Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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![[Read Rapid Response]](/icons/misc/sectionDOWN.gif)
absolute idiocy
- Andrew G Montgomery (18 November 2005)
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Safety of Nurse Prescribing
- Stephen C Earwicker (18 November 2005)
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Interesting Reference
- Joseph F Standing (19 November 2005)
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Re: absolute idiocy
- Lisa C Blakemore-Brown (19 November 2005)
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Is it really necessary??
- Alistair R Ramsden (20 November 2005)
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Triumph of common sense
- Sam Richmond (20 November 2005)
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Re: Re: absolute idiocy
- Ellen C G Grant (21 November 2005)
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Experience of nurse prescribing
- Victor B Maxwell, London NW4 1AE (21 November 2005)
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Another waste of time
- andrew rosser (21 November 2005)
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Eroding standards
- Martin P Mayfield (21 November 2005)
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Whoever prescribes should be accountable
- Ramakant sharma (21 November 2005)
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Re: absolute idiocy
- Gail Chan (21 November 2005)
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Damascene conversion?
- Orest Mulka (21 November 2005)
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Sorry, I Just Don't Understand
- Graeme M Mackenzie (22 November 2005)
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The final death throes of general practice?
- Keith R Sumner (22 November 2005)
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Re: Re: absolute idiocy
- Andrew Montgomery (22 November 2005)
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Clearly written scripts help.
- Phillip J. Colquitt (23 November 2005)
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Its the outcome that matters
- Garry R King (23 November 2005)
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Mental Health Nurse Prescribing: New Ways
- Martin Jones, Dawn Miller, Ben Lucas, Joanna Bennett, Richard Gray (23 November 2005)
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A useful step in the right direction
- N Portman (24 November 2005)
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Response from a non medical prescriber
- Deborah Bond (24 November 2005)
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A Sensible Thought
- NISHANT RANJAN (24 November 2005)
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Re: A useful step in the right direction
- andrew montgomery (25 November 2005)
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Perceptions of Patients to Extending Prescribing to Nurses and Pharmacists
- Kashif M Qureshi, Shahram Kashani, Scott Robbie, Nabil Malik (10 August 2006)
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Re: Perceptions of Patients to Extending Prescribing to Nurses and Pharmacists
- Stevie M Gamble (12 August 2006)
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Response to S Gamble
- Scott J Robbie, Kashif Qureshi, Shahram Kashani, Nabil Malik (26 August 2006)
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Andrew G Montgomery, locum practitioner New Zealand
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After practicing medicine for 15 years it would be fair to say that I am confronted with diagnostic conundrums on an almost daily basis. I am generally regarded as one of the more competent practitioners by the many different people with whom I work. Medical training in New Zealand is of a very high standard. The prescribing of medicines should be absolutely restricted to those with full medical qualification - ie doctors. If nurses and pharmacists want to do doctors work then they must have a doctor's training. This is tautological. The population of the UK are about to be subjected to a most unfortunate experiment. Incidentally many "controlled drugs" such as narcotics and benzodiazepines are substantially safer for the naive practitioner to prescribe than, for example, methotrexate, amiodarone, digoxin and many antihypertensives - to name but a few. Competing interests: medical practitioner |
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Stephen C Earwicker, GP & PEC Chair Broxtowe & Hucknall PCT 1 Derby Road Beeston Nottingham NG9 2TA
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I welcome Prof Avery & Prof Pringle's assessment of where we are with Nurse & Pharmacist prescribing. They are right to raise the issue of patient safety which must be at the heart of all we do. We have been in the forefront of Nurse Prescribing in our General Practice and have found both good practice and some frustrations. Intrinsically we have found our Extended & Suplementary Nurse Prescribing to be safe. Nurses by their training are driven by the concept of competency and we have found it central to the way of working to assess & prescribe only within the bounds of clear competency. There is no doubt that the introduction of safe nurse prescribing has been helped by the presence of a strong & open clinical team who have supported the nurses throughout their initial training and on an ongoing basis. The frustration for us has been the lack of integration of nurse prescribing with our clinical computer system. This has, as the editorial points out, removed a potential safety feature open to doctors when they prescribe. There are ways around this, but it would have been far better to encourage computer prescribing by nurses from the outset. Let's hope that with this welcome announcement by the Secretary of State, there will be a rapid roll out of Nurse Prescribing software on GP & community clinical computing systems before April 2006. Competing interests: Medical Practitioner |
