Non-Medical Prescribing Policy - P015

Transcription

1 Document Information Board Library Reference Document Author Assured By Review Cycle P015 NMP Forum Quality & Safety Committee 3 Years Note: This document is electronically controlled. The master copy is maintained by the author department within the document library on OurSpace. Once printed, this document becomes uncontrolled. Document Version Tracking Version Date Revision Description Editor Status Nov 2007 Approved by Board NM Approved Dec 2009 Approved by Quality & Healthcare Committee MB Approved Dec 2012 Quality and Safety Committee MR Approved Dec of 38

2 Table of Contents 1. Introduction 3 2. Purpose or Aim 3 3. Scope 4 4. Policy Statement 5 5. Training and Preparation 5 6. Prescribing in Practice 6 7. Supplementary Prescribing 8 8 In-patient Prescribing 8 9 Non-medical Prescribing and the Mental Health Act Controlled Drugs Related Procedural Documents Roles and Responsibilities Individual Responsibilities Definitions Standards Governance and Audit References 16 Appendix A : Criteria for Independent / Supplementary Prescribing programme 18 Appendix B : Clinical Management Plan 20 Appendix C A single competency framework for all prescribers Dec of 38

3 1 Introduction This policy is to provide guidance for the use of non-medical prescribers within AWP, adhering to the legislative and policy parameters (DH 2006, 2012) and relevant professional guidelines (NMC 2006, RPSGB 2006), to ensure safe and effective prescribing for service users. It should be read in conjunction with the Medicines Policy, which outlines standards for the safe use of medicines within AWP. The Medicines and Human Use (Prescribing) (Miscellaneous Amendments) Order of May 2006 (amended April 2012) and associated medicines regulations enable nurses and pharmacists who have successfully completed the appropriate training course to prescribe any licensed medicine, including most controlled drugs (CDs), for any medical condition within their clinical competence. The Department of Health requires Trusts to develop a strategic plan for the use of non-medical prescribing to include independent prescribing by nurses and pharmacists, which will: recognise the benefits to patients of non-medical prescribing; identify an initial range of clinical areas where patients could benefit; identify a way to support and sustain the transition of staff to extended roles and the services they currently provide; develop a communications plan aimed at informing both patients and all clinical and managerial staff; include timescales for implementation; identify a lead director to be responsible for implementation. 2 Purpose or Aim The aim of this policy is to ensure that prescribing by non-medical prescribers adheres to the principles as defined by government policy to: improve patient care without compromising patient safety; make it easier for patients to get the medicines they need; increase patient choice in accessing medicines; make better use of the skills of health professionals; Dec of 38

4 contribute to the introduction of more flexible team working across the NHS. (DH 2006) Adherence to this policy will ensure that practitioners are safe in their practice and up to date in their knowledge. 3 Scope This policy relates to all non-medical prescribers employed within AWP, who fulfil the following criteria to practise: Have an approved job description clearly identifying scope to practise as a NMP Successfully completed the appropriate training Be registered with the appropriate regulatory body (General Pharmaceutical Council (GPhC), Nursing and Midwifery Council (NMC)) Be authorised to prescribe by the Trust Lead for Non-Medical Prescribing and the Trust Chief Pharmacist. This policy also outlines those who are eligible to apply for training, the procedure for agreeing applicants and the process for accessing this. It also outlines the scope for use of non-medical prescribing in practice. 4 Policy Statement The Trust Board supports Non-Medical Prescribing when conducted within the parameters defined by this policy as part of the overall approach to modernisation and increased flexibility in the roles of professionals working in the NHS (DH 2000), with the purpose of improving the care provided to service users and their experience of that care (NPC, 2005). 5 Training and Preparation The opportunity to undertake training to qualify as a non-medical prescriber is limited to specific practitioners, as defined by legislation (see Appendix 1). The current parameters for these groups are: Nurses and pharmacists who are eligible to undertake training to qualify as nurse or pharmacist independent and supplementary prescribers Dec of 38

5 Some allied health professional groups are eligible to undertake training to qualify as supplementary prescribers, these are: physiotherapists, chiropodist / podiatrists, radiographers and optometrists. These professional groups predominantly work in general medical settings rather than specialist mental health services AWP currently supports the training of nurses and pharmacists only. Eligibility criteria to undertake the non-medical prescribing course for both nurses and pharmacists is set out in Appendix A. Whilst there are minimum statutory entry requirements to access the course, each applicant will be assessed on an individual basis including any intention to work past retirement age. The Non-Medical Prescribing Course is available through a number of different Universities, with each institution complying with the Disability Discrimination Act (2006), in supporting and making reasonable adjustments for students to prevent any disadvantage. The DH (2006) also states that All individuals selected for prescribing training must have the opportunity to prescribe in the post that they will occupy on completion of training, and managers supporting any application must be aware of this criteria. Whilst those suitably trained are legally eligible to prescribe independently on completion of the programme, in AWP prescribing will be initially limited to that as a Supplementary Prescriber. Any decision to progress to Independent Prescribing will normally be taken following a minimum of six months practice as a supplementary prescriber, but exceptions to this can be made on a case by case basis. The decision will be taken by the Non-Medical Prescribing Lead and Chief Pharmacist in consultation with the relevant Strategic Business Unit; and will be based on discussions with the Non-Medical Prescriber, their Team Manager and Consultant Psychiatrist regarding their professional competencies to practice in this role. 6 Prescribing in Practice In partnership with the service user, prescribing is one element of their clinical management. For nurse NMPs this requires an initial service user assessment, interpretation of that assessment, a decision on safe and appropriate therapy, and a process for ongoing monitoring. For pharmacist NMPs, prescribing activities can cover a broader range of roles and responsibilities depending upon the area they work across. In all cases, the prescriber is responsible and accountable for their prescribing practice Dec of 38

