Category:Prescribing

From Ganfyd

Jump to: navigation, search

Contents

Introduction

Prescribing is to give a (medical) direction and in most legal systems is highly regulated.[1] Originally such controls resulted from regulation of access to opioids. There is evidence that computerised prescribing can be safer. There is evidence of unexpected variability in prescribing skill output of medical schools across Europe[2].

United Kingdom

Flag of the United Kingdom.png

Doctors writing prescriptions in the UK should adhere to Good practice in prescribing and managing medicines and devices (2013)

Most prescriptions are written on the NHS requiring a specific form. Prescription charges can be raised. Private scripts should be used for non-NHS patients. There is a particular form for private scripts for controlled drugs.

General Practice Prescribing

UK General Practice prescribing is nowadays almost all done with the assistance of automation. This reduces errors of various sorts and improves medical records.

Introducing additional prescription-like instructions for administration may have advantages for nurses and health care assistants administering medicines, but if these are to be handwritten it inevitably introduces errors as well as scaling poorly. Modification of existing prescribing software so that it can produce standard or arbitrary forms to record administration of dispensed or prescribed drugs is a far better approach but may founder on differential inter-professional expectations.

General Practices (or primary care in general) operate repeat prescribing systems, which are to a large extent responses to various regulatory and other traditions. They correspond to the possibly more accurate American description of "refills" of a prescription and are far more complex than they appear in sociological and informatic terms.

Acute prescribing is more straightforward and less different from traditional prescribing in general practice than elsewhere. It is notable that a considerable proportion of prescriptions do not result in medication being taken in the manner prescribed, if at all. This issue of compliance has been well studied. Although better concordance with a doctors recommended therapy has been correlated with health gain, studies have also demonstrated that when Pharmacists made an effort to increase concordance out of total patient context, adverse effects outweighed any gains and the intervention was not cost effective[3][4].

The BMA has provided excellent and comprehensive advice on prescribing in general practice.[5]

LogoKeyPointsBox.pngResponsibility for a prescription lies with the doctor who signs the prescription. It cannot be assumed by letter by another doctor, be they ever so eminent. Thus to transfer prescribing, knowledge must be transferred, since responsibility cannot be.

Hospital Prescribing

Simple prescribing errors within the first 24 hours of admission on hand written charts are so close to universal (90%) that the 15% significant prescribing error rate [6] is challenging to address and electronic systems are not the complete answer as they create their own potential for different important errors.

It is customary that when patients who usually take prescription drugs are admitted to hospital, these have to be written up - prescribed again - by the hospital doctors. This is particularly important with seriously ill patients: Jack Adcock's death appears to have been at least partly attributable to the fact that he, while already in septic shock, was given enalapril - in accordance with a local hospital policy which allows medicines to be given without their having been prescribed by hospital staff (and, in this case, despite the doctor responsible for his care having documented that it should be withheld).

Interface prescribing between primary and secondary care

Flag of the United Kingdom.png

The UK NHS can be used as an example of the problems say in prescribing. The best interests of the patient does not necessarily apply if the system is designed to commission for populations and individuals can not be disciplined effectively either in tertiary, secondary and primary care when they push the boundaries, although some issues do arise from complete ignorance or are caused by those that can not be bothered to ascertain the status of a medication. Other issues arise with the interface between private and NHS care. The assumption that the GP is the coordinator of all healthcare can start to fail when the patient can access secondary or tertiary care treatment more conveniently.

One of the issues relates to the perception by GPs that they are being asked to do work which they are not contracted and/or trained to do. This can also apply to a secondary provider who is not commissioned to provide treatment for a condition. There can be some conditions such as renal haemodialysis where it might be most logical for all prescribing to be done by the service in weekly contact with the patient

There are other perverse incentives and disincentives both ways. Proper communication on responsibility takes time. Monitoring often goes with prescribing responsibility but is not reimbursed consistently in primary care. Finance often gets in the way of a patients best interests, so for example a hospital supplied medication attracts VAT while prescriptions taken to a pharmacy are VAT exempt. Policy is local so a tertiary centre may operate under prescribing agreements made with its local commissioners that are quite different to those of a local commissioner and might make assumptions including potential miscommunication. Any prescriber may find it inconvenient to undertake appropriate competency training amongst their other priorities. If a prescriber does not have a full prescribing and monitoring record it increases the chances of interaction between medications and prescription errors.