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Joseph F Standing, Research Pharmacist Great Ormond Street Hospital, London, WC1N 3JH
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It is interesting that Avery and Pringle are against "virtually the whole of the BNF" being available to pharmacist prescribers. As can be seen in the book's preface, the BNF is written and edited by pharmacists. Competing interests: I am a paediatric hospital pharmacist |
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Lisa C Blakemore-Brown, Psychologist UK based
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Dr Montgomery has picked up on the experiment to take place in the UK. I can also inform him that this is just a part of a wider experiment of social and professional engineering which ensures politicians increasingly dictate how the system operates. The professional barriers are being brought down in many areas including medicine, social work, education etc. Many highly qualified professionals are being marginalised in the UK and this can only be because given their qualifications and experience, they may have their own thoughts about things. years of experience and long memories, and perhaps will be less easy to control. Lesser qualified individuals will be very grateful to politicians for giving them the power to undertake tasks hitherto only undertaken by others who had spent many years qualifiying. In the case of prescribing, one must also raise the issue of drug company influence and how easily politicians will be able to influence the grateful as to what they prescribe once these barriers are down. Competing interests: Specialist in autism |
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Alistair R Ramsden, Urology Registrar Royal Bournemouth Hospital
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I have no doubt that, despite the lack of reliable evidence, nurse prescribing is perfectly feasible; but is it really necessary? Most of us are very comfortable prescribing within the limited boundaries of our expertise and are equally happy to bow to the superior knowledge of an appropriately qualified colleague when we find ourselves in unfamiliar territory. I don't imagine that, given unlimited prescribing powers, nurses would behave any differently. What I find utterly incomprehensible is this; there are currently an insufficient number of qualified nurses to adequately staff hospital wards. At the same moment in time there are thousands of unemployed doctors who already have the training and qualifications to prescribe. Would it not be more sensible to make use of the skill mix that already exists rather than breed halflings who are neither proper nurses nor proper doctors? Competing interests: None declared |
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Sam Richmond, Consultant Neonatologist Sunderland Royal Hospital, SR4 7TP
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As a consultant neonatologist in a neonatal intensive care unit I am absolutely delighted that the Department of Health has at last seen sense with respect to nurse prescribing. This now means that the Neonatal Nurse Practitioners who form 40% of our first line 'medical' team on the unit will have almost the same prescribing powers as the senior house officers who form the remaining 60%. If, in the context of a hospital, they would extend this permission to 'controlled drugs' and unlicenced drugs, I would be even more pleased. At present what stands in the way of this progress is Article 12 of the Prescription Only Medicines (Human Use) Order 1997 which forbids any pharmacist from supplying any prescription-only medicine except “in accordance with the written directions of a doctor or dentist in the course of the business of the hospital.” Those who remain concerned that nurse prescribing will lead to pharmaceutical chaos should perhaps pause to consider how feeble the current law is in this regard. As things stand at the moment it is perfectly legal for a dentist or a consultant pathologist to prescribe medication for the babies in our neonatal intensive care unit purely by virtue of their medical or dental qualification and despite their total lack of neonatal experience (I mean no disrespect here, I am merely using these as examples). At the same time it is illegal for the Neonatal Nurse Practitioners, each with many years of senior neonatal nurse experience followed by 12 months Nurse Practitioner training and a further 6 months closely supervised practical experience, to do the same. Obviously no-one would carry out the prescription of a dentist or a pathologist in this situation - despite its legality - because, in practice, it is not laws in Parliament that ensure the quality of prescribing but the presence of local controls. Senior House Officers joining our unit have little idea about prescribing in neonatal intensive care despite many years of medical training. The quality of their prescribing is the responsibility of those in clinical charge of the unit who must lay down appropriate guidance. If this guidance is appropriate then prescribing will be safe and effective; if it is not it will not be. I remain somewhat anxious as to how the DoH are going to approach the area of licenced drugs used 'off-licence' because a considerable number of drugs used in neonatal intensive care fall into this category. Competing interests: None declared |
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Ellen C G Grant, physician and medical gynaecologist Kingston-upon-Thames, KT2 7JU, UK
