It seems some Doctors are kicking up a fuss over non-medical prescribing.
It's front page news 'Nurse prescribing a threat to safety'
'Nurses can qualify by simply attending a training course lasting a minimum of 26 days plus 12 days of supervised practice'
'since May, those in England and Scotland had access to the full formulary for all clinical conditions'
'The RCGP warned the expansion of prescribing rights had gone too far and demanded stronger regulation of non-medical prescribing'
'Experts in medical education are convinced Nurses and Pharmacists will not be well enough trained to be let loose on the whole BNF'
'...this wild expansion must be stopped.'
What joy, they had a consultation and they replied to it, so what are they complaining at now ?

I've re-read this and it doesn't seem to mention it's degree or masters level study ?

Simon, I am unsure what you mean by "what are they complaining at now". If you mean "why are they concerned" then I think I can confirm the concerns that some of us have. There have been concerns raised by postgraduate tutors for medical staff that today's newly qualified doctors are not showing that they are trained sufficiently. The spin off from this is that the short period of training that it appears the nurse prescribing course offers is not sufficient to prescribe safely. I have seen myself the protocol-driven advice given by our nurse prescribers in congestive cardiac failure and I have to admit some of the suggestions for treatment have been potentially dangerous. Believe me learning about prescribing is not just about theory but also experience. I am in favour of expanding prescribing but I have seen the dangerous side of protocol-driven advice. Despite my support for nurses taking on prescribing I am concerned about the expansion to what I see as the prescriber being given powers to prescribe beyond their vision and expertise. Degree or masters level study is of no use without tutored experience. The postgraduate tutors are correct to be concerned about junior doctors' training and I have concerns about expansion of nurse prescribing.

James,
Hmm all the colleges were involved with the expansion of non-medical prescribing. Yes we all need to be aware and concerned. I think current evidence suggests that Nurses are pretty good at prescribing within specialist areas.
It's pretty bad if someone has written protocols that are not fit for purpose or are simply flawed. There is no excuse for blindly following a protocol like a robot.
Non-medical prescribers should not be prescribing beyond their scope of practice as it would be illegal.
The tutored experience would come from a Doctor and from the area of speciality the Nurse or Pharmacist works in. The Doctor does have to sign off that the person is competent.
The article in Pulse is rather strong and who regulates the 'Physicians assistant ' ?
It fetches me back to we need to be working together and constantly looking at competence. What do we need to learn and how do we go about it.
Within substance misuse we will probably on the whole be using a few drugs that we know well. I'm sure this is the same for most specialities.

The pulse articles are always strong that's how they get their readership I'm afraid. Nurses can follow protocols but in my experience have difficulty with an holistic approach. Prescribing an ACE inhibitor to a 90 year old lady at home in grade 4 CCF has it's worries................. I'm sorry but why should the doctor have to sign off someone's competence? Surely they've passed the test and so now they have to take the responsibility.Your assertion that the doctor should "sign the person off" underlines the problem. If nurses are going to prescribe they have to take full responsibility. At the moment that is not happening. Remember I am on the side of limited expansion of prescribing!! My concerns in the example earlier is that the nurses advised an inexperienced doctor to prescribe this drug against BNF guidelines. The nurse should have been free to prescribe and thus take on the responsibility-and if she had been then she could have been responsible for the patient's death 2 weeks later. The example is sad but I have had others too. Controlled expansion is what we need. By the way it was me who interviewed and with others trained the aforesaid nurses. They have improved the outcome for countless patients with heart failure but there have been sporadic problems.

James,
Nurses not holistic ?, they should be that is what the Nursing process was all about.
http://en.wikipedia.org/wiki/Nursing_process
I have no great experience of cardiac failure as an RMN.
The 'signing off' is part of the medical mentors role, if they don't think someone is competent then they should be giving them more work to satisfy themselves that they are.
Nurses/Pharmacists do when qualified take full responsibility for the prescribing that they do.
The Doctor that you mention was also responsible for the decision they took, despite who advised them to do so.
It is no defence in law for me to prescribe something and say 'Doctor said I should'
We will all make mistakes and always will.
I appreciate your replies as someone who says what he thinks rather than gives responses that people want to hear.
best wishes

Simon

I have ben prescibing for 18 months now and fully agree about experience rather than just theory. I prescribe in mental health and substance misuse and feel fully competent to do so - nobody should go outside of their scope of practice. There are good and bad prescibers in medicine also!

My usual cry in debates like this is "where is the evidence?" We all have anecdotal experience of poor and dangerous prescribing, but the balance of evidence is that most of it is effective and well considered for each individual (but always open to improvement).

The evidence of nurse prescribing in mental health is mainly from the US, which I know is different, but is seen as successful when compared to medical prescribers, and better in terms of patient concordance and satisfaction.

Preparation for the role in the UK is robust (believe me!) and strictly understood to be directly related to competence in the field of practice. Pushing the boundaries is part of all professional develoment and needs to be done carefully and not in isolation. Protocols need to be good ones, fully understood by practioners and reviewed regularly, and never used instead of professional assessment and the application of judgement, with consultation as required.