6 The three key principles are: service user safety; maximum benefit to service users and the NHS in terms of quicker and more efficient access to medicines for service users; better use of the professional s skills. The individual practitioners must also understand and accept the higher level of clinical responsibility associated with prescribing. Prescribers should follow the seven principles of prescribing: 1. Examine the holistic needs of the service user. Is a prescription necessary? 2. Consider the appropriate strategy 3. Consider the choice of product 4. Negotiate a contract and achieve concordance with the service user 5. Review the service user on a regular basis 6. Ensure record keeping is both accurate and up to date 7. Reflect on their prescribing. (National Prescribing Centre 1999) Nurse and Pharmacist Independent Prescribers can only prescribe for a service user who she/he has personally assessed for care. In the absence of the original independent prescriber, a Nurse or Pharmacist Independent Prescriber may issue a repeat prescription or order repeat doses following a further assessment of need, and taking into account continuity of care. Accountability rests with the non-medical prescriber who has prescribed the medication. A non-medical prescriber prescribing as a supplementary prescriber (SP) will sign the prescription and endorse it with the letters SP. A non-medical prescriber prescribing as an independent prescriber (IP) will sign the prescription and endorse it IP. The decision to engage in non-medical prescribing with an individual service user should be driven by potential benefits to that service user rather than by the needs of the service. Individual service users will only be involved with their agreement, with due regard to capacity issues (Mental Capacity Act 2005). There must be adequate Dec of 38

7 supervision in place for the non-medical prescriber; this should include routine clinical supervision as well as prescribing supervision with the Designated Medical Prescriber (DMP) (See Section 8 for fuller detail). Pharmacists will receive supervision from the Chief Pharmacist. Non-Medical Prescribers must participate in the evaluation of non-medical prescribing through the audit process. 7 Supplementary Prescribing Supplementary prescribers must have a service user specific clinical management plan (CMP) in place prior to any prescribing (see Appendix 2). This is a voluntary three way agreement between the independent prescriber (who is responsible for the assessment and diagnosis), supplementary prescriber and service user. All three parties to this must sign the CMP, although they do not have to be in the same room at the same time. Any CMP must be uploaded electronically to RIO and the original kept in the service user s supplementary care record. Whilst each service user must have their own specific CMP which is specific to their own conditions to be treated, it is acceptable that prescribing by more than one nonmedical prescriber for that service user can take place, provided they are each specifically identified on the CMP. 8 Inpatient Prescribing Non-medical prescribers within the hospital setting will be eligible to write on the service user s prescription card once the Non-Medical Prescribing Lead has passed their details on to the Chief Pharmacist and the prescriber has provided the pharmacy department with the details required for their records. All prescriptions written by Non-Medical Prescribers will identify their professional status, registration number, and IP/SP status to assist in the event of any queries and for audit purposes. The same governance arrangements will apply to the hospital setting as to an outpatient or community setting. 9 Non-medical prescribing and the Mental Health Act The treatment of detained service users subject to Part IV of the Mental Health Act 1983 is strictly governed by the Code of Practice and in the context of non-medical prescribing, consent to treatment is paramount. Where a service user is treated subject to Part IV of the Act, the Responsible Clinician (RC) retains overall responsibility for prescribing and generally the Dec of 38

8 supplementary prescriber will practise as part of a team prescribing approach, involving the consultant, pharmacist and the service user. The key principles to consider are that: Medical treatment for a mental disorder must be under the direction of the Responsible Clinician A detained service user is not necessarily incapable of giving consent (i.e. consent versus capacity). Consent should not be given under duress and can be withdrawn at anytime. (DoH 1999) It is on this basis that supplementary prescribing can be considered: where clinically appropriate a Clinical Management Plan (See Appendix 2) can be agreed and drawn up by the responsible clinician and supplementary prescriber for a service user subject to Part IV of the Mental Health Act. Supplementary prescribing may also be considered for service users on section 17 leave or section 17A a Community Treatment Order. Independent Prescribing is also possible under Part IV of the Mental Health Act, but only once the relevant form has been completed by the RC. Non-medical prescribing is authorised in the usual way and subject to the same conditions, provided that the medication in question remains compliant with the type, dosage, administrative route and range documented on the statutory form. For further details see CQC guidance note for nurses on medications for detained service users (CQC, 2009). Service users able to consent under Section 58: If the service user has been deemed to be able to consent, and has so consented under the terms of section 58, i.e. medication is being given via the use of form T2, then supplementary prescribing may continue as part of the team prescribing relationship. Service users unable/unwilling to consent under Section 58: If the service user has been deemed either, not capable of understanding the nature, purpose and likely effects of medications or, has not consented to the medications, then medications will be being administered under the jurisdiction of a form T Dec of 38