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Once more the UK leads the world. This time with an idiotic decision to extend prescribing by nurses. A main motive for providing schools with prescribing nurses is to aid teenage access to contraceptive hormones. The UK was one of the first countries to encourage hormonal contraceptive use in younger women in the 1970s. Dramatic increases in breast cancer in young women were soon recorded, together with sharp increases in diseases in children. Does the official advice, to use the lowest doses of progesterones and oestrogens for the shortest time as possible if given as HRT, not also apply to very young females? Younger age hormone starters are more likely to have longer use. Longer use results in higher risks of serious adverse effects both for the young women and their children. Competing interests: None declared |
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Victor B Maxwell, Retired G.P. 21 Sherwood Road, London NW4 1AE
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Editor-The editorial by Avery and Pringle strikes a chord.' 6 years of hospital medicine in the 1950s prior to a career in general practice taught me the benefit of learning from nursing colleagues and recognising just what skill many of them possessed. On setting up in practice in Cheshire in 1960 I could not understand why I could not continue the working relationship. In 1963 I employed a practice nurse, one of the first to do so. By the time I retired in 1991 there were three nurses, providing full time cover during all the hours the health centre was open. Nurse and I produced a document which established the areas in which she had competence and this was extended as her experience grew. We started with a short list of perhaps half a dozen drugs and added others as she became more experienced. The document was signed by both of us and I undertook in writing to back her if any problems arose. In 28 years there was never, to my knowledge, any such problem or a single case in which she exceeded her competence to prescibe. I support the view of the authors that with appropriate training nurses have the knowledge and self discipline to recognise the extent of their competence to prescribe. Certainly in my own practice it was the patients who benefitted from this experimental approach. 1. Avery AJ, Pringle M. Extended prescribing by U.K. nurses and pharmacists. BMJ 2005; 331:1154-5 (19 November) Competing interests: None declared |
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andrew rosser, SHO SE13 6LH
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Nurses require alot more training before they start initiating even simple treatment. The intiation of treatment requires the clinician to have diagnosed the problem correctly and understand potential contraindications to the treatment they are thinking of intiating. The majority of nursing staff I have met do not have a satisfactory understanding of pathophysiology or pharmacology required for this. Will they be up to date with the best evidence based medicine? Who will end up with the responsibility for the inevitable drug errors? It will be the doctors sorting out the inevitable mistakes made. Competing interests: None declared |
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Martin P Mayfield, General Practitioner Yorkshire (LS20 9HE)
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It’s all a bit confusing. In the 1840’s it was considered necessary that all practising as doctors –ie in the diagnosis, management and prescription of/for illness- should be adequately trained, hence the establishment of the General Medical Council for the supervision of MB ChB/MB BS courses at medical schools. In the 1990’s it was felt necessary that any doctor practising in general practice should meet the minimum standards set out by a committee to ensure such standards –the JCTGP (Joint Committee for Training in General Practice). In the past few months the criteria have been tightened further and all future GPs will have to attain MRCGP. Why then the move to have practitioners with a different level of training working in what is still essentially General Practice? How does removal of the established standard maintain, let alone raise, standards? This is not to say that other practitioners are unworthy; but that the MBChB and JCTGP were established for a purpose, and those aspiring to their priveleges and responsibilities should undertake the appropriate training. (Would you let the navigator take over the controls of an airliner? [and for the benefit of any aircrew reading, would you let a pilot navigate?]). It might be pointed out, as many of my patients have to me, that in Spain one does not need to see a doctor to obtain antibiotics, but one may purchase them in a pharmacy. It might not come as a surprise then, to note that the emergence of antibiotic-resistant pneumococci was observed in Spain long before it became a problem in the UK where, up until now, antibiotics have been restricted in their supply. The argument that pharmacists are unlikely to prescribe antibiotics is undermined by my own observation that a mother buying Optrex eye drops for her child was completely surprised to find that the formulation purchased contained chloramphenicol. Sadly, the experience of the present government is that they will only listen to those ‘experts’ who tell them what they wish to hear, and will follow their own agenda come what may. Morituri te salutant. Martin Mayfield
Competing interests: None declared |
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Ramakant sharma, reg PE29 6NS
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Dear Sir, It does not matter who is prescribing as long as they are accountable for their action. Thats the most important safety net. Its another matter whether the patient would take a medicine prescribed by the nurses? Competing interests: None declared |
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Gail Chan, Pharmacist Central Liverpool PCT L7 9AB
