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3. Culture - defining NMAHP prescribing

Governance

Risk assessment is at the heart of a strong governance culture for NMAHP prescribing.

Robust procedures for allowing health care professionals to report "near misses", errors and adverse drug reactions should be in place, bolstered by a culture of just and fair accountability which seeks primarily to capitalise on the learning arising from adverse events rather than the need to seek out and punish those responsible. NHS boards must ensure that current policies encompass the NMAHP prescriber's role and that appropriate training in reporting procedures has been put in place.

It is inescapable, however, that any health care professional who blatantly disregards policies and procedures at any stage in the prescribing, dispensing and administration of medicines, and in so doing puts patients at risk, will be held accountable for his or her actions (DoH, 2004; Scottish Executive, 2006d).

Equally important to the culture is an efficient system through which NMAHP prescribers can gain rapid access to the information they need to support their practice. This includes access to electronic patient records (see Chapter 4) and effective and timely dissemination of Hazard Notices, Safety Action Notices ⁵ and other alerts, but also relates to having supervision, mentoring and management lines in place that will ensure NMAHPs can access the right support and ongoing professional development opportunities to function at maximum safety and effectiveness.

Governance of an NMAHP prescribing service is a complex issue. NMAHP prescribers are working in different clinical areas with different groups of patients and are prescribing different kinds of drugs. Their needs for ongoing supervision and education are consequently very different, and there is a risk that unless proper governance arrangements are in place, some NMAHP prescribers with high-visibility needs and pressures will prosper at the expense of others. This can lead to a fragmented service characterised by varying degrees of quality and inconsistent delivery - a completely unacceptable situation.

For these reasons, a strong, highly-visible senior member of staff should be in place to manage the NMAHP prescribing service across the NHS board area. This person would not have day-to-day line management responsibility for the NMAHP prescribers, but would be in a position to monitor quality, assess prescribing practice, provide professional support and advice and develop the service to meet future needs on behalf of the NHS board (see Chapter 4).

Recommendations

NHS boards should have robust systems in place to report and respond to "near misses", errors and adverse drug reactions.

Appropriate mechanisms should be in place to ensure NMAHP prescribers can rapidly access the information they need to prescribe effectively and protect patients' safety.

Appropriate mentoring, supervision and line management structures should be in place for NMAHP prescribers.

A senior member of management should be identified and prepared at NHS board level to manage the NMAHP prescribing service across the board area.

Policy

The University of Stirling research found "a fragmentation of nurse prescribing policy [among NHS boards]." It stated that "implementation and management is a cause for concern in some boards, although it is gradually being addressed." An audit of nurse prescribing which reported in July 2006 (Pollock and Dudgeon, 2006) found that just slightly over 60% of NHS boards in Scotland reported having a Nurse Prescribing Policy for their area, with little direction being given to guide the development of nurse prescribing at strategic level within NHS boards.

It is widely considered that an NMAHP Prescribing Policy at NHS board level as part of the General Medicines Management policy is the necessary starting point for running a safe, effective and efficient NMAHP prescribing service.

Policies can develop to reflect local needs, but as a minimum, a policy should address the following core issues:

• how the NMAHP prescribing service can contribute to meeting patient and service needs;
• governance, line-management and resourcing issues;
• articulation of the NMAHP Prescribing Policy with other board polices and structures;
• candidate selection, preparation and integration into the service;
• mechanisms for informing patients, unpaid carers, the public and health professionals about the service;
• ongoing support for the service and NMAHP prescribers.

Further advice on content for an NMAHP Prescribing Policy is given at Appendix 1.

Some NHS boards have well-developed NMAHP prescribing policies which could be shared as exemplars with NHS boards currently (or about to embark on) devising their own policies.

Recommendations

NHS boards should review current Medicines Management Policy and ensure that there is a NMAHP Prescribing Policy in existence/being developed.

The NMAHP Prescribing Policy should be developed by a multi-disciplinary group and should be reviewed regularly.

An assessment of local service needs, detailing the patient groups and clinical conditions for which NMAHP prescribing would be appropriate, should be carried out at regular intervals.