9 In this situation a non-medical prescriber may still act as a supplementary prescriber as part of the team prescribing relationship. Medications prescribed under Section 62: The prescribing of medication under section 62 of the Mental Health Act will remain the responsibility of a registered medical practitioner. 10 Controlled Drugs Independent Non Medical prescribers As of 23rd April 2012, legislative changes have been made by the Home Office which allow nurse and pharmacist Independent Prescribers (within their sphere of competence) to prescribe all controlled drugs from schedules 2, 3, 4, and 5 except for diamorphine, cocaine and dipipanone for the treatment of addiction.. Additionally, nurse and pharmacist Independent Prescribers are able to requisition controlled drugs and authorised to possess, supply, offer to supply ( ie write a prescription) for controlled drugs they are authorised to prescribe. Persons acting in accordance with the directions of the nurse or pharmacist Independent Prescriber are authorised to administer any schedule 2-5 drugs that the nurse or pharmacist can prescribe.( The Trust allows Independent Non Medical Prescribers to prescribe Controlled drugs in accordance with the legislation provided they have completed the relevant Trust training for prescribing controlled drugs. Unless a prescriber is using an electronic prescribing system, all Controlled Drug prescriptions must be written on FP10 pads individually assigned to that specific prescriber It is the Non Medical Prescriber s responsibility to ensure a record of prescribing is kept of all Controlled Drug prescriptions. This should include the date, the dose, the formulation, the prescription number and service user Rio number as a minimum set of information. Supplementary non medical prescribers Any controlled drug can be prescribed by a supplementary non-medical prescriber within their sphere of competence, provided this is specified within a clinical management plan Dec of 38

10 Unless a prescriber is using an electronic prescribing system, all Controlled Drug prescriptions must be written on FP10 pads assigned to them by their medical supervisor. It is the Non Medical Prescriber s responsibility to ensure a record of prescribing is kept of all Controlled Drug prescriptions. This should include the date, the dose, the formulation, the prescription number and service user Rio number as a minimum set of information. 11 Related Procedural Documents The following Trust policies should be read in conjunction with this policy: Medicines Policy Staff Supervision Policy Business Conduct Policy 12 Roles and Responsibilities Effective Clinical Governance arrangements must be in place to ensure the safe practice of prescribing to service users. The overall responsibility for these arrangements lies with the Quality and Safety Governance Group Individual Responsibilities The Chief Executive is legally accountable for the quality of care that service users receive and for securing service user safety. The Trust Non-Medical Prescribing Lead is responsible for monitoring and agreeing all applications for nurse training. They are responsible for ensuring all nonmedical prescribers are annotated on their professional registers before agreeing for them to prescribe. They are responsible for maintaining a register of all non-medical prescribers within the Trust, both practicing and non-practicing, and that each nonmedical prescriber maintains their own continuing professional development requirements to be eligible to continue to prescribe. In the event of any competency concerns with an individual non-medical prescriber, they are responsible for reviewing and/or removing authorisation to undertake their role. The Chief Pharmacist is responsible for agreeing for any pharmacist to undertake the non-medical prescribing course and authorising practice once qualified. The Chief pharmacist is responsible for monitoring prescribing across the Trust and Dec of 38