The NHS is a system which - as a result of government policy - is under severe financial pressure. Consequently, all the parts of the system have lost staff and resources, and struggle to do what they have historically done. As a result, many have started looking at what they do, and looked at ways to get others to do it.

Many NHS contracts were rather loosely worded, so it is not too difficult for many of the players to say that something isn't explicitly part of our contract, so we don't need to do it.

GPs have traditionally had something of a "John Wayne contract" - "a man's gotta do what a man's gotta do". Which has meant that they have, traditionally, filled some of the gaps - nobody else will do it, so the GP does it (s/he's gotta do it).

Now that the financial screws have been applied, many hospital trusts have been quick to pass work to GP practices. Examples include:

  1. Providing fit notes for patients for conditions which the hospital is treating.
  2. Providing medication (such as sedatives or prophylactic antibiotics) prior to a procedure
  3. Prescribing drugs recommended by a hospital doctor (without a shared care agreement)

The BMA has created a suite of standard "quality first" template letters that GPs can deploy in responding to such requests.

One of the ganfyd editors, writing on Resilient GP, a closed facebook forum, has proposed that:

"…practices could publish a schedule of fees for doing secondary care work - fees which are set at a level which ensures that they make the work worth doing for the GP, and cost hospitals more than it would cost them to do the work themselves; with a statement that the fees apply WHEN THE WORK IS AGREED IN ADVANCE and will be [trebled] if a hospital asks the practice to do it without prior agreement. Make sure it's clear that any such request from a hospital will be considered as acceptance of this fee structure. Publish the schedule on the practice web site, and write to all the local hospitals to inform them that you will be charging. Don't put the fees in the letter - that way you can't amend them so easily, just put a permanent link to the page on the practice web site where the fees are published. You might want to point out that this is not core GP work (it's the hospital's responsibility) and it takes you away from your core work (caring for your patients) and that's why you are charging such high fees - so that the patients who are your responsibility do not suffer."

External links

Flag of the United Kingdom.png


Flag of England.png


Flag of England.png

There is clear guidance on this from NHS England, published in 2018.[7]

Non-Medical prescribing

Before prescribing became regulated everyone could do it. Even with regulation often nurses working in institutions were up to the 1980s able to order laxatives and simple remedies. This did not apply to independent community practice which drove clarification. The Cumberlege Report from the DHSS in 1986 recommended ""The DHSS should agree a limited list of items and simple agents which may be prescribed by nurses as part of a nursing care programme, and issue guidelines to enable nurses to control drug dosage in well defined circumstances.". While the enabling primary legislation was the Medicinal Products: Prescription by Nurses Act 1992 other necessary secondary legislation did not get passed until 1994. In 1996 the Nurse Prescribers’ Formulary for District nurses and Health Visitors was created, which since 2005 has been known as The Nurse Prescribers’ Formulary for Community Practitioners. In 1997 Dr June Crown was appointed by the government to a Review of Prescribing, Supply and Administration of Medicines and the second report in 1999 of this group recommended extension of prescribing to further healthcare professionals. By 2000 first-level registered nurse or registered midwives after training as EINPs could prescribe from the Nurse Prescribers' Extended Formulary (NPEF) which contained all General Sales List (GSL) and Pharmacy (P) medicines prescribable by GPs, together with almost 180 specified Prescription Only Medicines (POMs), including some opioids. In April 2003 it became possible for nurses and pharmacists to train to become supplementary prescribers. Now nurses, pharmacists, physiotherapists, radiographers, podiatrists and optometrists can prescribe in partnership with a doctor (or dentist). Nurse and pharmacist supplementary prescribers are able to prescribe any medicine including controlled drugs and unlicensed medicines that are listed in an agreed clinical management plans (CMP). All supplementary prescribers may prescribe for any medical condition, provided they do so under an agreed, patient-specific CMP. Legislation from 31st May 2006 enabled all qualified Extended Independent Nurse Prescribers (now known as Nurse Independent Prescribers) and suitably qualified pharmacists to prescribe any licensed medicine. Nurse Independent Prescribers can prescribe a range of controlled drugs for specific medical conditions but Pharmacist Independent Prescribers cannot prescribe controlled drugs.

