We are looking at starting a low threshold prescribing service and are aware of a few new models developing around the country.
Can anyone describe their approach and how it fits especially with manpower and clinical safety ? Do clinics have a Doctor all the time, or can a Nurse Prescriber ( ever ) carry on a script for higher risk clients, under clear protocols.
We are a community drugs team, taking on all comers, and might consider holding clinics in a central pharmacy as a real one-stop-shop approach.
Any advice or experience from others welcome - I have emailed one or two people about this and failed to follow it up - time got in the way but we are still considering what might work best
Many thanks
Gill

Hi Gill, Come and visit us in Barnsley, we run a scheme in a needle exchange/counselling service. A GP does 2 sessions a week on a Monday getting untreated patients into treatment, they are given a rx for mainly Methadone and reviewed by a Nurse two days later and titrated upwards.
This scheme has a retention rate at almost 100%

Thanks Simon - do Nurse Prescribers do follow up scripts ? And do you have clear protocols on doses, supervision etc.
I would love to visit, time allowing. We're not too far away. Did some training in Barnsley DGH in the 80's so fond memories
Can I email you to arrange ?
Gill

Gill,
The key is in the clinicla management plan drawn up before a Non medical prescriber can prescribe CDs for addication. The dose range can be specified in it, no limits apart from DoH guidelines and relevant local protocols, and the CMP reviewed as often or a little as you like, up to to maximum of 12 months.

So you could write "Methadone 1mg/ml 10-120 ml daily, review in 2 weeks" and the Non medic would tirrate (or otherwise) based on their re-assessment when they see the client. The CMP can have standard statements regarding the conditions covered and the relvant guidelines, and do not have to be completed by the doctor, client and nurse at the same time. The first meeting can be between doctor and client, agree the CMP and the nurse can agree it ( or not) when they see the client at a later date.

None of this would be necceassary if that darn Misuse of Drugs Act amendment was carried out. Then nurses could do the initial assessment and starting dose (always at a safe level) and the doctor appointment done shortly aferwards at a convenient time for further, more detailed work up, review of investigations etc.

I'll send you the CMP I use if i can find your e-mail address

quote:

Originally posted by gill redshaw:
Thanks Simon - do Nurse Prescribers do follow up scripts ? And do you have clear protocols on doses, supervision etc.
I would love to visit, time allowing. We're not too far away. Did some training in Barnsley DGH in the 80's so fond memories
Can I email you to arrange ?
Gill

Hi Gill,
We have all the protocols in place and the Nurse prescribers do the follow on prescribing normally.
You are more than welcome to visit.

Hi Gill, we (GPsI,SHO, and myself as a prescribing nurse) run a low threshold prescribing clinic weekly -clients see drug workers first then one of us -whoever is free -for the script. It works well, and no a doctor doesn't always need to be there -I have run the clinic alone on several occasions and often with the new SHO learning from me early on in their 6 month rotation.

Hi all - we are still trying to develop this idea, but have a number of queries from Nurse Presribers about risk management, especially as we are a Secondary care service rather than shared care, and have no dual diagnosis consultant ( though we do have DD link workers ).
However with the right protocols ( and a precedent elsewhere ) I wonder if there is a possibility of this happening somehow locally.
Does anyone have protocols that they could share with us ?
We're a bit stuck with visiting practices, as we are short staffed just now.
Happy to speak on the phone once we have seen the protocols to discuss further.
my works email is gill.redshaw@kirklees.nhs.uk
Many thanks !
Gill

Gill,

I have clinic that runs weekly, similar model to Harniman. As long as CMPs are in place I cannot see the issue. It is up to the NMP to assess risk at each consultation and make sure they are staying within their competency/comfort zone.

Dual diagnosis services are a problem whatever. I would consider an RMN qualified NMP to be as able as a GP to carry out reviews of mental health status and refer or consult as required. An RGN only NMP may have some understandable reservations in this area.

THe whole point about NMP is to improve the timely access to prescribed medicine. This kind of service is IMHO exactly what it was intended to do.

Of course there may be issues about cheap labour.........

Hello Gill,
you are inundated with replies from Yorkshire - are we more innovative or more cost-conscious, do you think? The NP at the NFA (I'm back here, out of prison!) does lots of work from CMPs and feel free to contact us about this. I can see, however, that secondary care work might be different. That said, we are managing a lot of dual diagnosis people here, some via CMPs and NP.

