Non medical prescribing: the actual facts

Some information has been extracted from the DoH on the topic of nurse and pharmacist prescribing via the freedom of information act. Here are the facts of what actually happened:

"The Commission on Human Medicines (CHM) and its predecessor, the Committee on Safety of Medicines (CSM), is the independent body responsible for advising Ministers on matters relating to medicines and patient safety. The Commission is chaired by Professor Sir Gordon Duff and members include several other eminent professors of medicine from the UK.

The CSM has over a number of years advised on the expansion of the then Nurse Prescribers’ Extended Formulary. A sub-group of the CSM considered the options for the future of Nurse Independent Prescribing in September 2005. The sub-group’s recommendation was not based solely on the volume of responses in favour or against any particular option; it also took into consideration the merits of the views and arguments put forward and also had the benefit of advice from practitioners, including doctors, from the NHS.

The full Committee met on 27 October 2005 to consider in detail the responses to the consultations on nurse and pharmacist prescribing, as well as reviewing the sub-group’s findings. Following the meeting, the Committee recommended to Ministers that qualified nurse and pharmacist independent prescribers should be allowed to prescribe any licensed medicine for any medical condition within their competence. Ministers accepted the CSM’s recommendations and the Secretary of State for Health announced changes in November 2005. These changes came into effect in May 2006.

The Department of Health had also commissioned national research under its Policy Research Programme. The University of Southampton’s Evaluation of Extended Formulary Independent Nurse Prescribing, published in June 2005, had concluded that extended formulary independent nurse prescribing was operating safely, clinically appropriately and effectively in practice. The evaluation had sought the views of a range of stakeholders, including doctors and patients, and it was peer-reviewed before publication. A copy of the Executive Summary is on the Department’s website:

http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4114084 "

Essentially the CSM typically makes decisions and recommendations on specific prescribing issues such as 'The Committee considered and advised on a medicine to be used in the treatment of diabetes'. It seems very strange indeed that this issue as big as 'non medical prescribing' was left to this small body of pharmacological experts. They are not used to making decisions of this nature, they are not set up for making this kind of decision and they do not seem to be the best qualified to make this decision.

Interestingly there was no vote at all. Here is the the link to the meeting details, followed by the meeting summary:

http://www.mhra.gov.uk/home/idcplg?IdcService=GET_FILE&dID=19345&noSaveAs=0&Rendition=WEB

"The Chairman thanked DH colleagues for their views and clarifications, restating that the Committee would support options D (for nurses) and 5 (for pharmacists) within the context of the concerns they had raised. In thanking the CSM on behalf of herself and the Chief Pharmacist, the Chief Nursing Officer said that while the original limitations on the NPEF were understandable, subsequent expansions had made it complex. Safe practice included making legislation and procedures easy to understand and therefore easy for individuals to act correctly. Adopting the options recommended by the Committee in partnership with clinical governance structures would provide a strong accountability framework which would underpin improvements in patient care and make the best use of professional skills."

"As indicated above, the former Committee on Safety of Medicines (CSM) made recommendations to Ministers, taking account of all responses to the consultations and the advice of the sub-group. The CSM does not conduct its business by vote.": to quote the DoH again; it appears that this massive decision was made on the basis of an undemocratic committee process, which was then pushed through by ministers.

This must be seen in the context of the consultation process. In fact all but one of the medical bodies consulted for nurse prescribing were against the CSM's proposals, while all the medical bodies consulted were against the CSM's decision for pharmacist prescribing. Thus the small committee of the CSM has effectively been made the judge, jury and executioner in this process.

http://www.dh.gov.uk/en/Consultations/Closedconsultations/DH_4112047

http://www.dh.gov.uk/en/Consultations/Closedconsultations/DH_4112774

Unsurprisingly the DoH website does contain the responses to the consultation process on non medical prescribing! This is ridiculous, how can the process be seen to be transparent? Pulse had to obtain the information that all medical bodies were against the moves by the Freedom of Information Act, this information should have been available with the need to use FOI act. The DoH's selective release of information makes this process look very corrupt and suspicious indeed.

The evidence behind non medical prescribing is weak to say the least:

(http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4114084)

This 'evidence' consists of a survey of 246 nurse prescribers and ten case study sessions, and....that's it I'm afraid, this is the sum total of DoH backing for their reform. Is their a recurrent theme here?

'The most common conditions prescribed for were skin conditions, family
planning and soft tissue injuries.' and 'Experts made a small number of comments about
possible limitations in nurses’ history taking, assessment and diagnostic skills.' and 'Doctors were positive about the development of nurse prescribers in their teams, although were not able to unequivocally conclude that it had reduced their workload.'

Thus overall this small piece of work showed that nurses could safely prescribe for minor ailments, albeit more slowly than doctors and in a way that didn't provide any real benefit for the patient and healthcare system. This is while some experts were concerned about their clinical skills, a matter that was largely ignored in the conclusions. How on earth this 'evidence' can be then used to allow nurses and pharmacists to prescribe anything under the sun is beyond me. There is a rather glaring gap between the propaganda and the reality of the situation.

It seems the danger began in 1999 thanks to a review by June Crown, mysteriously the panel was made up of a rather large number of nursing managers, pharmacists and the Southampton cohort who produced the earlier quoted 'evidence'. There are no conflicts of interest here of course. The main motives for extending prescribing were:

'• make it easier and more convenient for patients to obtain the medicines they need;
• improve the service to patients, without compromising safety;
• increase patient choice in accessing services; and
• make better use of the skills of NHS professionals. '

It appears to me that the DoH can come up with precisely zero evidence that the service has been improved by extending prescribing rights, and this is surely the most important aim. They can also come up with no evidence that extending prescribing is safe. Their 'evidence' of safety only applies to minor health problems and is a very weak piece of evidence indeed; the sample size is small, there are numerous other flaws in the study design and it has not been peer-reviewed or published. Given that experts had concerns about nurses' clinical skills related to relatively minor medical conditions, then it is obvious that these concerns would be amplified when applied to more serious medical conditions. The potential for compromising patient safety is enormous. Logically the more the less trained are handed more responsibility, the more damage to patient care will result; this piece of logic has not been picked up by the DoH radar.

This is yet another in a long line of examples of DoH policy that is based on zero decent evidence. It is bad enough that this reform is incredibly expensive to research, create and implement; but add to this the fact the the reform is likely be less cost effective in the long term than previous arrangements. The propaganda network established between government reformers, the DoH and a small group of the compliant professionals seems to be the key to the process forcing ideological policy through against the public interest. If this corrupt ideological pursuit is not stopped, then in the future the consequences for patients could be quite disastrous.