11 raise concerns with the appropriate professional lead where there is concern regarding competency. The Accountable Officer is responsible for monitoring all prescribing across the Trust and ensuring the safe and secure use of controlled drugs in particular across the Trust. The AO is responsible for reporting concerns to the Trust board and the Local CD Lin Chair. The Accountable Officer can remove authorisation to prescribe from any prescriber in consultation with their appropriate professional lead. SBU Directors and Clinical Directors are responsible for agreeing a strategy for use of non-medical prescribers within their service in conjunction with the Non- Medical Prescribing Lead. They are responsible for identifying the numbers of staff required and opportunities for use of these skills, to maximise the benefits to service users and service delivery in a safe, cost effective and sustainable manner. These plans should be approved at Board level. The Quality and Safety Management Group is responsible for overseeing and ratifying each SBU strategy. They are responsible for agreeing any audit of the use of Non-Medical Prescribing, and are the direct line of reporting for the Non-Medical Prescribers Forum. The employee s Line Manager, or designated senior nurse where the line manager is a non-nurse, is responsible for undertaking an appraisal of the employee before any application for training, to ensure that they are competent in their area of practice, including competent to take a history, undertake a clinical assessment and diagnose. They are also responsible for annually appraising the ongoing efficacy of the role with the non-medical prescriber and raising any concerns both with the individual and with the Non-Medical Prescribing Lead. The Line Manager is responsible for ensuring the Non-Medical Prescriber has protected time to both undertake their role effectively and for their CPD. Each Non-Medical Prescriber is accountable for remaining up-to-date and competent and is responsible for their own Continuing Professional Development (CPD) requirements by keeping a portfolio of evidence. They are also responsible for ensuring records are kept of all their prescriptions in whatever format they are issued (e.g. FP10, Inpatient prescription sheets or electronic prescriptions). For Supplementary Prescribing, the Medical Practitioner is responsible for making the diagnosis and must review the Clinical Management Plan (CMP) at least annually. In exceptional circumstances and where clinical need dictates, it may be acceptable to review the CMP less frequently, for example if the service user s Dec of 38

12 condition is stable and well managed. In this instance, a review date must still be agreed and the decision documented (DH 2004). The Supplementary Prescriber is responsible for ensuring that they only prescribe medicines within the parameters of the individualised CMP. Prescribing as a supplementary prescriber outside a CMP constitutes a criminal offence under the terms of the Prescriptions Only Medicines Order and could be subject to sanctions under the Medicines Act Definitions Non-medical prescribers within AWP can be nurse and pharmacist prescribers who will be suitably qualified to treat conditions within their area of experience and competence, either as Independent or Supplementary prescribers. Independent Prescribing prescribing by a practitioner (e.g. doctor, nurse, pharmacist) responsible and accountable for the assessment of service users with undiagnosed or diagnosed conditions and for decisions about the clinical management required, including prescribing. Supplementary Prescribing a voluntary partnership between an independent prescriber (a doctor) and a supplementary prescriber, to implement an agreed service user specific management plan with the service user s agreement. Clinical Management Plan A plan that must be in place before Supplementary Prescribing can start, which relates to a named service user and to that service user s specific condition(s) to be managed by the supplementary prescriber. The CMP is required to include details of the illness or conditions that may be treated, any known sensitivities, the class or description of medical products that can be prescribed or administered, and the circumstances in which the supplementary prescriber should refer to, or seek advice from, the doctor/dentist. Supplementary prescribers must have access to the same patient/client health records as the doctor Designated Medical Supervisor Identified named medical practitioner who provides supervision and support to nurse and pharmacist prescribers, assesses their application of theory to practice and signs off satisfactory completion of the period of learning and assessment in practice. They also provide ongoing support and supervision to the NMP post qualification. 14 Standards Non-medical prescribers must also adhere to their professional bodies standards and regulations as set out in the following documents: Dec of 38

13 National Institute for Health and Clinical Excellence (2012) A single competency framework for all prescribers. The National Prescribing Centre Nursing and Midwifery Council (2006) Standards of proficiency for nurse and midwife prescribers Nursing and Midwifery Council (2008) Standards for Medicines Management Nursing and Midwifery Council (2008) Guidance for Continuing Professional Development for Nurse and Midwife Prescribers Royal Pharmaceutical Society (2007) General Pharmaceutical Council (2010) Clinical Governance Framework for Pharmacist Prescribers and organisations commissioning or participating in pharmacist prescribing General Pharmaceutical Council (2010) Standards of conduct, ethics and performance duct,%20ethics%20and%20performance.pdf 15 Governance and Audit General Governance Procedure All non-medical prescribers are individually responsible for maintaining their continuing professional development (CPD) and competence to continue to prescribe through the keeping of a CPD Portfolio. This can be evidenced from a wide range of sources, with the emphasis being on those areas which can be verified by either the individual s line manager or medical supervisor. The following (not exhaustive) list indicates acceptable areas for evidence in the portfolio: Mandatory: Annual Appraisal forms Written evidence of supervision/ mentor notes etc Supervised practice session/s with a medical prescriber Desirable: Dec of 38

14 Attendance at Trust NMP Forum Meetings Attendance at local prescribing forums Attendance at specialist prescribing forums Attendance at local Academic meetings Peer Supervision Group/Case study notes Formulary audit / policy audit Service user and/or colleague feedback Providing part of the DMP supervision and support for NMP students Verbal knowledge/ awareness of guidelines/ standards/ policies/ procedures etc relevant to prescribing and area of practice Minutes of meetings with manager/ colleagues/ other prescribers Reflective practice evidence in relation to change/ improvement in practice Evidence of incident / near misses / learning from experience (if relevant) Prescription logs Certificates relevant to practice from Courses/ training sessions Attendance at relevant regional and national events may be specific to a service area Copies of clinical management plans /audits of CMPs Copy of prescribing audits carried out Service evaluations and research This evidence will be reviewed on an annual basis by the Non-Medical Prescribing Lead. Periods of absence from prescribing If a qualified prescriber s post changes, is reviewed, or they undertake a period of secondment which means they are no longer able to undertake a prescribing role, they are responsible for advising the Trust Non-Medical Prescribing Lead Dec of 38

