So you want me to prescribe dexamfetamine?

A post by guest blogger Graham Parsons, Lead Pharmacist, Turning Point.

What makes a “specialist” NMP in the modern day substance misuse service?

On the 4th November 2016 at the RCGP/SMMGP Managing Drug and Alcohol Problems in Primary Care conference, a group of Non-Medical Prescribers (NMPs) and doctors discussed what may be seen by some as a controversial topic – should NMPs become specialist prescribers within drug and alcohol services? Specialist prescribing will often be defined by the organisational formulary and prescribing policy but, in simple terms, it includes the prescribing of interventions such as dexamfetamine, slow release oral morphine (SROM) and injectable opioids. This article will briefly outline:

  • the background to non-medical prescribing
  • competency frameworks and
  • the debate during our workshop

My aim with this article is to start a discussion within drug and alcohol services following our workshop discussions over whether this is an area to explore rather than to develop a comprehensive plan for implementation.

Non-medical prescribing is now well established in the majority of drug and alcohol services. Its history dates back to 1992 when primary legislation was enacted to allow nurse prescribing. In 2003, pharmacists became the second profession to engage in this field following recommendations of the Second Crown Report in 1999. In 2012, access to controlled drugs for NMPs provided an opportunity for them to reach their full potential within our specialist environment of practice. There are currently around 19,000 nurse independent and supplementary prescribers[1] and around 3500 pharmacist independent and supplementary prescribers[2].

A framework for specialist prescribing developed by the Royal College of Psychiatry (RCPsych) and the Royal College of General Practitioners (RCGP) in 2012 provides guidance for doctors working in the drug and alcohol field[3]. It defines 3 levels of prescribers: specialist, intermediate and generalist. Developed around the two themes of supporting people to recover and clinical leadership it allows doctors, commissioners and organisations to clearly define the level of prescriber from their experience, qualifications and competencies. A national competency framework developed jointly with a number of national prescribing organisations (including the RCGP) and published by the Royal Pharmaceutical Society (RPS) provides a broader framework of competencies for prescribers[4] (figure one). Some organisations also have their own competency documents for drug and alcohol practitioners.

Figure One: The prescribing competency frameworkFigure One: The prescribing competency framework

The workshop

On the question on whether NMPs should be allowed to prescribe as specialists the majority verdict was “yes” (89%) provided the appropriate governance framework was in place to support this. However, there was a consensus that this should not be at the expense of the multidisciplinary skill mix. Nurses and Pharmacists have diversified this skill mix within the modern day service and the input of specialist doctors and addiction psychiatrists should not be lost as part of this process especially as part of a fiscal re-balancing of service provision. There was also a recognition that the individual NMP should decide, with their clinical supervisor, whether they should take on this role. Naturally any element of prescribing should be within the prescribers’ competency but there was recognition that NMPs should not be “forced” into such roles through “organisational pressure” which could destabilise both the individual NMP and the local drug and alcohol team.

The group considered that there should be no restriction to a formulary of drugs: the prescriber should define their own formulary through their competencies. This included the prescribing of diamorphine. Although legislation does not permit this currently for NMPs, the view was that some services may benefit from having an NMP who holds a licence to prescribe diamorphine. Does the political and clinical landscape support this? This is a full article in itself. Suffice to say the draft Clinical Guidelines does support the prescribing of diamorphine to those currently prescribed – the so-called “old-system” patients – and does not discount its use with the appropriate clinical governance in place locally i.e. supervised injectable treatment[5]. Perhaps 2017 could see an application to the Home Office for NMPs to hold licences for diamorphine prescribing?

There was a difference of opinion within the group on whether a specialist framework similar to CR173 discussed above is needed. Some NMPs considered that a framework would be a useful addition and allow a robust clinical governance process in an area where there may be some concerns and uncertainties from some individuals and professional groups. Others considered this “another document to complete” in a milieu of paperwork and processes. This cohort argued that an individual approach between the NMP and clinical supervisor which defined the competencies (from the RPS and RPsych documents) and experience needed was acceptable. One organisation currently uses the CR173 as a framework for NMPs as the “generic” nature of the guide supports this. Perhaps a blend of both approaches is the way forward? Again there remains some discussion within this area to find a route forward.

Finally the group discussed what NMPs required to become “specialist” prescribers within drug and alcohol services. Regular and good quality peer and clinical supervision with annual appraisals were regarded as prerequisites. Training should be individualised and outlined within the NMP’s CPD programme and supported by the organisation. While no specific time-frame was agreed on the experience of the NMP, it was agreed that a period of experience prescribing regularly in a service should be in place before prescribing in a specialist field. It was noted one organisation has a suggested minimum period of 3 years. A period of supervised prescribing with the specialist was also regarded as an important element of the transition to specialist prescribing.

In conclusion there does seem to be an appetite to explore “specialist” non-medical prescribing. It may already be the case that some services are engaged with this and I would be eager to hear how NMPs have engaged with this process. However, an appropriate clinical governance framework needs to be in place to support this which a) protects the NMP b) protects the service user and c) gives confidence to colleagues and commissioners. There may also be an opportunity to take the final step and cross the final frontier into diamorphine prescribing.

Let the debate begin…

– Graham Parsons, Lead Pharmacist, Turning Point

Contact: graham.parsons@turning-point.co.uk

 

References

[1] RCN Fact Sheet (2012) Nurse Prescribing in the UK. Available at https://www2.rcn.org.uk/__data/assets/pdf_file/0008/443627/Nurse_Prescribing_in_the_UK_-_RCN_Factsheet.pdf (accessed 22/01/2017)

[2] RPS (2017) Pharmacist prescribers. Available at http://www.rpharms.com/home/home.asp (accessed 22/01/2017)

[3] RCPsych (2012) CR173 Delivering quality care for drug and alcohol users: the roles and competencies of doctors. Available at http://www.rcpsych.ac.uk/files/pdfversion/CR173.pdf (accessed 22/01/2017)

[4] RPS (2016) A Competency Framework for all Prescribers. Available at http://www.rpharms.com/support-pdfs/prescribing-competency-framework.pdf (accessed 22/01/2017)

[5] DH (2016) Drug misuse and dependence: UK guidelines on clinical management – Consultation on updated draft 2016. Available at http://www.nta.nhs.uk/uploads/cg-2016-consultation-draft.pdf (accessed 22/01/2016)