The author of this work currently works within a large NHS acute health board as an Advanced Nurse Practitioner (ANP), on successful completion of this non-medical prescribing course, will function as an independent prescriber. However the knowledge and understanding of the process involved in supplementary prescribing is necessary to function and gain experience at all the levels that are included under the non-medical prescribing remit.
Supplementary prescribing is defined by the Department of Health (2003), NMC (2006) and NHS Scotland (2006) as a voluntary partnership between an independent prescriber ( Doctor or Dentist ) and a supplementary prescriber, to implement an agreed patient specific clinical management plan, with the patients agreement . (Competence 2.9, 3.4)
The aim of supplementary prescribing is to allow patients to have faster more efficient access to the required medications, allowing the utilisation of skills held by other health care professionals. This in turn will help to reduce the workloads of medical staff, making them more available to spend time with patients who have much more complicated conditions which require complicated treatment plans.
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Clinical management plans (CMP) are necessary to allow the supplementary prescriber to carry out their role. Beckith & Franklin (2007), agree that the clinical management plan is the legal framework from which the supplementary prescriber can prescribe any medication within the clinical management plan, as a result of any change within the patient’s condition. As a result of the CMP must be patient specific and be within the supplementary prescriber’s scope of competence, where they agree to take responsibility for. The CMP should be kept as basic as possible and stored in the patients notes where for ease of access. When compiling a CMP reference to current clinical guidelines are useful in the validity of treatment choice and the furthering of patient safety. Once the clinical management plan has been discussed, either the supplementary prescriber or the independent prescriber can draft a copy of the plan, where both must formally agree, before the supplementary prescribing can commence.
The CMP, consists of several parts all in which must be completed in full, as follows, the condition in which to be treated, the aim of the treatment, the drugs that may be prescribed, the frequency of monitoring and review, the specific indications for referral, any adverse drug reactions (ADRs), reporting responsibility, and the clear identification and signatures of all involved including the patient, supplementary prescriber and independent prescriber (Competence 2.4, 2.5, 1.7,1.5, 2.6, 2.7, 2.9,3.2).
The supplementary prescriber should be responsible for the monitoring and assessment of the treatment plan that was put into place and how it Is progressing, the prescribing within the drugs stated in the clinical management plan, manage the care within their own level of competence, and where necessary referring back to the independent prescriber, the SP must accept professional accountability and responsibility for prescribing as stated by NMC (2006). Throughout this process the SP must maintain clear and concise records in line with the NMC guidelines for record keeping (2010).
(Competence 1.1,1.5,1.6,1.7,2.1,2.2,2.4,2.6,2.7,2.9,3.2,3.5,3.6)
The patient that is receiving treatment through a clinical management plan should have regular clinical reviews, these reviews should be carried out by the independent prescriber, and should take place within twelve months of when the CMP was commenced, if a review has not been carried out by the IP within the twelve months then prescribing on the CMP should not continue, until a review is carried out and further consent/agreement is sought from this a new review date should be set. McHale (2003) does however state that this time frame may be extended is the condition detailed within the CMP remains to be stable and the chance of deterioration is unlikely.
Courtney and Griffiths (2005), Hall (2005) and Baird (2005) all document that patients with long term medical conditions or health requirements e.g. asthma, coronary heart disease, diabetes and anticoagulation therapy would benefit mostly by the use of supplementary prescribing. Baird (2005) also gives the rational to reinforce this statement as that many nurses have developed expertise within the management of these conditions.
In 2005 a study was carried out by the University of Southampton on behalf of the Department of health, this was for an evaluation of nurse prescribing within England. The study was carried out in two phases, within the first phase a survey was carried out on 246 nurse prescribers in which 71% responded. The second phase included the observation of nurse prescribers. In this study two thirds of these prescribers worked within primary care or general practice (Avery et.al 2005). This study was however carried out six years ago but reinforces the fact that supplementary prescribing is more common within the primary care setting.
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The Scottish Executive health department (2006), state that due to the requirement for individualised CMP`s supplementary prescribing would not be able to be utilised in all clinical areas, as stated earlier the author works within secondary care, and within my particular area CMP`s are never used, due to this the benefits that may be included within SP have never been witnessed. The author has included a copy of a clinical management plan, for the Acute NHS trust in which they work, for the post-acute phase following ischemic stroke (Appendix 1a) to detail the authors understanding. (Competence 2.5) The clinical management plan was compiled with the independent prescriber (Designated Medical Practitioner), supplementary prescriber (Myself) and the patient ensuring all parties were consulted. For the purpose of this piece of work the patient gave consent, and a pseudonym was used to help maintain confidentiality. The patient used, had regularly been reviewed by the independent prescriber and the formal diagnosis of an ischemic stroke was confirmed by a computerised tomography scan (CT scan). For each patient diagnosed with an ischemic stroke the treatment protocol is patient specific but to a certain degree can be generalised with regards to local and national guidelines as all should be prescribed an anti-pyretic, anti-platelet therapy, ACE inhibitor and statin, dependant on clinical condition. (Competence 2.5)
The information gathered for the purpose of the CMP was based on up-to-date guidance for the medicinal management through the utilisation of local and national polices and protocols, these include:
Managed Clinical Network (MCN) for stroke, acute stroke, multidisciplinary management (local protocol).
British Hypertensive Society fact file stroke.
SIGN guideline 108 Management of patients with stroke or TIA.
NICE guideline 68 Stroke diagnosis and initial management of acute stroke and transient ischemic attack (TIA).
(Competence 2.5, 3.1, 3.6, 1.7, 1.3, 4.4)
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