15 immediately of this situation. If the change is on a temporary basis (i.e. no more than six months) and, they subsequently return to the same clinical area the prescriber will be able to resume their previous role provided the same supervision structure is still available; again notifying the Non-Medical Prescribing Lead of their return to prescribing. In the event of a prolonged change in role or period of sick leave of six months or more, a non-medical prescriber will need to discuss any competency issues with their manager and the Trust Non-Medical Prescribing Lead, and may need a period of time before resuming their prescribing function or, alternatively only be able to prescribe on a Supplementary basis. In this event each person will be dealt with on an individual, case by case basis, as will the timescales involved. Withdrawal of permission to prescribe Non-adherence to the Trusts CPD requirements or concerns about fitness to practice may result in authority to prescribe being withdrawn by the Non-Medical Prescribing Lead or Accountable Officer. Audit An annual audit of prescribing practice will take place following a work plan agreed by the Non-Medical Prescribing Lead and the Forum in conjunction with the Trust audit department Additionally regular audits of the use of non-medical prescribers will be commissioned by the Non-Medical Prescribing Lead or Chief Pharmacist through consultation with the Clinical Standards Group as part of the Non-Medical Prescribing Strategy. General compliance with this policy will be monitored through review of any relevant medication incidents, serious untoward incidents and unexpected death audits so that lessons can be learned and disseminated throughout the Trust. 16 References CQC (2009) Nurses, the administration of medicine for mental disorder and the Mental Health Act Care Quality Commission Department of Health (2000) The NHS Plan: a plan for investment, a plan for reform. London: Crown Department of Health (2004) Extending independent nurse prescribing within the NHS in England: a guide for implementation. London: Crown Dec of 38

16 Department of Health (2006) Improving Patients Access to Medicines. London: Crown Home Office circular 009/2012 Nurse and pharmacist independent prescribing, mixing of medicines, possession authorities under service user group directions and personal exemption provisions for schedule 4 Part II drugs National Institute for Health and Clinical Excellence (2012) A single competency framework for all prescribers. The National Prescribing Centre National Prescribing Centre, National Institute for Mental Health in England, Department of Health (2005) Improving mental health services by extending the role of nurses in prescribing and supplying medication: Good practice Guide. London: Nursing and Midwifery Council (2006) Standards of proficiency for nurse and midwife prescribers. London: NMC Nursing and Midwifery Council (2008) Standards for Medicines Management. London: NMC Nursing and Midwifery Council (2008) Guidance for Continuing Professional Development for Nurse and Midwife Prescribers. London: NMC Dec of 38

17 Appendix A : Criteria for Independent / Supplementary Prescribing Programme Nurses selected for prescribing training will need to meet the following requirements: Be a first level registered nurse Have at least three years post-registration clinical nursing experience, of which at least one year immediately preceding their application to the training programme should be in the clinical area in which they intend to prescribe Must provide evidence of ability to study at minimum academic level three (degree), through completion of an approved Medication Management Course Have written support from the employer to undertake the programme Have written confirmation from the NMP Lead Have a designated medical practitioner who has agreed to provide the required term of supervised practice Been assessed as competent to take a history, undertake a clinical assessment and make a diagnosis Criteria to undertake the role of designated medical practitioner are: Three years recent clinical experience in the relevant field of practice. Has the support of the employing organisation to act as the DMP, who will provide supervision, support and opportunities to develop competence in prescribing practice. Has experience or training in teaching and / or supervising in practice Normally works with the trainee prescriber Pharmacists selected for prescribing training will need to meet the following requirements: Current registration with the General Pharmaceutical Council as a practising pharmacist Have at least two years appropriate patient orientated experience practising in a hospital, community or primary care setting following their registration year Dec of 38

18 Identify an area of clinical practice and need in which to develop their prescribing skills Have up-to-date clinical, pharmacological and pharmaceutical knowledge relevant to their intended area of prescribing practice Demonstrate how they reflect on their own performance and take responsibility for their own CPD Demonstrate how they will develop their own networks for support, reflection and learning, including prescribers from other professions Dec of 38

19 Appendix B : Clinical Management Plan (CMP) Name of Service User: Sensitivities/allergies: Service User identification (RIO/NHS number and date of birth): Independent Prescriber: Contact Details: Condition(s) to be treated: Supplementary Prescriber(s): Contact Details: Aim of treatment: -To prevent relapse of illness. -To maintain positive mental health. -To reduce intensity & frequency of symptoms of illness. Medicines that may be prescribed by Supplementary Prescriber: Preparation Indication Dose schedule Specific indications for referral back to the Independent Prescriber Questionable diagnosis Service user declining treatment Treatment resistance Difficult to treat side-effects Guidelines or protocols supporting Clinical Management Plan: AWP Policy on Non-Medical Prescribing, BNF guidelines, NICE guidelines, The Maudsley Prescribing Guidelines Frequency of review of this clinical management plan and monitoring by: Supplementary prescriber Supplementary prescriber and independent prescriber As indicated by response to treatment Annually Process for reporting Adverse Drugs Reactions: AWP Medicines Policy, AWP Non-Medical Prescribing Policy, BNF guidelines Yellow Card Dec of 38