Implications

The tight monitoring of the introduction of Non-Medical prescribing identified a few issues but actually demonstrated high quality use of the prescribing rights granted with acceptable error rates[8]. Issues included a shift in industrial marketing efforts, the poor pharmacology and biosciences grounding of some undergraduate nurse training programs[9] and interestingly a potential invidious comparison situation between the output prescribing skills of some medical schools and those schools for independent healthcare professional prescribers. This was addressed concurrently with other concerns about medical school output from about 2003[10] by UK medical schools with for example a national prescribing skills assessment[11] and input (first job) assessment demonstrating by 2015 a marked improvement in standards .

England

Flag of England.png

Although the explanation below relates to the situation in England as of 2005 onwards, the enabling legislation is UK wide, and similar enabling regulation may exist in Scotland, Wales and Northern Ireland. In the United Kingdom a prescription only medicine (POM) can only be supplied by a pharmacist at the request of a qualified prescriber. Further rules apply for controlled drugs (CD). Doctors and dentists have long been recognised as qualified prescribers who prescribe using a "Patient Specific Direction". Such directions are prospective (with regard to supply and administration by other health professionals). Retail Pharmacists have a restricted right to provide emergency supplies of medicines. Community NHS prescribing must be done on a standard form while presently in hospitals a written Patient Specific Direction must be created by a doctor or dentist. Other health professionals can have prescribing rights which may be limited depending upon context.

  1. Supplementary prescribing enables qualified nurses, pharmacists, physiotherapists, chiropodists/podiatrists, radiographers and optometrists to prescribe any medicine (including controlled drugs), within the framework of a patient- specific clinical management plan, agreed with a doctor.
  2. Independent prescribers utilise a Nurse Prescribers’ Extended Formulary which is a formulary of most commonly used prescription-only medicines, including some controlled drugs.
  3. District nurses and health visitors are able to prescribe from the Nurse Prescribers’ Formulary for District Nurses/Health Visitors (Community Practitioners)
  4. Patient Group Directions (PGDs) actually do not confer true prescribing rights. They are a written instruction created formally by a health organisation for the supply or administration of a medicine (or medicines) where the patient may not be individually identified before presenting for treatment. Only named individuals who are nurses, midwives, health visitors, paramedics, optometrists, chiropodists, radiographers, orthoptists, physiotherapists, pharmacists, dietitians, occupational therapists, prosthetists and speech and language therapists can use them.
  5. Specific exemptions in medicin24290875es legislation exist to allow certain recognised health professionals to supply or administer medicines. These include nurses providing occupational health schemes, midwives, chiropodists and optometrists.

Thus certain health professionals such as nurses and pharmacists might therefore be able to prescribe PoMs within their professional competence and under appropriate governance frameworks. Sometimes they might be more familiar with some rare drugs than doctor prescribers. However they are likely to have more restrictions on unlicensed medication prescribing than doctors


Dysfunctional Health Trusts

Can play political games, wasting effort and disadvantaging patients, by refusing to accept each other's identical paperwork - thus discharge prescriptions and medication administration documents prepared in hospital as part of a properly managed and safe discharge to community nursing care may be refused and the opportunity to make mistakes working from inadequate information in a hurry pressed upon GPs.

For the two Trusts involved to not talk and resolve the argument suggests that management changes should take place.

Classification of medicines

Products that might be considered to be drugs or medicines can fall into any of the following categories - products which can be:

  • Bought and sold freely "over the counter" (otc, without a prescription)
  • Be bought and sold without a prescription, but only in a registered pharmacy (P drugs).
  • Dispensed only with a prescription (Prescription only Medicines - PoMs.)
  • Dispensed only with a prescription, and subject to various other controls as they are drugs that may be abused (e.g. opiates) - CD or Controlled Drug.

In addition:

  • Some drugs may not be prescribed on the NHS, or may be prescribed on the NHS only in particular circumstances.
  • Most drugs that are prescribed are licensed; but unlicensed products may also be prescribed. If unlicensed products are prescribed, more of the liability rests with the prescriber than when products are prescribed in accordance with their license. Strictly prescription of a medicine for an indication outside its licensed indications is an unlicensed script (off-license) but liability with a manufacturer might be easier to share. Off-license use of medications is common and indeed often a necessity to treat patients to currently accepted standards of care.

24290875 Note that prescribing has to do with what may legally be prescribed; NHS prescribing also has to do with cost-efficacy and rationing.