At the moment non-medical prescribers cannot mentor and sign off new ones, that has remained with doctors, recognising the depth of experience that is needed in assessing prescribing-related skill and which few NMPs have yet to attain. Work needs to continue to assess the effectiveness and safety of non-medical prescribing compared to the traditional doctor only system. When there evidence is collected and evaluated I will be the first to complain if patient safety and the effectiveness of treatment has not improved

Having read the threads on this, I sense a growing resentment and anger from the nurses concerned, who have trained and been assessed as competent to have completed the course successfully... so, where does the issue of a nurse being "an autonimous practitioner, accountable for their actions and ommissions" come in to play? I feel that if you have the skills, knowledge and experience then you should be able to practice... maybe nurses should only be allowed to do the course after so many years practice in that particluar field... as for other reasons, they are bound to be political, power based and possibly financial... good luck

Putting my ANSA hat on (not nearly as safe a feeling as a good old tin one) . . .

ANSA has broadly supported the introduction of Nurse (non medical) prescribing. We recognise that in many work environments it rubber stamps what was frequently common practice of the nurse in a Clinic advising the Doctor re script content and dose and also often presenting scripts for the Dr to sign off on.

Both of the above will continue to happen (I am not trying to debate the rights & wrongs, just stating the facts).

Many routes have been tried to legitamise the above, PGDs/Supplimentary prescribing and so on.

The advent of the non medical prescriber does introduce full accountability to the non medic for their practice & identifies as both Simon & Beverley point out that it must be within the scope of practice of the NMS prescriber. I know for example that Beverley cannot and does not Px antibiotics. As a diligent professional she sticks to what she recognises (and has agreed with her employer) is her area of expertise. Likewise I know that even then she would if at all unsure seek advice from a fellow clinician in the same way a GP may have a quiet word with another clinician if advice(consultation) was required.

ANSA has expressed concern that employers may put pressure on NMPs as a cost saving exersize. Will NMPs be able to stand against such pressures? As a professional who has said 'NO' to my employer several times (both within the NHS & Independant sector, I have to trust others will be as strong. I raise this point as at the one day conf in July, a Nurse who had completed training & was set to start prescribing & had wanted to limit her caseload until she felt more comfortable - she was then put under pressure to start with a higher case load - she resisted. An example of (in this case a nurse) setting and working to a self recognised professional boundry related to her scope of practice.


Taking my ANSA hat off & making a personal comment . . .
Good practitioners be they Drs, nurse, pharmacists should always be prepared to say to a collegue "can I have a quiet word" be it to seek advice or give advice. Sad to say James that we will always have Shipmans & Allets + those who know best - how often have we debated on this board those who step outside the orange book (often who dont know what the book says).

Joe just to reflect on your point, I personally would be horrified to see nurses with less than at least two years experience in any speciality wanting to Px. Additionally I would (I hate to use the phrase) risk assess any nurse I manage re their ability to not only complete the NMS course but also practise competently, both for their safety & the service user safety. I say that having declined two applications for NMS training with my service manager hat on.

And finally Simon, we in this field (as nurses) dont know enough about what our peers in other specialities are doing (to take Jmaes examples re cardiac care) - good/bad/indifferent. Thats one of the reasons that ANSA wants to pull in other specialities for the next one day conf. To share & learn from good practice generically and also to make sure that they have an awareness of subsatnce misuse issues & its impact on their speciality.

I was at the DRD working group & someone made a very good point about holism . . . it should be circular and all encompassing, sadly it is sometimes egg shaped with the speciality in the big centre(ish) bit but non the less with a bias!! Is that what you were getting at James?

Regards

Malcolm

My concerns are really that the decisions are protocol driven and not taken with a broader thought process. I'm still learning after 18 years post-graduation. I still make mistakes too.I am sorry but the nursing process is not producing holistic practice in some specialist nurses. I am still in favour of non-medical prescribing but at the moment although I DO see the service working well I also see dangerous blinkered decisions.

James,
Our protocols just follow RCGP guidelines and are not so restrictive. We can review any clinical management plan quickly if there is a problem. I think it is important to be a team and not say we are a team.
I appreciate your concerns and we all need to be aware of bad practice and agree we all make mistakes.
I would hope that I'm never blinkered and if I get so it might be time for me to move on.

I use the same protocols in substance misuse as any clinician should - the Clinical Guidelines and the RCGP methadone and buprenorphine guidelines. I am a specialist in my field and frequently advise the GPs about substance misuse, and then refer to them if clients have medical problems - the team approach works well.

The Pulse article gives an (old)quote from an eminent medical prof. He says it like the stewardess having a months training and then flying the jumbo jet. A poor analogy as airline pilots are the most protocol-driven occupation I can think of, with every decision having to meet the carrier's standard operating procedures.The stewardesses probably have more autonomy about their work!

'Pulse' seems to be the GP equivalent of the Sun, reporting its own surveys as 'news', and not telling us what the questions were. Tomorrow's chip paper as they say up here.