20 Shared record to be used by Independent Prescriber and Supplementary Prescriber: Signature of independent prescriber(s) Date Signature of supplementary prescriber(s) Date Signature of service user / carer (or reason for not signing) Appendix C : A single competency framework for all prescribers A single competency framework for all prescribers This word version can be used as a template to record notes and actions. Please refer to the full PDF version for further information. Date of publication May 2012 Date of review May 2014 This single prescribing competency framework replaces all previous profession specific competency frameworks published by the National Prescribing Centre Dec of 38

21 Framework design The competency framework (illustrated below) sets out what good prescribing looks like. There are three domains, each containing three dimensions of competency (nine in total). Within each of the nine competency dimensions there are statements which describe the activity or outcomes prescribers should be able to demonstrate Dec of 38

22 Tips on using the competency framework to identify strengths and development areas 1. Before reviewing the competency framework take some time to think about the following questions. This can be done alone or with relevant colleagues. In your view, what are the most important behaviours and skills that prescribers use, and need to maintain, to be good prescribers? Why? Reflect on a recent 'prescribing' encounter that you had with a patient that you felt did not go well, or resulted in an error - what happened? How might it have been prevented? Reflect on a recent 'prescribing' encounter that you had with a patient that you felt went well - what happened? 2. Approach the framework one competency at a time to keep it manageable. There may be overlap between the different sections. 3. All competencies will be relevant to all prescribers however some of the supporting statements may be more relevant to some prescribers than others. Spend some time thinking about how the statements apply to your individual prescribing context Dec of 38

23 The prescribing competency framework Domain A: The consultation Competency 1: Knowledge Has up-to-date clinical, pharmacological and pharmaceutical knowledge relevant to own area of practice. Competence Evidence / Comments 1. Understands the conditions being treated, their natural progress and how to assess their severity. 2. Understands different non-pharmacological and pharmacological approaches to modifying disease and promoting health, identifies and assesses the desirable outcomes of treatment. 3. Understands the mode of action and pharmacokinetics of medicines and how these mechanisms may be altered (e.g. by age, renal impairment), and how this affects treatment decisions. 4. Understands the potential for adverse effects and how to avoid/minimise, recognise and manage them. 5. Uses up-to-date information about relevant products (e.g. formulations, pack sizes, storage conditions, costs). 6. Applies the principles of evidence-based practice, including clinical and costeffectiveness. 7. Aware of how medicines are licensed, sourced and supplied, and the This is an outline framework of prescribing competencies relevant to all prescribers. The statements in this framework should be interpreted in the context in which individuals are prescribing, taking into account their scope of practice. Non-Medical Prescribing Policy.doc

24 implications for own prescribing. 8. Knows how to detect and report suspected adverse drug reactions. 9. Understands the public health issues related to medicines and their use. 10. Appreciates the potential for misuse of medicines. 11. Understands antimicrobial resistance and the roles of infection prevention, control and antimicrobial stewardship1 measures. Competency 2: Options Makes or reviews a diagnosis, generates management options for the patient and follows up management. 12. Takes an appropriate medical history and medication history which includes both current and previously prescribed and non-prescribed medicines, supplements and complementary remedies, and allergies and intolerances. 13. Undertakes an appropriate clinical assessment using relevant equipment and techniques. 1 Antimicrobial stewardship - Advisory Committee on Antimicrobial Resistance and Healthcare Associated Infection (ARHAI) This is an outline framework of prescribing competencies relevant to all prescribers. The statements in this framework should be interpreted in the context in which individuals are prescribing, taking into account their scope of practice. Non-Medical Prescribing Policy.doc

25 14. Accesses and interprets relevant patient records to ensure knowledge of the patient's management. 15. Makes, or understands, the working or final diagnosis by considering and systematically deciding between the various possibilities (differential diagnosis). 16. Requests and interprets relevant investigations. 17. Considers all treatment options including no treatment, nonpharmacological interventions and medicines usage. 18. Assesses the effect of multiple pathologies, existing medication, allergies and contraindications on management options. 19. Assesses the risks and benefits to the patient of taking or, not taking a medicine or treatment. 20. Where a medicine is appropriate, identifies the different options. 21. Establishes and maintains a plan for reviewing the therapeutic objective, discharge or end point of treatment. 22. Ensures that the effectiveness of treatment and potential unwanted effects are monitored. 23. Makes changes to the treatment plan in light of on-going monitoring and the patient's condition and preferences. This is an outline framework of prescribing competencies relevant to all prescribers. The statements in this framework should be interpreted in the context in which individuals are prescribing, taking into account their scope of practice. Non-Medical Prescribing Policy.doc

