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<GP Surgery Name> Non-Medical Prescribing Policy Version 1.0 Name of author/job title Liz Harrison, Quality & Patient Safety Manager for primary care co-commissioning Ratified by CP&R CCG Quality & Governance Committee Date Ratified 17th March 2016 Review Date March 2018 Target audience All practice staff POLICY STATEMENT This policy sets out a framework for the development and implementation of non-medical prescribing within the <GP Surgery Name> practice in order to establish a consistent approach. This policy applies to all registered nurses and allied health professionals with a non-medical prescribing qualification; employed or engaged by the GP practice and required to prescribe as part of their role. EQUALITY IMPACT <GP Surgery Name> strives to ensure equality of opportunity for all service users, local people and the workforce. This document has therefore been equality impact assessed to ensure fairness and consistency for all those covered by it regardless of their individual differences. The results are shown in the Equality Impact Tool at Appendix A. DOCUMENT CONTROL The <GP Surgery Name> Non-Medical Prescribing policy was developed through the Non-Medical Prescribing Forum. Non-Medical Prescribers (NMPs) across the Castle Point & Rochford locality and the Medicines Management Team were involved in the development process. Finally the policy was disseminated to members of the Medicines Management Team and the Non-Medical Prescribing Lead (Chief Nurse) for ratification. ASSOCIATED LINKS Medicines Management guidance is available on the Castle Point & Rochford CCG website via this link All local medicine and appliance formularies for CP&R are accessible via this link This BNF online link also leads to the BNF for children and Nurse Prescribers’ Formulary National Institute for Health and Care Excellence (NICE) guidance link The NMC Code link The NMC standards for medicines management link The NMC standards of proficiency for nurse and midwife prescribers link The NMC revalidation guidance link The professional duty of candour guidance link Page 1 of 11 Adapted from the University Hospital of South Manchester Community Services NMP policy v1.0 2013 PURPOSE To govern the practice of non-medical prescribing within the practice; To ensure prescribing practice is compatible with the practice’s development plans and is an appropriate extension of practitioners’ roles; To ensure that new prescribers are appropriately qualified for the role, work within agreed national and local policies and are identified within the practice; To ensure that prescribers are supported in their role and maintain the continued professional development (CPD); To set out guidance for how non-medical prescribers will use the clinical record system and electronic prescribing safely. ROLES & RESPONSIBILITIES Non Medical Prescribing Lead The Chief Nurse for Castle Point & Rochford CCG is the Non-Medical Prescribing Lead and authorised signatory for approving registration of non-medical prescribers. They have responsibility for: Promoting and co-ordinating non-medical prescribing information and communication Maintaining a register of non-medical prescribers Monitoring clinical governance systems Provision of support and training The Medicines Management Team The Medicines Management Team are responsible for promoting safe and effective prescribing and monitor prescribing practices across Castle Point & Rochford CCG, Southend CCG and Southend University Hospital Foundation Trust. <GP Surgery Name> <GP Surgery Name> is responsible for developing and maintaining this Non-Medical Prescribing Policy and highlighting any queries or concerns to the Non-Medical Prescribing Lead. As the employer <GP Surgery Name> will hold vicarious liability for their non-medical prescribers. Line Managers The Line Manager will ensure that: Non-medical prescribing (NMP) is necessary and beneficial to patient care and does not pose unnecessary risk Only staff who meet the eligibility criteria are supported to undertake training for NMP The staff member has completed the necessary training/courses in order to prescribe and provide evidence of such to the NMP Lead The non-medical prescriber engages in continuing professional development relevant to their prescribing practice and maintains evidence of such in their professional portfolio The non-medical prescriber has read and adheres to this Policy, related national guidance and legislation The non-medical prescriber’s job description includes their role and responsibilities in relation to NMP. Prescription pads are returned for safe keeping or secure destruction if the staff member is absent for more than four weeks, e.g. maternity leave, long term sickness absence, termination of employment. Line managers of non-medical prescribers should inform the NMP Lead (Chief Nurse) of any nonmedical prescriber additions/deletions or changes to their information (i.e. change of surname) Page 2 of 11 Adapted from the University Hospital of South Manchester Community Services NMP policy v1.0 2013 using one of the relevant proformas via this link. As the authorised signatory, the NMP Lead can register this information with NHS Prescription Services. The Non-Medical Prescriber In order to be entitled to prescribe within the organisation, practitioners must be registered as prescribers