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I have to take issue with Dr Montgomery's comments that only doctors should be prescribing drugs such as methotrexate, digoxin, amiodarone and many antihypertensives. As part of risk management procedures our medicines management team spends time reviewing prescribing of these drugs, in order to prevent serious prescribing errors. Every year we uncover cases of unsafe prescribing. There is no reason why appropriately trained pharmacists and nurses should be any worse at prescribing than doctors. Competing interests: PCT employed Pharmacist |
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Orest Mulka, Dispensing GP The Medical Unit, High Street, Measham, Leicestershire DE12 7DQ
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Dear Editor I was interested to read Professors Avery’s and Pringle’s editorial on extended prescribing for nurses and pharmacists. As a dispensing G.P. I have been involved in the long-running debate about whether G.P.s should dispense. A powerful argument that the pharmacists used was to question the ethics of doctor dispensing. According to pharmacists, G.P.s were in moral jeopardy if they prescribed and then profited from the prescribing by dispensing. Doctors should only prescribe whilst pharmacists only dispense. I disagreed. With the new arrangements being welcomed by pharmacists, I can only assume that the pharmacists have seen the error of their ways? Orest Mulka Competing interests: dispensing G.P., although perhaps now collaborating rather than competing? |
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Graeme M Mackenzie, gp Whitehaven CA28 7RG
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A GP prescribes in the context of a full medical DEFAULT record (the backbone of the UK system). The default aspect is important because the GP has access to ALL previous history and prescriptions. A nurse can prescribe as part of that default record and of course many GPs have nurse practitioners. But how can a pharmacist prescribe without access to that record? If you give him access, is he not just becoming another part of the practice team? Why train him up when we already have trained prescribers (GPs!). Is a pharmacist going to spend 30 mins taking a full medical and prescription history so that he can prescribe safely when a GP could have taken 5 mins to make the same decision? Is there going to be an endless and needless paper trail of communication to try and preserve the default aspects of the GP record? Who is training those nurses and pharmacists and how much money is that costing? How can that training be defended when you already have an army of trained, available prescribers! GPs are prepared to take some responsibility for anything which comes through the door. Undermine their effectiveness by having multiple prescription points and what do you gain other than a sense that somehow you have got the better of the GPs? It also gives the GPs a way of opting out of responsibility by saying, "It was not my prescription so why should I have to deal with the problems?". I cannot see how extending prescribing will benefit patients at all and the whole thing just smacks of undermining the extremely useful GP monopoly. It is that monopoly which serves the patients. Sometimes I despair at the lack of understanding at the top for the basic strengths of the NHS. Competing interests: None declared |
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Keith R Sumner, GP principal 53 Borough St, Castle Donington, Derby DE74 2RX
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Editor, having spoken to friends in business who all felt that Patricia Hewitt failed to cover herself in glory at the DTI, it was with trepidation that I learned of her arrival at the DoH,and I was not at all surprised that almost her opening words after arriving were to the effect that primary care needed to change. I had not imagined that the bombardment facing us would be as intense as it has been. Right on the heels of the contrived and distressing listening exercises we get full prescribing rights for nurses and pharmacists. Not only that but we now have editorials from normally sane doctors, Professors Pringle and Avery, giving almost whole hearted endorsement to this disastrous notion. If the minister is determined to proceed with this absurd policy,might not a local trial be a good idea? NHS Direct is still a painful sore for some of us. Frank Dobson introduced this scheme as a trial in seven localities but then rolled it out before the studies to assess it's worth had been done. I have a number of concerns about this barmy idea on prescribing: Whose budget will the drugs come from? (I bet I know the answer to that one-the first registered GP, since patients are going to have a few to choose from.) Who is going to answer all the queries that the nurses will have about drug interactions when they come to issue complex prescriptions, especially to the elderly? (I bet I know the answer to that one too-see above.)I sometimes get 20 warnings to look at in one consultation. Who takes responsibility when things go wrong? This is but one of the policies which seem custom built to destroy general practice, but for me the one that elicited this angry response. The invasion of Iraq and the overthrow of Saddam Hussein ought to have taught this government that it is very easy to destroy things, but you need to know what you are going to put in it's place.We GPs are the only generalists left and the ones that patients turn to to try and make sense of what every other health professional is doing. When we have been driven out there will be a void of immense proportions, but it will be too late to put it back together. I urge Pringle and Avery, and all the other "experts" to step back and think a bit more about the future of general practice before they aid and abet the vandals at the DoH. I thank God I am near to the end of my career and feel for all the young doctors who must be wondering where to emigrate to or how to survive in the NHS. Yours sincerely Keith Sumner Competing interests: None declared |
