Linda YoungClinical Specialist Radiographer for Lung

Cancers.Belfast Health & Social Care Trust.

The value of supplementary prescribing

Thanks!

Medicines Act

1968

MedicalPrescribers:

• Doctors

• Dentists

• Vets

Dr June Crown CBE

• 2nd Crown Report:Department of Health. Review of prescribing, supply and administration of medicines: final report. London: DH; 1999

Non Medical Prescribers

1999: 2nd Crown Report

2005:Supplementary Prescribing by Nurses, Pharmacists, Chiropodists/Podiatrists, Physiotherapists and Radiographers

How and Why of the 2nd Crown Report

Recognised changes on the education and training of other healthcare professional• Post graduated education

• Leading to extended autonomous practice

• Specialist qualifications

• Highly trained health professionals using their full range of skills and able to accept clinical responsibility for doing so

Within Medicine • Development of evidence based

practice clinical guidelines and protocols

• Development of Specialities within medicine

• Recognised specialist registers by GMC

Recognised changes in Professional Relationships• Development of the multi-

professional team– Advanced healthcare practitioner

2nd Crown Report: Recommendations

Overall ObjectiveAny change from current practice should result in improved health outcomes, or else equivalent health outcomes with improved patient convenience or more appropriateprofessional practice.

Any proposed change should be assessed against the following criteria:-• health outcomes and patient safety• patient choice• patient convenience• professional appropriateness• effective use of resources

IMPROVING HEALTH AND WELL-BEING THROUGH POSITIVEPARTNERSHIPS

A STRATEGY FOR THE ALLIED HEALTH PROFESSIONS IN NORTHERNIRELAND

2012 - 2017

“Quotes”

“AHPs will actively enhance people's lives through the planning and delivery of high quality and innovative diagnostic, treatment and rehabilitation services and practices that are safe, timely, effective and focused on the service user.”

4 Strategic Themes:• Promoting person-centred

practice and care;

• Delivering safe and effective practice and care;

• Maximising resources for success; and

• Supporting and developing the AHP workforce.

Aims of NMP

• Improve patient care without compromising patient safety

• Make it easier and quicker for patients to get the medicines they need

• Increase patient choice in accessing medicines • Make better use of the skills of health professionals • Contribute to the introduction of more flexible team

working across the Health Service

Strategic Theme 4-Supporting and Developing the AHP Workforce : Workforce Planning

• Workforce Planning– Right people– Right place– Right time– Right outcome

• Extended roles &Changing work practices

• Extended Roles• Changing Work Practices• Skills and Grade Mix

– Future skill mix to support strategic shift in how and where care is delivered

– Clinical AHP Consultant Grades in Northern Ireland implemented in the next 5 years

Strategic Theme 4-Supporting and Developing the AHP Workforce: Learning & Development

AHP Support Staff to Advanced Consultant Practitioners

Staff Development– Current Grade– Career progression

Strategic Theme 4-Supporting and Developing the AHP Workforce: Learning & Development

Postgraduate Certificate in Prescribing for Allied Health Professionals• 2010• 11 AHP

– 3 radiographers– 2 podiatrists– 6 physiotherapists

AHP Prescribing in Northern Ireland:

Non Medical Prescribing for AHP’s : Supplementary Prescribing

Supplementary Prescribing

Supplementary prescribing is a voluntary prescribing partnership between an independent prescriber and a supplementary prescriber, to implement an agreed patient-specific clinical management plan with the patient's agreement. The independent prescriber must be a doctor (or dentist).

IP & SP: The Definitions

Independent Prescriber• professionals who are

responsible for the initial assessment of the patient and for devising the broad treatment plan, with the authority to prescribe the medicines required as part of that plan.

• NMP must only prescribe as IP’s within their scope of practice

Supplementary Prescriber• professionals who are

authorised to prescribe medicines, for patients whose condition has been diagnosed or assessed by an independent prescriber, within an agreed clinical management plan.