with their professional regulator and demonstrate up-to-date clinical competence in their intended field of prescribing. The Non-Medical Prescriber will: Prescribe in line with organisational formularies and guidelines Adhere to Trust policies, national/local guidance, and their professional code of conduct Maintain their registration as a prescriber with their professional regulator and ensure that their role as a prescriber is clearly described in their job description Provide evidence-based, safe, effective, cost-effective prescribing for their patients within the scope of their service, competence and with reference to approved personal / service / organisational formularies maintain accurate, legible, unambiguous, contemporaneous records of patient care accept responsibility and accountability for their prescribing decisions and practice Ensure that patients are aware of the scope and limits of NMP, that they understand their right to refuse treatment / prescribing from a non-medical prescriber and that the non-medical prescriber may refer them to other healthcare professionals as necessary Complete prescriptions legibly and legally, paying particular attention to annotation of designation, prescriber code, contact number and practice code (where applicable) co-operate with audit, monitoring and investigations DEFINITIONS Community Practitioner Nurse Prescribing Nurses who have completed a specialist practice programme that includes the V100 module, or who have completed the standalone V150 module. Prescribing is limited to the Nurse Prescribers’ Formulary for Community Practitioners. Community Practitioner Nurse Prescribers must only prescribe for patients that they have assessed. In the event of being requested to prescribe for a patient under the caseload of another practitioner the prescriber must undertake his/her own assessment. Supplementary Prescribing Supplementary prescribing is a voluntary partnership between a responsible medical prescriber (doctor or dentist), a supplementary prescriber and the patient, to implement an agreed patient specific clinical management plan (CMP). This mode of prescribing is available to nurses, pharmacists, physiotherapists, podiatrists, optometrists and radiographers. There are no legal restrictions on clinical conditions that may be treated under supplementary prescribing, although it is expected that it would usually be employed in the management of chronic medical conditions. Supplementary Prescribers may prescribe any medicine, including controlled and unlicensed drugs, as long as they are specified in the agreed CMP. The medical prescriber must conduct an initial clinical assessment of patient, provide a diagnosis and provide advice and support to the supplementary prescriber, as required A patient-specific clinical management plan (CMP) will be drawn up and agreed by the independent prescriber, the supplementary prescriber and the patient before supplementary prescribing begins. Both prescribers must sign the plan and patient consent must be documented. The CMP must be drawn up using the Practice template, which takes account of legal requirements; all fields must be completed. All details of the CMP must be reviewed and updated at least once a year and Page 3 of 11 Adapted from the University Hospital of South Manchester Community Services NMP policy v1.0 2013 the frequency and timing of the review must be specified on the CMP. If either the independent or supplementary prescriber cease to be involved the patient’s care a new CMP must be agreed between all three parties before any further prescribing occurs. The CMP must specify the range of medicines and circumstances and parameters within which the supplementary prescriber can vary dosage frequency and formulation of medicines identified. It may include reference to recognised guidelines for a specific condition. Copies of the agreed CMP must be filed in the patient record and sent to the patient’s GP. Additional copies may be sent to other health professionals who are involved in the patient’s care where appropriate. The supplementary prescribing arrangement may be ended at any time, by either prescriber or the patient, at which time the medical prescriber will resume full responsibility for prescribing. Independent Prescribing The prescriber is responsible and accountable for the assessment of patients with undiagnosed or diagnosed conditions and for decisions about the clinical management required. Nurses, pharmacists and optometrists may be qualified as independent prescribers. They must have successfully completed a recognised independent prescribing course and registered their qualification with their professional body. Independent prescribers may only prescribe for patients they have assessed. In the event of being requested to prescribe for a patient under the caseload of another practitioner the independent prescriber must undertake his/her own assessment. Nurse and pharmacist independent prescribers may prescribe any medicine (including unlicensed medicines and controlled drugs) within the scope of their role, their clinical competence and according to any agreed formularies. Repeat prescribing Repeat prescribing is only acceptable where the prescribed drug is within the NMP’s scope of competence. Non-medical prescribers must not authorise repeat prescriptions for drugs that are out of the scope of their