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Andrew Montgomery, locum Auckland
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I note Gail Chan's concerns re doctors' prescribing errors. She is absolutely on the button. Doctors regularly make mistakes. And so do pharmacists (which I am made aware of on a weekly basis), nurses, midwives and so on. This will always be so. In order to minimise error society must dictate that those who diagnose and prescribe have the highest level of training. This is so obvious that it should not need to be pointed out. This training is provided in medical schools and hospitals. Always has been and always will be. So Brits - get real and demand common sense from your politicians. You will all suffer economically and healthwise from this daft decision. We've seen it in New Zealand with midwives. Good luck. Competing interests: author of absolute idiocy |
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Phillip J. Colquitt, RN Independent comment
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Based on long experience of seeing and experiencing newly qualified doctors enter their profession via a position as a resident in an Australian public hospital, I can make the following observations of doctors prescribing practice:- 1. Doctors scripts are often illegible, requiring a team nursing effort to decide what is written - this constitutes prescribing on the part of the nurse. 2. Doctors often order IV fluids that can't be given due to problems of IV access - this is compounded by the fact that junior doctors are approximately only 10% as good as experienced doctors at gaining IV access. 3. Doctors do prescribing roughly and very often in a hurry . 4. Doctors often prescribe nausea producing oral medications to patients when IV would be a better choice. 5. Doctors often don't know the correct dosage of medications that would be effective. They ask the nurse. 6. Doctors often presribe ambiguously - eg. give the drug "in 1000 mls" together with "in 100 mls" on the same script. 7. Doctors often order sliding scale IV insulin with no stated frequencey of BSL readings - so nurses in effect are prescribing since they must make a decision as to how often to change the rate of the infuision. 8. Doctors order oral heparin - this is useless. Nurses just give it sub-cutaneously because they know what is right. So once again they are prescribing. No time to find junior and put him right. 9. Doctors make fun of the prescribing rules by ordering things like "ted stockings" with the route of administration left blank. Nurses only compound the problems by doing stupid things like giving IV fluids to patients from an order written with no patient ID details at all. Competing interests: None declared |
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Garry R King, Manager Pharmacy Resources Regina Qu'Appelle Health Region, Regina, Sask. Canada
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Here is a view from a distance. In our health region we have established a collorative prescribing agreement for pharmacists caring for patients in the hemodialysis unit and the chronic renal insufficiency unit. At the wish of the physicians and endorsed by the regulators of pharmacy and medicine this is a success story. Primary care is the wave of the future. I agree physicians should diagnose but once made, treatment plans can be carried out by those equally qualified. Surgeons are called to check the dosage of antihypertensive medications they have written, however overtime have forgotten key points of therpay. A team working together ( including the patient) will have the best outcome. With the statistics still showing poor adherance to medications under current practices it may be time to move in another directions. Out- patient anticoagulant clinics, stroke clinics, transplant clinic now involve pharmacists who adjust dosing of medications once they are prescribed. Initiating therapy with some non precription medications happens everyday in pharamcies in Europe and Canada. In reality there are significant difference between countries whcih items are non prescription. In North America between USA and Canada there are vast differences between the two countries in this area. I expect these differences exist in Europe as well. Hence by default we may already being " prescribing" in one country that which is restricted in another. Appropriately trained nurses or pharmacist can make access to evidenced base treament a reality. Competing interests: None declared |
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Martin Jones, Nurse Consultant Hillingdon PCT, UB8 3NN, Dawn Miller, Ben Lucas, Joanna Bennett, Richard Gray
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In response to your editorial of 19 Nov 2005, ‘ Extended prescribing by UK nurses and pharmacists’ , we recently conducted a qualitative evaluation study assessing the impact of Mental Health Nurse Supplementary Nurse Prescribing (MHNSP), which addresses some of the issues raised in your editorial. The salient points being that service users do indeed benefit and that nurses work within their area of competence. 