Thanks Sally - hope things are going well at NFA. Our NP's have visited the Leeds NP and team at RAPS. I think the combination of DD, possibly complex medical problems and not being able to do restarts is putting them off, and maybe we need a new philosophy to run alongside our present service rather than try to set up a different one, though I also feel that some clients are not ready for a structured service, and low threshold is all they are able to or want to manage.
We have a lot of people who just repeatedly refuse to engage with their keyworker or attend appts. It seems to be almost condoned by allowing clients to turn up when they choose and just collect a script. We have a DNA policy and send letters ( to wherever necesary eg via the pharmacy ) or advise clients that keywork is a vital part of treatment, but it's perhaps too easy to let this drift.
I have quoted Simon and others who say that keeping the script with the prescriber is one way to go, but we don't have many prescribers here and clinic appts are at a premium.
LT prescribing would seem sensible and safe if we have the right policies to review and manage the risk, and some clients might actually prefer it.
Our local Service User group felt the same. Any thoughts from Tony Birt, Drew and others ?
thanks
Gill

Gill

I am sorry to hear that clients can be neglected in this way. Not coming for key work appointments seems crazy in this target-driven age. Why is it not a target set by the commissioner? We know treatment works better when prescribed medication is combined with psycho-social interventions, which is what the key worker is for. 'Pressures' can result in a sense of rushing and urgency, usually originating in the client. (Turning up for a 30 minute appointment 2 minutes before the next one is due, not being able to stay because they are to see their dentist/ lawyer/ landlord/ probation officer at this very same time, arriving wihout an appointment when their keyworker is busy and seeing the duty person for a script etc etc).Good practice means dealing with this as part of the pathology, and good supervision can enable workers to hold the line in a positive way.

Restarts by NMPs should not be a problem if a CMP exists for the client and is still current, they can be valid for a year and can specify a wide range of doses (O to 120 mgs methadone for example). I do them all the time and is 'timely access to prescribed treatment'.

We must have a chat Gill.

Not sure I totally agree with you Jim - forcing people to have key work when they don't want it seems to me to be unproductive and potentially punitive. When low threshold started it was not to neglect people but to be able to give more focused harm reduction advice when people were collecting scripts, originally daily dose, hence loads of good focused 5 minutes rather than one hour of counselling by a worker who couldn't do it to a person who didn't want it. We have the luxury of 3-4 people running the clinic with 'flexible'appointment times and people can choice what they want when they want it except for regular medical and social reviews which everybody has every 3 months

Thanks both - I think this topic brings up various emotions - some to do with serious risk for prescribers and clients, some to do with fairness of treatment access and aversion to "enforcing" attendance or " witholding " treatment, and we all work in different types of services with different configuration of staff. Gritty reality is that some clients aren't ready for more than the basics, and won't engage with keywork voluntarily, but they do need and should have basic HR and other input ( I see Chris has referenced elsewhere the document "towards successful treatment completion: A good practice guide" by John Dunn on the NTA website ). Maybe underneath it all there is a need to review our clients regularly, even if for some that is a 5 minute regular catch up with supervised consumption of their script and for others it is a once a month or bimonthly 30 mins ( I find that not many keyworkers manage an hour unless the client is truly in crisis ? ). This discussion is slowly giving me more ideas.
Jim, I agree we should chat, and Chris thanks for your input - maybe your service is configured in a way that works more effectively with clients. I think it's complex but for me a few details are being overlooked by assuming that its better to simply be on a script than off one. I will now look more closely at John Dunn's suggestions and evidence base ....

quote:

Originally posted by Dr Chris Ford:
Not sure I totally agree with you Jim - forcing people to have key work when they don't want it seems to me to be unproductive and potentially punitive. When low threshold started it was not to neglect people but to be able to give more focused harm reduction advice when people were collecting scripts, originally daily dose, hence loads of good focused 5 minutes rather than one hour of counselling by a worker who couldn't do it to a person who didn't want it. We have the luxury of 3-4 people running the clinic with 'flexible'appointment times and people can choice what they want when they want it except for regular medical and social reviews which everybody has every 3 months

No disagreement I think Chris, it is balancing between positive engagement in a way the client finds acceptable, using positive reinforcement principles and the 'neglect' that can occur when clients are wary of services. It is very common to find workers reflecting something like 'oh, haven't really caught up with X for months now, always seems busy or has a good excuse, didn't realise it had been so long'. I've done it myself and it is a side effect of a successful service with lots to do

Linking scripting with appointments should be a positive experience as it allows greater responsiveness to client need rather than trundling along the same rut.

OKey dokey and I admit to have those reviews dates enter the red on occasions!