Motivated by the shortage of doctors, government is pushing the idea of nurses writing out prescriptions. But is it really a bad idea?
Nurse, can you write me a prescription?
WORKERS, MAR 2006 ISSUE
You don't get to hear about a change until it is already way down the line. So it may come as a surprise when you first encounter a nurse, not a doctor, writing out your prescription. In fact nurses have been training as extended formulary nurse prescribers since 2002 and as supplementary prescribers since 2003.
What does this mean? The term "formulary nurse" relates to nurses prescribing independently, that is, without recourse to a doctor's signature on the prescription. Importantly for the present debate, it also means prescribing within their competency. This term can mean within one or across several specialisms, depending on the nurse's job.
Supplementary prescribing relates to nurses prescribing within a clinical management plan (CMP). These two phrases – within their competency and clinical management plan – are important because they tell the patient that nurses can only prescribe independently if they meet at least one of two criteria: either they are prescribing in an area of nursing in which they are qualified and experienced or they are prescribing under the auspices of a CMP, a patient's personalised plan. These plans are devised with the patient's and the GP's involvement as well as that of the nurse.
Other nurse prescribers are district nurses and health visitors who are able to prescribe from a limited formulary, mostly dressings.
Finally, nurses can prescribe under Patient Group Directives. An example of this is the flu vaccine given to at-risk patients. But they all amount to the same: nurses, like doctors, cannot prescribe outside either their competency or their responsibility.
Nurse prescribing is a difficult issue because there is no question that the government is motivated by the shortage of doctors.
Typically, a cheaper and more numerous set of workers are being drafted in to fill the gap. But on the other hand, nurses are well placed, within the strictures above and with proper training, to prescribe for patients whom they will frequently know better than the GP. It is a waste of time, and frankly degrading for the nurse, to have to wait around outside the GP's door for a signature on a prescription. The chances are the GP won't even look at the prescription because he trusts the nurse, even without training for prescribing, to make the right decision. Nurse prescribing means that the nurse can follow the patient through to a conclusion. It is easier for both the patient and the nurse, and yes, the GP too.
It is tempting to stand on principle and oppose nurse prescribing, knowing the politics behind it. Nurses are aware that they are being used: for all that they may seem down to earth, caring types, they are also educated, intellectual professionals – reflective practitioners in the jargon of the trade. But the Association of Nurse Prescribers has been campaigning long and hard for the extension of nurse prescribing, and with growing support from nurses. They have their own professional reasons for wanting to prescribe and nurses will always put that before politics, like it or not.
In addition to campaigning for better pay, and for the employment of more GPs and nurses generally, the Royal College of Nursing and other nurses' organisations need to ensure that the training is well funded. In particular, nurses should receive the pharmacological education they need for the all-important background theory to prescribing that GPs and pharmacists receive as an essential part of their training. Already, those nurses who have gone through prescribing courses are experiencing the satisfaction of speaking to GPs and pharmacists on equal terms. They are able to give their input into the whole discussion on the best patient care and to provide the patient with the explanations they need about the drugs. As the nurses become more experienced in prescribing, there are calls for them to become training supervisors. Currently this role is performed by GPs who are overstretched even when they are supportive of nurse prescribing.
Inevitably, doctors are not wholly in favour of the extension of prescribing powers to nurses. They worry about nurses' capacity to understand the pharmacological theory because many will remember how much trouble they had themselves. Reasonably they point out that nurses (and many others along with them!) are likely to be less academically able and are educated to a lower level than doctors. This is a serious point, which cannot be dismissed as mere protectionism or out of some liberal notion of false equality.
Like GPs (though unlike pharmacists) nurses do not need to know how to make up drugs. Also like GPs, they do need to know how the drugs work on the body, what can inhibit or accelerate their absorption, how they interact, their side effects and appropriate clinical applications. This knowledge can be presented in a perfectly understandable way to the increasingly well-educated nursing profession while taking into account that they do not have, and neither do they need, advanced qualifications in chemistry. The pharmacology theory given out to medical students may benefit from being repackaged for nurses, with more focus on practice – an approach that may also work best with the proposed multidisciplinary training. Patients should be confident that all those with responsibility for prescribing have had rigorous, and accessible, training.
As the nurse prescribing training is intensive and very time consuming, nurses' organisations will need to renegotiate caseloads. But this is an issue that is not confined to prescribing. Nurses cannot carry on with the necessary level of continuing professional development and be expected to maintain the same level of work for the same level of pay. Prescribing, another responsibility, means more time-consuming duties, even taking into account their not having to wait around outside GPs' doors. Like GPs, nurses will have to ensure they keep up with the changes in drugs; like GPs they will have to know the BNF inside out and backwards for their specialism. The BNF is the British National Formulary, produced by the British Medical Association and the Royal Pharmaceutical Society of Great Britain. It is the Bible of all those responsible for drug prescribing and dispensing and nurse prescribers have to learn to refer to it at any moment.
They also have to learn how to resist any unethical persuasion from the pharmaceutical companies, already rubbing their hands with glee at the thought of fresh recruits. The companies will be increasing their production of pens and mouse mats with the corporate logos, but provided they don't start offering free chocolate (!), nurses can learn to be just as capable as doctors in brushing them aside.
...and the pharmacists
Other groups of health service professionals are also being trained up for prescribing – most notably the pharmacists. This is one group where any concerns about inadequate knowledge and training really do have no place. It is to pharmacists in hospitals and chemists that doctors turn when they need to know more about a drug, and nurses will do the same. However, pharmacists may have a conflict of interest if they are running a business where profits depend upon the sale of drugs. And a patient might not actually need a drug, but advice from their doctor instead. As for the other groups, for example, physiotherapists, the case will need to be made for and against them as it has been for the two groups discussed here.
Current concerns about nurse prescribing relate to the extension of the nurses' formulary to the whole BNF. At present nurses are only allowed to prescribe independently from a limited formulary (number of drugs) even within their own competency, but many find this hardly less constraining than before they became nurse prescribers. To give any group of people access to a vast range of drugs creates a potential danger, whether they be nurses, pharmacists or GPs. If we had the real number of GPs we need then each one of them would still be a potential danger. But ultimately we rely on these people and the system of training and regulation to protect us. Of course, they are not foolproof or the Shipman murders would not have occurred. However, it is just as likely that we will have more watchful eyes in our surgeries and our hospitals to spot a potential Shipman as it is that another one will be created by the opening up of the BNF to nurses.
Of course nurse prescribing is still controversial, not least amongst nurses themselves. Understandably they worry not only about the training, the increased workload and keeping up to date but also the heightened risk of making a mistake. Beverly Malone, general secretary of the Royal College of Nursing, talks of creating maxi-nurses and not mini-doctors. Nurses and doctors each have different roles in patient care. Each is dependant on the other but traditionally it is the latter who has the higher status since they have to reach a higher academic level, train longer, and carry more responsibility associated with risk-laden duties. But nurses are increasingly unprepared to be seen in a servile role and are taking responsibility for looking at how they can best provide quality patient care. Nurse prescribing, a risk-laden duty, is one part of that debate.