugs to help alleviate suffering. Nurses are likely to see these patients on a more regular basis than GPs, so they will be qualified to make decisions such as titrating the initial dose and increasing or adjusting the dose as the disease progresses and prescribing drugs to manage side-effects. Extended formulary nurse prescribing is an exciting opportunity that both nurses and doctors should grasp. It is an example of how healthcare delivery in the UK is changing.
- Tina Carney is a nurse prescriber, working for AstraZeneca
Benefits to practice
- Smoother, less fragmented patient care.
- Time- and labour-saving for GPs.
- Patient concordance.
- Nurse acts as partner, not subordinate.