International prescribing differences

International prescribing differences can be large[12]. Some jurisdictions restrict opioid prescribing more than others[13] and few Western nations are as generous with non-medical prescribing as is the UK. In the USA the situation varies from state to state with most allowing Nurse prescribing after an appropriate course and some Pharmacist prescribing. Nurse prescribing is possible for example in Australia, Canada, Sweden, Finland, Ireland, Netherlands, New Zealand and Spain. Pharmacists can prescribe in Canada and New Zealand. Australia is expected to follow but no other EU country has committed yet to follow this route.

Related articles

External links

References

  1. Statutory Instrument 2004 No. 291: The National Health Service (General Medical Services Contracts) Regulations 2004. England, 2004
  2. Brinkman DJ, Tichelaar J, Schutte T, Benemei S, Böttiger Y, Chamontin B, Christiaens T, Likic R, Maˇiulaitis R, Marandi T, Monteiro EC, Papaioannidou P, Pers YM, Pontes C, Raskovic A, Regenthal R, Sanz EJ, Tamba BI, Wilson K, Vries T, Richir MC, Agtmael MV. Essential competencies in prescribing: A first european cross-sectional study among 895 final-year medical students. Clinical pharmacology and therapeutics. 2017 Feb; 101(2):281-289.(Print-Electronic) (Link to article – subscription may be required.)
  3. Lenaghan E, Holland R, Brooks A. Home-based medication review in a high risk elderly population in primary care--the POLYMED randomised controlled trial. Age and ageing 2007;36(3):292-7. (Direct link – subscription may be required.)
  4. Pacini M, Smith RD, Wilson EC, Holland R. Home-based medication review in older people: is it cost effective? PharmacoEconomics 2007;25(2):171-80.
  5. BMA. Prescribing in General Practice: BMA, 2015(June); 1-9.
  6. Franklin BD, Reynolds M, Shebl NA, Burnett S, Jacklin A. Prescribing errors in hospital inpatients: a three-centre study of their prevalence, types and causes. Postgraduate medical journal. 2011 Nov; 87(1033):739-45.(Link to article – subscription may be required.)
  7. NHS England Direct Commissioning Change Projects. Responsibility for prescribing between Primary & Secondary/Tertiary Care. Leeds: Produced in partnership with BMA, RCGP, NAPP, RCN, and NHS Clinical Commissioners, 2018(January (online 13 March)); (https://www.england.nhs.uk/publication/responsibility-for-prescribing-between-primary-and-secondary-tertiary-care/). (direct link to pdf.)
  8. Reid F, Power A, Stewart D, Watson A, Zlotos L, Campbell D, McIntosh T, Maxwell S. Piloting the United Kingdom 'Prescribing Safety Assessment' with pharmacist prescribers in Scotland. Research in social & administrative pharmacy : RSAP. 2017 Jan.(Print-Electronic) (Link to article – subscription may be required.)
  9. Abuzour AS, Lewis PJ, Tully MP. Practice makes perfect: A systematic review of the expertise development of pharmacist and nurse independent prescribers in the United Kingdom. Research in social & administrative pharmacy : RSAP. 2017 Feb.(Print-Electronic) (Link to article – subscription may be required.)
  10. Maxwell S, Walley T. Teaching safe and effective prescribing in UK medical schools: a core curriculum for tomorrow's doctors. British journal of clinical pharmacology. 2003 Jun; 55(6):496-503.(Print) (Link to article – subscription may be required.)
  11. Maxwell SRJ, Coleman JJ, Bollington L, Taylor C, Webb DJ. Prescribing Safety Assessment 2016: Delivery of a national prescribing assessment to 7343 UK final-year medical students. British journal of clinical pharmacology. 2017 Apr.(Print-Electronic) (Link to article – subscription may be required.)
  12. Miguel LS, Augustin U, Busse R, Knai C, Rubert G, Sihvo S, Baeten R. Recognition of pharmaceutical prescriptions across the European Union: a comparison of five Member States' policies and practices. Health policy (Amsterdam, Netherlands). 2014 Jun; 116(2-3):206-213.(Print-Electronic) (Link to article – subscription may be required.)
  13. Vranken MJ, Lisman JA, Mantel-Teeuwisse AK, Jünger S, Scholten W, Radbruch L, Payne S, Schutjens MH. Barriers to access to opioid medicines: a review of national legislation and regulations of 11 central and eastern European countries. The Lancet. Oncology. 2016 Jan; 17(1):e13-22.(Print-Electronic) (Link to article – subscription may be required.)

Subcategories

This category has the following 3 subcategories, out of 3 total.

P

R

U