competence and remit. It may be more appropriate for chronic medication to be issued by the GP as part of the patient’s routine repeat prescription. Off-label / off-licence medicines Nurse and Pharmacist independent prescribers may prescribe medicines for use outside of their licensed indications / marketing authorisation (so called ‘off-licence’ or ‘off-label’). In doing so they accept professional, clinical and legal responsibility and should only prescribe ‘off-label’ where it is accepted clinical practice. The prescriber must explain the situation to the patient or their guardian/carer/advocate and clearly document their reasons for prescribing such a medicine and their discussion with the patient. Supplementary prescribers may prescribe medicines for use outside of their licensed indications / marketing authorisation (so called ‘off-licence’ or ‘off-label’) as long as it is within the terms of an agreed clinical management plan. In doing so they accept professional, clinical and legal responsibility and should only prescribe ‘off-label’ where it is accepted clinical practice. The prescriber must explain the situation to the patient or their guardian/carer/advocate and clearly document their reasons for prescribing such a medicine and their discussion with the patient. Community Practitioner Nurse Prescribers may not prescribe medicines for use outside of their licensed indications / marketing authorisation with the exception of Nystatin oral suspension, which may be Page 4 of 11 Adapted from the University Hospital of South Manchester Community Services NMP policy v1.0 2013 prescribed for children from 28 days of age. The prescriber must explain the situation to the patient or their guardian/carer/advocate and clearly document their reasons for prescribing such a medicine and their discussion with the patient. Unlicensed medicines Nurse and pharmacist independent prescribers may prescribe unlicensed medicines within their competence and field of expertise, where it is accepted and evidence-based clinical practice. Supplementary prescribers may prescribe unlicensed medicines if they form part of an agreed CMP. The independent / supplementary prescriber remains accountable and liable for prescribing of unlicensed medicines and should comprehensively document their reasons for prescribing. The patient or patient’s guardian should be informed and consent obtained for the treatment. Community Practitioner Nurse Prescribers may not prescribe unlicensed medicines. Mixing of Medicines “Mixing” has been defined by the MHRA as “the combination of two or more medicinal products together for the purposes of administering them to meet the needs of a particular patient”. By mixing two licensed drugs an unlicensed preparation is created and the prescriber assumes the same responsibility as they would when prescribing an unlicensed medicine. Due to the risks of drug incompatibility and chemical reaction, which may have serious adverse effects, the mixing of drugs should be avoided unless it is essential to meet the needs of the patient, e.g. in palliative care where an analgesic and anti-emetic may be mixed and delivered in a low-volume, continuous, sub-cutaneous infusion. Nurse and pharmacist independent prescribers are permitted to mix medicines prior to administration and provide written directions for others to do so. They must ensure that the medicines are compatible for mixing before prescribing, mixing, administering or providing directions for others. Supplementary prescribers are permitted to mix medicines prior to administration and provide written directions for others to do so, only when it is safe to do so and the preparation forms part of the clinical management plan for an individual patient. Community Practitioner Nurse Prescribers may not provide written directions for others to mix medicines, but may mix medicines on the direction of an independent / supplementary prescriber. Those involved in prescribing or mixing should be competent to do so and take full professional and clinical responsibility for their actions. Controlled Drugs (CDs) Controlled drugs are those which are listed in one of the schedules of the Misuse of Drugs Act, 1971. The Misuse of Drugs Regulations stipulates the prescribing, storage, documentation, etc. requirements associated with each of the schedules. Supplementary prescribers may prescribe schedule 2, 3, 4 and 5 controlled drugs as long as they are detailed in the clinical management plan. Prescribers must ensure that they are familiar with the various drug schedules, details of which can be found in the British National Formulary (with the exception of schedule 5). All NMPs are also required to familiarise themselves with, and adhere to, the Trust’s Controlled Drug Policy. Page 5 of 11 Adapted from the University Hospital of South Manchester Community Services NMP policy v1.0 2013 DOCUMENTATION All prescribing must be carried out using FP10 stationery, which is only available after registration as a prescriber with the organisation and with Prescription Services. The prescription form must be completed in full, irrespective of whether it is computer generated or handwritten. Non-medical prescribers’ designation (e.g. Community Practitioner Nurse Prescriber, Nurse Independent Prescriber, Podiatrist Supplementary Prescriber, etc.) must be indicated on the prescription; this would usually be