Legal Requirements for Supplementary Prescribing:

• the independent prescriber must be a doctor (or dentist)

• the supplementary prescriber must be an eligible AHP, pharmacist, optometrist or nurse

• there must be a written or electronic clinical management plan agreed by all parties including the patient

• the independent prescriber and the supplementary prescriber must be able to access the common patient record

Supplementary Prescribing:The Prescribing Partnership

CMP

Patient

Supplementary PrescriberDoctor

CMP hinges on the Doctor/AHP Prescribing Partnership

IP is responsible for determining conditions the CMP covers, special

considerations inrealtion to the individual patient and the limits of the

SP’s

SP is autonomously responsible for clinical assessment and personally

accountable for prescribing decisions (i.e. drug choice, and dose ) within the

limits of the CMP

CMP

• Must be Patient Specific– Take into account the patients medical history and any other

conditions they may have.

• Allergies or sensitivities the patient has• Not a blanket authority to prescribe medicines• May not be suitable for all patients• Must clearly state the limits of prescribing i.e. when

referral back to IP should take placeHowever

Clinical Management Plans (CMPs) have to be relatively simple and quick to complete – or supplementary

prescribing will simply not be worth the effort. They should not duplicate a lot of information that is already recorded in

the shared record.

Regulations specify that the CMP must include the following:

• the name of the patient to whom the plan relates;• the illness or conditions which may be treated by the supplementary prescriber;• the date on which the plan is to take effect, and when it is to be reviewed by the doctor or

dentist who is party to the plan;• reference to the class or description of medicines or types of appliances which may be

prescribed or administered under the plan;• any restrictions or limitations as to the strength or dose of any medicine which may be

prescribed or administered under the plan, and any period of administration or use of any medicine or appliance which may be prescribed or administered under the plan;[NB The CMP may include a reference to published national or local guidelines. However these must clearly identify the range of the relevant medicinal products to be used in the treatment of the patient, and the CMP should draw attention to the relevant part of the guideline. Any guideline referred to also needs to be easily accessible]

• relevant warnings about known sensitivities of the patient to, or known difficulties of the patient with, particular medicines or appliances;

• the arrangements for notification of:-a) suspected or known reactions to any medicine which may be prescribed or administered under the plan, and suspected or known adverse reactions to any other medicine taken at the same time as any medicine prescribed or administered under the plan, andb) incidents occurring with the appliance which might lead, might have led or has led to the death or serious deterioration of state of health of the patient

• the circumstances in which the supplementary prescriber should refer to, or seek the advice of, the doctor or dentist who is party to the plan.

Clinical Management Plan: CMPDepartmental Protocol• Protocol for Lung Cancer

Clinical Specialist Radiographer Review for Patients with Lung Cancer

• Agreed by Lung Team Clinical Oncologists, Radiotherapy Lead Clinician, Clinical Director & Professional Lead

Shared Patient record

• Hardcopy & ‘COIS’ electronic case notes

• Gained user rights to input prescribing information electronically

• Meets statutorily requirements– Automatically available for IP

and other clinicians– Meets the trust’s NMP policy

requirement s– Governance

CMP hardcopy inserted to patient notes at the end of treatmentPotential of Electronic Version of CMP

BHSCT: NMP PolicyPrescriber details, Date,Drug, Quantity, Dose, Frequency, Treatment duration

Scope of Supplementary Prescribing: (NPC 2010)No restrictions on the clinical conditions SP may treat as CMP in place.Primarily used to treat chronic conditions or patients with who require long term care. This includes cancer.

All general sales list (GSL) medicines, pharmacy (P) medicines, appliances and devices, foods and other borderline substances approved by the Advisory Committee on Borderline Substances.

Medicines for use outside of their licensed indications (i.e. ‘off label’ prescribing), ‘black triangle’ drugs, and drugs marked ‘less suitable for prescribing’ in the 'British National Formulary' (BNF).

Medicines for use outside of their licensed indications (i.e. ‘off label’ prescribing), ‘black triangle’ drugs, and drugs marked ‘less suitable for prescribing’ in the 'British National Formulary' (BNF).

Controlled Drugs except those listed in schedule 1 of the 2001 Regulations . These drugs are not for use in humans.

Supplementary PrescribingLet the confusion begin!