26 24. Communicates information about medicines and what they are being used for when sharing or transferring prescribing responsibilities/information. Competency 3: Shared decision making (with parents, care-givers or advocates where appropriate) Establishes a relationship based on trust and mutual respect. Recognises patients as partners in the consultation. 25. Identifies and respects the patient s values, beliefs and expectations about medicines. 26. Takes into account the nature of peoples diversity when prescribing. 27. Undertakes the consultation in an appropriate setting taking account of confidentially, dignity and respect. 28. Adapts consultations to meet needs of different patients (e.g. for language, age, capacity, physical or sensory impairments). 29. Deals sensitively with patients' emotions and concerns about their medicines. 30. Creates a relationship which does not encourage the expectation that a prescription will be supplied. 31. Explains the rationale behind and the potential risks and benefits of management options. 32. Works with patients to make informed choices about their This is an outline framework of prescribing competencies relevant to all prescribers. The statements in this framework should be interpreted in the context in which individuals are prescribing, taking into account their scope of practice. Non-Medical Prescribing Policy.doc

27 management and respects their right to refuse or limit treatment. 33. Aims for an outcome of the consultation with which the patient and prescriber are satisfied. 34. When possible, supports patients to take responsibility for their medicines and self-manage their conditions. 35. Gives the patient clear accessible information about their medicines (e.g. what it is for, how to use it, where to get it from, possible unwanted effects). 36. Checks patient s understanding of and commitment to their management, monitoring and follow-up. 37. Understands the different reasons for non-adherence to medicines (practical and behavioural) and how best to support patients. Routinely assesses adherence in a non-judgemental way. Domain B: Prescribing Effectively Competency 4: Safe Is aware of own limitations. Does not compromise patient safety. This is an outline framework of prescribing competencies relevant to all prescribers. The statements in this framework should be interpreted in the context in which individuals are prescribing, taking into account their scope of practice. Non-Medical Prescribing Policy.doc

28 Competence Evidence / Comments 38. Knows the limits of their own knowledge and skill, and works within them. 39. Knows when to refer to or seek guidance from another member of the team or a specialist. 40. Only prescribes a medicine with adequate, up-to-date awareness of its actions, indications, dose, contraindications, interactions, cautions, and side effects (using, for example, the BNF/BNFC). 41. Accurately calculates doses and routinely checks calculations where relevant, for example for children. 42. Keeps up to date with advances in practice and emerging safety concerns related to prescribing. 43. Knows about common types of medication errors and how to prevent them. 44. Ensures confidence and competence to prescribe are maintained. 45. Makes accurate, legible and contemporaneous records and clinical notes of prescribing decisions. 46. Effectively uses the systems necessary to prescribe medicines (e.g. medicine charts, electronic prescribing, decision support). This is an outline framework of prescribing competencies relevant to all prescribers. The statements in this framework should be interpreted in the context in which individuals are prescribing, taking into account their scope of practice. Non-Medical Prescribing Policy.doc

29 47. Writes legible, unambiguous and complete prescriptions which meet legal requirements. Competency 5: Professional Ensures prescribing practice is consistent with scope of practice, organisational, professional and regulatory standards, guidance and codes of conduct. 48. Accepts personal responsibility for prescribing and understands the legal and ethical implications of doing so. 49. Makes prescribing decisions based on the needs of patients and not the prescriber s personal considerations. 50. Knows and applies legal and ethical frameworks affecting prescribing practice (e.g. misuse of drugs regulations, prescribing of unlicensed/off label medicines). 51. Takes responsibility for own learning and continuing professional development. 52. Maintains patient confidentiality in line with best practice and regulatory standards and contractual requirements. Competency 6: Always improving This is an outline framework of prescribing competencies relevant to all prescribers. The statements in this framework should be interpreted in the context in which individuals are prescribing, taking into account their scope of practice. Non-Medical Prescribing Policy.doc

30 Actively participates in the review and development of prescribing practice to optimise patient outcomes. 53. Learns and changes from reflecting on practice. 54. Shares and debates own and others prescribing practice, and acts upon feedback and discussion. 55. Acts upon colleagues inappropriate prescribing practice using appropriate mechanisms. 56. Understands and uses tools to improve prescribing (e.g. review of prescribing data, audit and feedback). 57. Reports prescribing errors and near misses, reviews practice to prevent recurrence. 58. Makes use of networks for support, reflection and learning. This is an outline framework of prescribing competencies relevant to all prescribers. The statements in this framework should be interpreted in the context in which individuals are prescribing, taking into account their scope of practice. Non-Medical Prescribing Policy.doc