pre-printed or automatically printed by computer software, but must be verified by the prescriber before the prescription is handed to the patient. The non-medical prescriber must keep a record of the serial numbers of FP10 prescriptions received and used to facilitate reporting of missing prescription forms should the need arise. Details of prescribing must be communicated to the patient’s GP and recorded in the patient’s record. It may also be prudent to record details for self-audit of prescribing practice. Community Services FP10 Prescriptions are the property of the organisation who hold the prescribing budget. It is the responsibility of the prescriber to ensure the security of prescription forms at all times. Lost or stolen FP10 prescription forms must be reported as such immediately according to the process detailed in appendix D. Patient record Details of assessments, diagnoses, treatments, prescriptions and monitoring / follow-up must be recorded in the patient record. All records must be comprehensive, contemporaneous and made according to professional standards. Copies of clinical management plans must be filed in the patient record. INCIDENTS AND ADVERSE DRUG REACTIONS All incidents (deviation from agreed process) and suspected adverse drug reactions must be reported according to the Trust incident reporting policy. Adverse drug reactions should also be reported according to the Medicines Policy, i.e. to the Yellow Card Scheme (where appropriate), to the GP, and recorded in the patient record. CONTINUING PROFESSIONAL DEVELOPMENT (CPD) All practitioners are required to undertake CPD in line with the standards laid down by their professional regulator. New NMC regulations for revalidation of nurses and midwives will be introduced in April 2016. Non-medical prescribers must ensure that this encompasses the legal, ethical and technical aspects of their prescribing practice as well as the clinical ones. It is the responsibility of non-medical prescribers to ensure that they maintain their knowledge and skills to prescribe by accessing relevant literature, e-learning programmes, professional meetings, clinical supervision and peer review. Non-medical prescribers may wish to attend the Non-Medical Prescribing Forum, details of which can be obtained from the CCG NMP Lead. Page 6 of 11 Adapted from the University Hospital of South Manchester Community Services NMP policy v1.0 2013 APPENDICIES APPENDIX A Equality Impact Assessment of Non-Medical Prescribing Policy 1. 2. 3. Does the policy/guidance affect one group less or more Yes/N Comments favourably than another on the basis of: o Race No Ethnic origins (including gypsies and travellers) No Nationality No Gender No Culture No Religion or belief No Sexual orientation including lesbian, gay, bisexual and transgender people No Age No Disability No Is there any evidence that some groups are affected differently? If you have identified potential discrimination, are any exceptions valid, legal and/or justifiable? No N/A 4. Is the impact of the policy/guidance likely to be negative? No 5. If so can the impact be avoided? N/A 6. What alternatives are there to achieving the policy/guidance without the impact? N/A 7. Can we reduce the impact by taking different action? N/A Page 7 of 11 Adapted from the University Hospital of South Manchester Community Services NMP policy v1.0 2013 APPENDIX B Clinical Management Plan (CMP) Template Patient Details Full name: NHS number: Independent prescriber (IP): Allergies/sensitivities: Date of birth: Supplementary prescriber(s): Condition to be treated: Aim of treatment: Relevant medical history: Medication history: Medication that may be prescribed by the supplementary prescriber(s) Preparation Indication Dose schedule Specific indications for referral back to IP Guidelines or protocols supporting CMP Frequency of review and monitoring with IP: Agreed by IP (sign): Agreed by SP(s) (sign): Date: Date: Date agreed with patient: Page 8 of 11 Adapted from the University Hospital of South Manchester Community Services NMP policy v1.0 2013 APPENDIX C Advice on Security of Prescription Forms Adapted from Security of prescription forms guidance issued by the NHS Security Management Service. Prescriptions are the property of organisation holding the prescribing budget. It is the responsibility of the prescriber to ensure the security of prescription forms at all times. Managers must ensure that a process is in place to record relevant details of prescription forms in a stock control system, including the following: date when new prescriptions were ordered date of receipt name of the receiving person quantity of prescriptions received serial numbers of prescription received which prescription forms have been issued to each prescriber where the prescription forms are stored Records of serial numbers of prescription forms received and issued should be retained for at least three years. It is advisable to hold minimal stocks of prescription stationery. Prescription forms (including any completed prescriptions) must be stored in a locked cupboard / drawer within a locked room when not in use. Blank prescriptions must never be pre-signed. Prescribers should keep a record of the serial numbers of prescription forms for reference in the event of theft / loss. The first and last serial numbers of prescription pads should be recorded. It is also good practice to