INDEPENDENTPRESCRIBER

SUPPLEMENTARY & INDEPENDENT

PRESCRIBER

The Prescribing Umbrella

Non-Medical Prescriber

Medical Prescriber

Non Medical PrescribersNurses Pharmacists RadiographersPhysiotherapists Chiropodists/ PodiatristsOptometrists

Non Medical Prescribers

INDEPENDENTPRESCRIBER

SUPPLEMENTARYPRESCRIBER

Non Medical Prescribers

INDEPENDENTPRESCRIBER

NMP: Independent Prescribers

SCOPE of PRACTICE

Some Controlled Drugs

ANY Medicine

NMP: Independent Prescribers

SCOPE of PRACTICE

Controlled Drugs

ANY Medicine

NMP: Independent Prescribers

SCOPE of PRACTICE

Controlled Drugs

Licensed MedicineOcular Condition Only

MNP: Supplementary Prescribers

SCOPE of PRACTICE

Controlled Drugs

ANY Medicine

CMP

SUPPLEMENTARYPRESCRIBER

Click icon to add picture

The BHSCT AHP Supplementary PrescribingExperience.

BCHAHPISP’sLinda YoungLung Cancer Specialist

Jenny KeaneHead & Neck Cancer Specialist

Helen VennardBreast and Gynae Specialist.

CSR • Clinical specialist radiographers– Principle Radiographers

• 6-8 years in current posts• Work in disease specific teams• MSc level Postgraduate

Education modules• Expert knowledge in the clinical

management and treatment of cancer relevant to our specialist disease site

Patient Centered Care Levels Matched Against Current Roles And Responsibilities.

Level 1 Providing appropriate specialist information and knowledge to patients and careers. Giving guidance and support around the diagnosis and treatment options.Ensuring seamless transfer from diagnosis to treatment and onward referral where appropriate.

Level 2 Core Member of the MDT.Functioning as a member of the multidisciplinary team, where decisions about the optimum treatment options to offer to each patient. Provide specialist knowledge to the lung cancer multi-professional team meeting.Participate at Lung Cancer Regional Network level.Play a lead role in development of radio-therapeutic practice pertaining to the treatment of lung cancers.

Level 3 Responsibility for the co-ordination of care across the radiotherapy pathway.Responsible for managing treatment related toxicities.CSR On-treatment and post treatment review

The NHS Cancer Plan and the New NHS: Providing a patient centered service (2004), DH

Lung Cancer Team

Clinical Navigation Radial intent Palliative intent

Managing treatment related toxicity

Gaining optimum control of symptoms of disease

Appropriate onward referral

Clinical Oncologists

Lung Cancer Nurse

Lung Cancer Radiographer

Medical Oncologists

THE POSTGRADUATE CERTIFICATE IN PRESCRIBING FOR ALLIED HEALTH PROFESSIONALS FEB 2010

Designated Medical Practitioners

Postgraduate Certificate Prescribing

There’s life Jim but not as we know it

Postgraduate Certificate Prescribing

Portfiolo……it was unending!!!!!!!

Postgraduate Certificate Prescribing

Portfolio of Prescribing Competencies

Postgraduate Certificate

Semester 2 February 2010• Pharmacotherapeutics in Prescribing

Semester 1 October 2010• Prescribing in Practice Jan 2011 Results Feb 2011

Semester 3 June 2010• Clinical Experience & Case Study “Scouting”

Register with HPC April 2011

Graduate June 2011 Paperwork July 2011

September 2011 Clinical Protocols in place

??????? Legislation in Place

October application to Register

January 2010 AHPISP

End Result! 14 months later

Prescribing in Practice

Lessons learnt in the first week at UU

• All drugs are poison!

•All drugs are poison!DR MARK CROSS

Drug Drug InteractionsImportance of Drug Historys & AllergiesCo-morbidities, e.g renal diseasePatients don’t tell the truth about taking their medication!THE BROWN BAG PHENOMEN!

CSR links to the Patient’s Journey

MDT New patient Clinic

Radiotherapy Planning Clinic

Radiotherapy On Treatment Review

(urgent & weekly for duration of treatment

Radiotherapy Follow-up

Clinic

CSR links to the Patient’s Journey

MDT New patient Clinic

Radiotherapy Planning Clinic

Radiotherapy On Treatment Review

(urgent & weekly for duration of treatment

Radiotherapy Follow-up

Clinic

CMP

• ROUTINE CASE

• Radical NCSCL 66Gy in 33 fractions • SUCRALFATE 1g PO TDS from start of treatment until for 4

weeks post +/- PPI • Oramorph 2.5mg PO 4-6 hrs PRN• Fluconazole 50mg PO 14 days

Case 1

Normal Grade 2 Grade 3 with candidiasis

• ALL DRUGS ARE POISONS!!!• FLUCONAZOLE:

– Caution in patients with renal impairment• EGFR <50 reduce dose by half after 1st dose

• Rare cases of hepatic failure!• As a causal relationship with fluconazole cannot be excluded,

patients who develop abnormal liver function tests during fluconazole therapy should be monitored for the development of more serious hepatic injury. Fluconazole should be discontinued if clinical signs or symptoms consistent with liver disease develop during treatment with fluconazole.