11 service users, the majority with a diagnosis of psychosis, were interviewed about their experiences of MHNSP, as were 12 consultant psychiatrist Independent Prescribers (IPs), and 11 trained MHNSP. At the time of the interviews 8 of the MHNSP had prescribed psychiatric medication. The interviews for the nurses and the psychiatrists focused upon; the quality of the training, support and supervision, physical health care and the experiences of providing a prescribing intervention. The service user interviews focused upon their perception of involvement in treatment decisions, the management of adverse effects and the quality of the relationship with the prescribing nurse. The following are some of the key themes that emerged from the data: Service users reported that nurse prescribers provided a greater focus on collaboration and treatment options, felt that the nurse listened to their concerns, acknowledged difficulties associated with using psychiatric medication as well as providing information as to how to minimise the risks of using psychiatric medication. ‘He (MHNSP) feels like a kind person collaborating with me. And it feels he is someone who respects me and takes me seriously’ (Service user) The majority of the psychiatrists reported that nurse prescribing made their life easier, improved the knowledge base of the team and that both they and nurses worked in a way that was more evidence based improving practice as a result. ‘The NSP has the time and resources to research evidence about prescribing decisions and introduce those into the discussion and production of the clinical management plan, which is an extra facet to my practice’ (Psychiatrist). The opportunity for improved physical health care for service users with mental health difficulties. ‘Training as a MHNSP has made me focus more on physical health investigations associated with my prescribing practice’ (Nurse prescriber) Both nurses and psychiatrists said that ‘It’s early days’, in the process of MHNSP. All of the nurses interviewed, except for the nurse consultant, made relatively straightforward decisions and prescribed for only a few service users. ‘At the moment, we keep it plain and simple’. (Nurse prescriber) The study also revealed that pharmacy have not returned any prescriptions and no prescribing mistakes have been made. A number of nurse prescribers and psychiatrists felt there is a need to redefine roles so that nurse-prescribing practice becomes an advanced role with the necessary support structures in place. This study suggests that nurse prescribing can lead to improvement in clinical practice and that there are clear benefits for service users. We therefore welcome the Department of Health‘s recent announcement. Martin Jones, Nurse Consultant Hillingdon PCT, UB8 3NN,
Competing interests: None declared |
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N Portman, Patient Tunbridge Wells, Kent
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The vitriolic response from many doctors to the government's decision to grant greater prescribing powers to nurses and pharmacists has been depressingly predictable. However, we need to be clear about one thing. The underlying reason for most of the objections is not concern for patients but concern over a shift of power away from doctors to other health professionals. There are two things that particularly offend me about some of the responses I've read so far. The first is the implicit and incredibly patronising assumption that patients are incapable of thinking for themselves. Most of us are perfectly capable of judging under what circumstances it would be appropriate to seek the advice of a doctor before obtaining a prescription and when it is unnecessary. The second is the way that some doctors have casually called into question the competence of two other groups of highly trained healthcare specialists namely nurses and pharmacists. It would be dangerous to over generalise. But in my limited experience nurses and pharmacists tend to have more humility that doctors and I therefore believe they are actually less likely to prescribe beyond their competence than many doctors. Let us also not forget that doctors (and indeed nurses and pharmacists) are there to serve patients and what really matters is what patients want. I believe the vast majority of patients will welcome the option to obtain a prescription through a pharmacist or nurse as it will often be both cheaper and more convenient than seeing a doctor. I am personally delighted by the news. Indeed I hope this is a first step towards abolishing our current prescription system altogether and allowing patients to self-prescribe. This is an issue I dealt with in a previous rapid response. http://bmj.bmjjournals.com/cgi/eletters/329/7459/182#70339 Perhaps our society is not yet ready for such a radical step. But for the time being Mrs Hewitt's initiative represent a useful step in the right direction and I congratulate her for it. This is a rare example of our government listening to the people. I would like to make one final point. Some GPs have expressed concern that these changes will undermine the service they provide. Maybe that's true but I'm afraid that GPs have brought this upon themselves. The reality is that it is often difficult to see a GP at short notice. The days when you could simply turn up and be seen in half an hour are long gone. Most GPs require you to make an appointment first unless it is an emergency, often days in advance, and the limited opening times of many surgeries means than it can be difficult to get an appointment at a time that doesn't conflict with work or family commitments. In the past these problems could perhaps have been addressed by training more GPs but now GPs are demanding salaries in excess of £100,000 per year that option is no longer affordable and frankly there are better ways of spending scarce NHS money. Competing interests: None declared |
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Deborah Bond, Rheumatology Specialist Nurse Queen Elizabeth Hospital, Kings Lynn, PE30 4ET