Monitoring

A robust process for auditing and monitoring quality of the NMAHP prescribing service should be in place. This should be directed towards auditing the effectiveness of services offered to patients and the public and ensuring practitioners are using their prescribing skills to maximum effect. The many existing auditing and quality monitoring systems in NHS boards, augmented by robust data on NMAHP prescribing being generated by NHS National Services Scotland ( NHSNSS), ⁶ can be used as the foundation for these mechanisms.

But quality monitoring is also necessary in spheres other than clinical prescribing practice. Governance of NMAHP prescribing services, line management, partnerships with the higher education sector, ongoing education and development provision and working in partnerships with patients and the public - all of these areas will need careful monitoring to ensure NMAHP prescribing is being given the support it needs and is providing the service patients expect.

The full implementation of systems described in the national eHealth Programme (see Chapter 4), will facilitate the audit of NMAHP prescribing services across primary and secondary care settings. In the meantime, NHS boards should explore innovative ways of auditing services.

Recommendations

NHS boards should build on their existing systems of auditing and quality monitoring to ensure effective scrutiny of the NMAHP prescribing service, consequently protecting patients, the public, the prescriber and the board. The system should be properly governed, properly organised and properly reported, and should build on existing resources such as NHSNSS data.

The lead person for NMAHP prescribing should have in place effective communication mechanisms and strategies with all relevant stakeholders, including service agreements with higher education institutions ( HEIs) regarding provision of the education programme.

Resourcing

General experience of NMAHP prescribing services suggests that resourcing is one of the most challenging issues faced.

Practice differs among boards, but big challenges tend to be found in defining resourcing responsibilities when patients move between secondary and primary care settings, where their medicines may be prescribed by NMAHPs. Poor collaborative working between primary and secondary care in the past has led to patients' access to medicines being restricted.

Similarly, infrastructure issues and delays in budget allocation can lead to frustrating hindrances in NMAHPs being able to prescribe effectively, such as lack of prescription pads and inadequate IT facilities.

Innovative and creative approaches to resourcing are necessary. Systems work best when they allow patients who move between secondary and primary care to access medicines when they need them, and not when the system finds it convenient. An approach that makes patients' needs and safety paramount and which encourages a co-operative ethos among different elements of the service needs to be in place.

In addition, bureaucratic inefficiencies that place barriers in the way of delivering a fast, effective service should be identified and challenged at all levels.

It is important that imaginative solutions to resourcing issues are shared in Scotland. As is the case with NMAHP prescribing policies, some NHS boards have developed sound systems for managing the resourcing of the service that could be shared with other NHS boards as exemplars. Sharing can occur through existing structures, such as the Prescribing Leads Network.

Recommendations

Existing mechanisms should be used for sharing good practice and innovative solutions to resourcing issues within NHS Scotland.

Processes should support and facilitate the NMAHP prescribing service, rather than delay and obstruct it.

Informing

While many thousands of patients are now benefiting from nurse prescribing in Scotland, and many more stand to benefit from AHP prescribing, non-medical prescribing in general remains a relatively new service and misconceptions and misunderstandings about its purpose and practice may persist.

Part of the NMAHP Prescribing Policy at NHS board level should address how information about the service - its character, its delivery, its impact and its future - is disseminated. The NMC brochure, What to Expect from a Nurse or Midwife who can Prescribe Drugs ( NMC, 2005) , is specifically designed to inform patients, unpaid carers and the public about the service, and exploiting links with the local and national media may also prove beneficial in helping patients and the public understand the benefits - and risks - NMAHP prescribing brings. All internal and external communication systems at the NHS board's disposal should be utilised to support this endeavour.

But information is necessary not only for those using the service and their carers, but also for professionals working within the service. Misunderstandings, questions and doubts can be addressed by a planned and sustained campaign to educate professionals about NMAHP prescribing and how it benefits patients and the service.

Recommendations

The Scottish Government should develop information materials/resources on NMAHP prescribing that can be used by NHS board leads to disseminate to patients, carers, the public, managers, professionals and the media.

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