Cautions!!!!!!!

• ALL DRUGS ARE POISONS!!!• SUCRALFATE:

– Bezoars (an insoluble mass formed with the gastric lumen) – Caution in patients with renal impairment due to increased

aluminium absorption– Concomitant administration may reduce the bioavailability of

certain drugs including tetracycline, ciprofloxacin, norfloxacin, ketoconazole, digoxin, warfarin, phenytoin, theophylline, thyroxine, quinidine and H2 antagonists. The bioavailability of these agents may be restored by separating the administration of these agents from SUCRALFATE by two hours.

Cautions!!!!!!!

• COMPLEX CASE

• Radical NCSCL 64Gy in 32 fractions• 3rd fraction described Pain in the left thorax• Open and close surgery• No brachial plexus neuropathy • No clinical indication for pain

• Described Pain with neuropathic element

Case 2

Pain Control:

Adjuvants

10mg

• Radical NCSCL 64Gy in 32 fractions• 2nd Week Nausea

– METOCHLOPRAMIDE– CYCLIZINE– ONDANSETRON– Added in Steroid

• Friday night at 5pm• Nausea and vomiting ? Admission

– LEVOMAPROMAZINE 6mg Nocte

Case 2

DRUG DRUG INTERACTION!LEVO with Amitriptylline

Contacted GP who after discussion felt that the drug combination was justified and she took responsibility for the prescription

GP issued the script to local pharmacy

Patient collected on way home

Nausea and vomiting was resolved by Monday. Pain remained controlled.

Case 2

DRUG DRUG INTERACTION!LEVO with Amitriptylline

• Medicine Reconciliation

Did this meet the aims of NMP

• No inpatient bed stay

Do we consider SP to be of value?

Patient’s: Yes!

“I get the same care, the same medicines, I just don’t have to wait so long to get them.”

Doctors: Definate Yes

“Can I head off to planning now? sure you can mange the clinic this morning, give me a shout if you need me. Any problems , I’ll come down asap. “

Why has Supplementary Prescribing appeared to fail in Nursing Models ?

The reasons!

• Available for Nurses since 1999• Over 50% of the nurses surveyed

could use NMP in their area of practice.

• Due to difficulties implementing NMP in practice only 22.7% were prescribing in practice.

• unavailability of prescription pads• awaiting prescribing code • impracticalities due to trust-wide

remit• not working in an area of practice

that lends itself to extended independent or supplementary nurse prescribing

• GRIBBEN, L., 2004. Meeting The Educational Needs of Independent and Supplementary Nurse Prescribers – An Interim Evaluation. MSc Learning & Teaching. University of Ulster Jordanstown

• At a local level NMP uptake was initially high within Northern Ireland however it is reported that within the Belfast Trust only 25% of nurses trained as non-medical prescribers actually practice.

V Hall Consultant Nurse.

• Pharmacist NMP’s • only 47% of them were actively

prescribing• BISSEL, P., COOPER,R., GUILLAUME, L., ANDERSON, C., AVERY,

A., HUTCHINSON, A., JAMES, V., LYMN, J., MARSDEN, E., MURPHY, E., RATCLIFFE, J., WARD, P., and WOOLSEY, L., 2008. Nurse and Pharmacist Supplementary Prescribing in the UK - a systematic Review of the Literature. London: DH

CAUTION!!!!!AHP’s Will Follow The Same Path If Candidates Are Not Able To Meaningfully Prescribe In Practice

Why has implementing supplementary prescribing worked for us?

Why has implementing supplementary prescribing worked for us?

Why has implementing supplementary prescribing worked for us?

Why has implementing supplementary prescribing worked for us?

Why has implementing supplementary prescribing worked for us?

Why has implementing supplementary prescribing worked for us?

Why has implementing supplementary prescribing worked for us?

Why has implementing supplementary prescribing worked for us?

Why has implementing supplementary prescribing worked for us?