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I have read with interest the editorial and rapid responses and while I was not surprised at some of the responses that have been received from what appears to be the older generation of doctors I am dismayed that in this day and age there is still such a negative attitude to other professionals. It is easy to be dismissive of others abilities and to want to protect one's own role, but at the end of the day we are all working in the patient's interest. Discussion with my colleagues who are non medical prescribers has made it quite evident that none of us would consider prescribing medications outside our field of expertise. This is no different from G.P.s who have no problem contacting specialist nurses for advice on medications outside their usual remit such as methotrexate. In response to some of the more specific comments. Budget, no we do not hold a separate budget, but as most of the medications we are now prescribing are the same ones we used to interrrupt your clinics to ask you sign the prescriptions for, how much difference will this make. If we are signing a prescription we are legally responsible for our actions the same as in any other aspect of our professional activities. We are supposed to be part of a team it is about time we all acknowledged this. Competing interests: non medical prescriber |
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NISHANT RANJAN, locum house officer cambridge
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I strongly believe that, prescribing by nurses and pharmacists is very good idea the UK Department of Health has come up with. I agree that it’s not safe to prescribe without training in diagnosis but what if they are trained. They can be definitely trained in diagnosing acute emergencies and prescribe in time, rather than wait for a medical practioner and lose the patient. We can’t afford to lose our patients just because somebody who knows but cant prescribe as he/she is not authorised. Our primary concern is safety of patients. Nurses and Pharmacists can be trained to diagnose a limited number of emergencies and prescribe a limited number of life saving drugs and also the safe drugs with fewer interactions. This will serve two purposes one save patients life and also help cut down on the busy schedules medical practioners and thus leading to better and safe medical practice. It’s certainly true that nurses and Pharmacists can't be allowed to prescribe any drug from the BNF. Their training is limited and so the power to prescribe should be limited. I agree that studies might be reassuring but if we expect that nurses won’t be prescribing for major drugs and major conditions why give them power to prescribe these independently. I would like to conclude by saying that extreme of anything is bad, Nurses and Pharmacists should allowed to prescribe but with limitations. Competing interests: None declared |
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andrew montgomery, locum Auckland
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No matter what intellectual contortions various medical and non medical folk might put themselves through with respect to this issue, the core problem remains unchanged. That being that sound prescribing arises out of sound diagnoses. Sound diagnosis requires basic medical training followed by exposure to thousands of patients per year with their highly varied complaints. Most doctors will make a considerable number of errors in their career despite this training. Wise doctors will always listen carefully to patients and all other health professionals. I have learnt and continue to learn a considerable amount form patients, nurses, pharmacists etc. It is an unfortunate fact of life that there are many doctors who would be better employed in other professions. The same is true of all health professionals. Society is safeguarded by catering for the lowest common denominator in professions, not the highest. There will be an inevitable lowering of standards following this decision. Morbidity will increase as will the cost of health care in general. I refer your readers to the maternity services debacle in New Zealand if they have any doubts. Competing interests: author absolute idiocy |
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Kashif M Qureshi, Research Fellow Moorfields Eye Hospital, London, EC1V 2PD, Shahram Kashani, Scott Robbie, Nabil Malik
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Sir - Avery and Pringle’s editorial¹ suggests that the legislation passed by the Department of Health, to extend prescribing rights to nurses and pharmacists, could provide benefits to the patient, by easing access to treatment. They argue that with adequate training, these professional groups could well prescribe from an unlimited formulary, whilst acknowledging that prescribing may fall within individual specialist. The editorial also states that current training programmes are too short to provide adequate grounding in general prescribing, particularly in areas outside sub-specialist interest. The perceptions of patients regarding this legislation, have not yet been fully established. This would seem to be an important consideration, since patients will be the main beneficiaries of any potential service providing shared care in the primary, secondary and tertiary care settings. We investigated the attitudes of patients to extended prescribing rights, by carrying out interviews with patients attending a number of outpatients departments in 4 hospitals. 400 patients were interviewed in Ophthalmology outpatients departments in 4 hospitals, nationally. Patients attending general clinics and sub-speciality clinics were interviewed by a doctor, and invited to answer a questionnaire. The questionnaire asked whether patients felt confident in nurses and pharmacists prescribing medications to them, independently, if they were trained in a particular speciality, and if they were not trained in a particular speciality. Other comments from patients were also recorded. If they were not confident, they were asked to provide possible reasons why - whether they felt there was a lack of appropriate medical training for nurses or pharmacists or whether this was due to a lack of familiarity (‘My GP has known me for years’) or a lack of supervision of the professionals involved. In an effort to assess how much understanding patients had regarding their