31 Domain C: Prescribing in context Competency 7: The healthcare system Understands and works within local and national policies, processes and systems that impact on prescribing practice. Sees how own prescribing impacts on the wider healthcare community. Competence Evidence / Comments 59. Understands and works within local frameworks for medicines use as appropriate (e.g. local formularies, care pathways, protocols and guidelines). 60. Understands the need to work with, or develop, safe systems and processes locally to support prescribing, for example, repeat prescribing, transfer of information about medicines. 61. Works within the NHS/organisational or other ethical code of conduct when dealing with the pharmaceutical industry. 62. Understands budgetary constraints and prioritisation processes at local and national level (health-care resources are finite). 63. Understands the national frameworks for medicines use (e.g. NICE, SMC, AWMSG and medicines management/optimisation). 64. Prescribes generically where appropriate, practical and safe for the patient. This is an outline framework of prescribing competencies relevant to all prescribers. The statements in this framework should be interpreted in the context in which individuals are prescribing, taking into account their scope of practice. Non-Medical Prescribing Policy.doc

32 Competency 8: Information Knows how to access relevant information. Can use and apply information in practice 65. Understands the advantages and limitations of different information sources available to prescribers. 66. Accesses relevant, up-to-date information using trusted evidencebased resources. 67. Regularly reviews the evidence base behind therapeutic strategies. Competency 9: Self and others Works in partnership with colleagues for the benefit of patients. Is self-aware and confident in own ability as a prescriber. 68. Thinks and acts as part of a multidisciplinary team to ensure that continuity of care is developed and not compromised. 69. Establishes relationships with other professionals based on understanding, trust and respect for each other's roles in relation to prescribing. 70. Recognises and deals with pressures that might result in inappropriate prescribing (for example, pharmaceutical industry, media, patient, colleagues). 71. Negotiates the appropriate level of support and supervision for role as a prescriber. This is an outline framework of prescribing competencies relevant to all prescribers. The statements in this framework should be interpreted in the context in which individuals are prescribing, taking into account their scope of practice. Non-Medical Prescribing Policy.doc

33 72. Provides support and advice to other prescribers where appropriate. This is an outline framework of prescribing competencies relevant to all prescribers. The statements in this framework should be interpreted in the context in which individuals are prescribing, taking into account their scope of practice. Non-Medical Prescribing Policy.doc

34 Appendix 1: Competencies for supplementary prescribers Supplementary prescribers require the same common competencies as independent prescribers to ensure safe and effective prescribing within the scope of their practice. The competencies for supplementary prescribers are the same as those of independent prescribers however there are several modifications and additions that reflect the unique nature of a supplementary prescribing relationship. The modifications to the competency framework are presented in the table below and cross referenced to the statements in the prescribing framework. Competency domain A: THE CONSULTATION Competency Statement Modification/ new statement Evidence / Comments Competency 2: Options Reviews diagnosis and generates management options for the patient within the clinical management plan. Always follows up management MODIFIED; overarching statement Reviews medical history and medication history which includes both current and previously prescribed and nonprescribed medicines, supplements and MODIFIED; statement 12 This is an outline framework of prescribing competencies relevant to all prescribers. The statements in this framework should be interpreted in the context in which individuals are prescribing, taking into account their scope of practice. Non-Medical Prescribing Policy.doc

35 complementary remedies, and allergies and intolerances Reviews the clinical condition using relevant equipment and techniques MODIFIED; statement 13 Reviews the working or final diagnosis MODIFIED; statement 15 Where a medicine is appropriate, identifies the different options in the clinical management plan MODIFIED; Statement 20 Makes changes within the clinical management plan in light of on-going monitoring and the patient s condition and preferences MODIFIED; statement 23 This is an outline framework of prescribing competencies relevant to all prescribers. The statements in this framework should be interpreted in the context in which individuals are prescribing, taking into account their scope of practice. Non-Medical Prescribing Policy.doc

36 Competency domain B: PRESCRIBING EFFECTIVELY Competency 4: Safe Knows how and when to refer back to, or seek guidance from, the independent prescriber, another member of the team or a specialist MODIFIED; statement 39 Competency 5: Professional Understands the scope of own prescribing responsibility in the context of a shared clinical management plan NEW STATEMENT Ensures that the patient consents to be managed by a prescribing partnership NEW STATEMENT This is an outline framework of prescribing competencies relevant to all prescribers. The statements in this framework should be interpreted in the context in which individuals are prescribing, taking into account their scope of practice. Non-Medical Prescribing Policy.doc

37 Competency domain C: PRESCRIBING IN CONTEXT Competency 7: The healthcare system Understands the principles behind supplementary prescribing and how they are applied in practice NEW STATEMENT Competency 9: Self and others Proactively negotiates with the independent prescriber to develop clinical management plans NEW STATEMENT Relates to the independent prescriber as a partner NEW STATEMENT This is an outline framework of prescribing competencies relevant to all prescribers. The statements in this framework should be interpreted in the context in which individuals are prescribing, taking into account their scope of practice. Non-Medical Prescribing Policy.doc