record the serial number of the first remaining prescription form in an in-use pad at the end of the working day. This will help to identify any prescriptions lost or stolen overnight. Patients, temporary staff and visitors must never be left alone with prescription forms or allowed into secure areas where forms are stored. All unused forms should be returned to stock at the end of the session or day. They must not, for example, be left in patients’ notes. Service stamps must be kept in a secure location separate from prescription forms. The stamp pads must be secured to the same standard as prescription forms. Services must keep a record of prescription forms / pads issued to locums. If an error is made on a prescription, best practice is for the prescriber to do one of the following: o o put a line through the script and write ‘spoiled’ on the form cross out the error, initial and date the error, then write the correct information Page 9 of 11 Adapted from the University Hospital of South Manchester Community Services NMP policy v1.0 2013 o destroy the form and start writing a new prescription. When making home visits or visits to care homes, prescribers must ensure that prescription pads are not left in view in a vehicle; they should be stored in a locked compartment, such as a car boot, in an unidentifiable lockable carrying case. Prescribers on home visits should also, before leaving their base, record the serial numbers of any prescription forms / pads they are carrying. Only a small number of prescription forms should be taken on home visits to minimise the potential loss. Prescription pads must not be left in vehicles overnight. Supplies of blank or signed prescription forms must not be left at care homes for prescriber visits. Each prescriber should carry his / her own supply of prescription forms as a matter of course when making care home visits. All staff members who have access to computerised prescribing systems must have an individual password. They must not share the passwords with anyone and systems should prompt users to change passwords on a regular basis. Computer systems should have a screensaver facility so that access can be denied or to prevent details from being read from the screen when the user is going to be away from the desk. The screensaver should be controlled by a password that is known only to the user and the computer only able to be unlocked when the password is re-entered. This may be the same as the user’s ‘log on’ password. In the following circumstances, all unused or obsolete prescription forms must be destroyed in a secure manner, and computer software amended so that no further prescriptions can be issued bearing the details of the prescriber in question: if a prescriber leaves the organisation, e.g. resigns or dies sickness or absence of more than 4 weeks prior to commencement of maternity leave when changing to a new role within the organisation that does not include prescribing. An appropriate person must securely destroy the prescription forms, e.g. by shredding before placing into confidential waste. The person who destroys the forms must make a record of the serial numbers of the forms destroyed and another member of staff should witness the destruction. For further information, including an example of a suggested prescription form register, see Security of prescription forms guidance issued by the NHS Security Management Service, which can be accessed via the following link Alternatively, contact the Community Services Non-Medical Prescribing Lead. Page 10 of 11 Adapted from the University Hospital of South Manchester Community Services NMP policy v1.0 2013 APPENDIX D Actions to be taken if Prescriptions are Missing / Stolen Adapted from Security of Prescription Forms guidance issued by the NHS Security Management Service (NHS SMS), October 2009 In the event of prescription(s) being lost or stolen the following actions should be taken: 1. Report the incident to Essex Police on101 2. Inform the Medicines Management Team (based at Harcourt House) in order to alert all pharmacies in the area and adjacent NHS organisations. Tel: (01702) 314311. 3. Inform your line manager and the Non-Medical Prescribing Lead (Chief Nurse, based at Pearl House, 12 Castle Rd, Rayleigh). Tel: (01268) 464508. The following information is required (if known): Date and time of loss/theft Date and time of reporting loss/theft Place where loss/theft occurred Type of prescription stationery Serial numbers Quantity. On being informed of the loss of FP10 prescriptions the NMP Lead should: Reinforce the actions to be taken by the person reporting the incident including ensuring that the matter is recorded as a security incident according to the organisation’s incident reporting policy. Liaise with senior Medicines Management staff within Castle Point & Rochford CCG. Inform the organisation’s Local Security Management Specialist (LSMS). Inform that organisations’ Accountable Officer for controlled drugs. The Supplies Officer will inform the prescriber of any action to take, e.g. writing and signing prescription forms in a particular colour for a specific period of time. Please note: Staff may report any concerns about fraud to the confidential NHS Fraud and Corruption Reporting Line on 0800 028 4060. Page 11 of 11 Adapted from the University Hospital of South Manchester Community Services NMP policy v1.0 2013