diagnosis and how much responsibility patients took in bringing their medications with them to hospital, patients were asked to name their diagnosis and were asked which medications or drops they were taking, and whether they had brought them with them. In all, 60% of patients were confident in trained specialist nurses (238/400) and pharmacists (241/400) prescribing medications independently to them. However, patients were mostly uncomfortable with the notion of untrained nurses, 82% (328/400) or pharmacists 85% (340/400) prescribing medications to them. The reasons given by those patients answering negatively were because there is lack of appropriate medical training by nurses or pharmacists, 64% (249/400), 12% (46/400)- lack of familiarity with the prescriber, 6%(24/400) - lack of supervision and 18% (68/400) - all of the above reasons. The second part of the questionnaire examined whether patients understood their diagnoses, 77% (306/400) of patients correctly named their condition, which was corroborated by the notes. 76% (305/400) of patients did take oral medications, of these patients, 34% (106/305) brought their medications or a list with them. 51% (202/400) of patients did take eye drops, but only 36% (74/202) of these patients had either brought their medication with them, or could provide a list of their eye drops. Most patients were well informed regarding their diagnosis, although some were attending specialist clinics and therefore may have surmised their diagnosis from the title and nature of the clinic. However only a third of patients brought a list of medications with them. This relatively small number does raise the question whether specialist nurses and pharmacists would be fully aware of other treatments that the patient may be on, which could interact with any required medication. In summary, a significant proportion of patients (40%) are not confident that nurses or pharmacists, with specialist training, can prescribe their medications. A larger proportion of patients (82% for nurses and 85% for pharmacist) do not appear to be confident with these professional groups prescribing if untrained. This constitutes a major problem as the authority of specialist nurses or pharmacists will undoubtedly be in question. A significant proportion of NHS patients would therefore have to be persuaded of the values of such an initiative, bearing in mind that it is often much easier to lose a patient’s trust than it is to regain it and that a patient’s level of confidence in their management has significant implications for compliance with medication and overall treatment success. Rigorous consultation with doctors, nurses and pharmacists as well as patients will provide the key to successfully re-defining professional boundaries within the NHS, it would appear that we have yet to fully take into account the views of patients regarding this important issue. References 1. Avery A, Pringle M. Extending prescribing by UK nurses and pharmacists. BMJ Vol 331 Nov 2005 1154-5. Competing interests: None declared |
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Stevie M Gamble, retired HMIT EC2Y 8BL
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I have no doubt that Kashif M Qureshi, Research Fellow, and his colleagues (see their Rapid Response of 10th August 2006) are more comprehensively trained in the basics of prescription than nurses or pharmacists, but they seem curiously ignorant of the fundamentals of scientific research. It is axiomatic that if you wish to obtain unbiased information from an interview, the interviewers themselves must be unbiased; that is, after all, the basis of double-blinding in all clinical trials. Perhaps they need a refresher on first principles before they go back and try to put together a piece of research which would actually tell us something meaningful… Stevie Gamble Competing interests: None declared |
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Scott J Robbie, SpR Ophthalmology Addenbrooke's Hospital CB2 2QQ, Kashif Qureshi, Shahram Kashani, Nabil Malik
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Whilst always grateful to receive the attentions of one of Her Majesty’s Inspectors of Taxes, we feel Mr Gamble’s criticism cannot pass by unremarked. Ours was a pilot study conducted in the absence of any published evidence on the subject. The researchers involved have a total of over 20 peer-reviewed publications to their names. Every effort was made to conduct the interviews as independently as possible and with the support of departmental staff (including nurses). Tellingly, no patient declined the opportunity to take part, despite being given the option to do so – many in fact welcomed the chance to voice their opinions. Unlike much of what has been written hitherto on the subject, our conclusions were at least backed-up by a modicum of evidence (however flimsy Mr Gamble may feel this evidence to be). Perhaps we were a touch naive in assuming that those same patients who willingly disclose personal information to doctors every day, would moderate their views when presented with a questionnaire by the same professionals. We freely admit to the drawbacks of such a study: it may well be the case that had nurses or pharmacists asked the same questions then the results would have been completely the reverse of what we found. If Mr Gamble wishes to supply funding towards the recruitment of four independent interviewers to canvass the opinions of 400 patients in 4 separate units across the country, he’s perfectly welcome to do so. Alternatively, he may see this as an unprecedented opportunity for someone in a neutral position and decide to undertake the work himself. Better still, the Department of Health might deign to consult patients on the subject of extended prescribing prior to implementing any policy changes. Competing interests: None declared |
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