How supplementary prescribing will work your you!

• A Trustwide Non Medical Prescribing policy reflects the prescribing rites of your profession

• Departmental Prescribing Policy/ AHP role specific clinical protocol

• Appropriate identification of applicant Right person Right place Right time Right outcome

How supplementary prescribing will work your you!

• AGREED Core Formulary: Which Which reflects Prescribers level of clinical management, skill and knowledge of medicine will be reflected in the classes of medication listed in the SP’s core formulary and referral back to IP trigger points.

• Close team working built on a mutual trust and respect for each prescribers role

• Access to the shared patient record

• A WORKABLE SYSTEM for implementing the CMP!

Head & Neck CSR Core Formulary5 InfectionsAntimicrobials:5.1Antibacterial drugs6 Endocine system9 Nutrition and blood9.1 Agents used for anemias and some other blood disorders9.2 Fluids and electrolytes9.5 Minerals9.6 Vitamins10 Musculoskeletal and joint disease10.1.1 Non-steroidal anti-inflammatory drugs11 Eye11.8 Tear deficiency, ocular lubricants, and astrigents12 Ear, Nose and oropharynx12.2 Drugs acting on the nose12.3 Drugs acting on the oropharynx13 Skin

13.2 Emollent and barrier preparations13.4 Local anaesthesia15 Anaesthesia:15.2 Local anaesthesiaControlled Drugs schedule 2,3 & 4:BUPRENORPHINE CODIENE PHOSPHATEFENTANYLMORPHINE SALTS:SEVREDOLMST CONTINUOUSOXYCODONE HYDROCHLORIDEOXYNORMOXYCONTINTARGINACTTRAMADOL HYDROCHLORIDEOff Label drugsOXCETACAINE in ANTACID: LEVOMEPROMAZINE:

1Gastro-intestinal system1.1Agents for dyspepsia and gastro-oesophageal reflux disease1.2Antispasmodics and other drugs and mucosal protectants1.3Antisecretory drugs and mucosal protectants1.4 Acute diarrhoea1.6 Laxatives1.7 Local preparations for anal and rectal disorders3.Respiratory system3.6 Oxygen3.9 Cough preparations3.10 Systemic nasal decongestants4 Central nervous system4.1 Hypnotics and anxiolytics4.6 Drugs used in nausea and vertigo4.7Analgesics controlled drugs listed below

Head & Neck CSR Core Formulary5 InfectionsAntimicrobials:5.1Antibacterial drugs6 Endocine system9 Nutrition and blood9.1 Agents used for anemias and some other blood disorders9.2 Fluids and electrolytes9.5 Minerals9.6 Vitamins10 Musculoskeletal and joint disease10.1.1 Non-steroidal anti-inflammatory drugs11 Eye11.8 Tear deficiency, ocular lubricants, and astrigents12 Ear, Nose and oropharynx12.2 Drugs acting on the nose12.3 Drugs acting on the oropharynx13 Skin

13.2 Emollent and barrier preparations13.4 Local anaesthesia15 Anaesthesia:15.2 Local anaesthesiaControlled Drugs schedule 2,3 & 4:BUPRENORPHINE CODIENE PHOSPHATEFENTANYLMORPHINE SALTS:SEVREDOLMST CONTINUOUSOXYCODONE HYDROCHLORIDEOXYNORMOXYCONTINTARGINACTTRAMADOL HYDROCHLORIDEOff Label drugsOXCETACAINE in ANTACID: LEVOMEPROMAZINE:

1Gastro-intestinal system1.1Agents for dyspepsia and gastro-oesophageal reflux disease1.2Antispasmodics and other drugs and mucosal protectants1.3Antisecretory drugs and mucosal protectants1.4 Acute diarrhoea1.6 Laxatives1.7 Local preparations for anal and rectal disorders3.Respiratory system3.6 Oxygen3.9 Cough preparations3.10 Systemic nasal decongestants4 Central nervous system4.1 Hypnotics and anxiolytics4.6 Drugs used in nausea and vertigo4.7Analgesics with the exceptions of controlled drugs listed below

How supplementary prescribing will work REGIONALLY!

• Have some ACTIVE prescribers as members of committees at strategic level to inform at regional level!

How AHP strategy will be implemented REGIONALLY!

Commissioners, don’t be a stranger!

THANK YOU FOR YOUR ATTENTION