Legislation to support nurse prescribing has been long awaited.

Since the initial advisory group was set up in 1989, and the subsequent pilot by the Department of Health in 1994, the benefits of nurse prescribing have been highlighted in a range of reports and consultation documents (see Figure 1). However, until now, nurse prescribing has been limited to primary-care staff accessing the, limited, Nurse Prescribers' Formulary (NPF), which consists largely of General Sales List (GSL) items and a few wound dressings.

Although a discrete course was offered initially, nurse prescribers now usually undertake this learning as a component of specialist-practitioner degree programmes for district nurses and health visitors. It is envisaged that this practice will continue to support nurses' access to the NPF.

In acute services, the situation has been more problematic as only nurses holding a District Nurse (DN) or Health Visitor (HV) qualification were approved to prescribe from the NPF. The introduction of Lawful Patient Group Directions: Supply and Administration of Medicines by Health Professionals under Patient Group Directions in August 2000 (1)and the amendment order to the Medicines Act 1968 enabled nurses and a range of other healthcare professionals to supply, or administer, medicines as named individuals.

Figure 1: The history of nurse prescribing

		1992 The Medicinal Products Act: Prescription by Nurses, Midwives and Health Visitors
		1993 Amendment Regulations Pharmaceutical Services
		1994 Pilot of Nurse Prescribing
		1998 Report on the Supply and Administration of Medicines under Group Protocols
		2000 Lawful Patient Group Directions: Supply and Administration of Medicines by Health Professionals under Patient Group Directions
		2002 Extending Independent Nurse Prescribing within the NHS in England

The way forward

In May 2001, government ministers announced a new initiative for the extension of independent prescribing to include:

		minor ailments;
		minor injuries;
		health promotion; and
		palliative care.

In addition, ministers also identified a strategy to enable "supplementary prescribing" by nurses and other professionals in accordance with a clinical management plan. Although more detail is awaited, this form of prescribing will be of benefit to nurses working with chronic conditions. Nurses may also continue to use Patient Group Directives where this is more appropriate to patient needs (2).

Where before it was compulsory for nurse prescribers to hold a DN or HV qualification, amendments are currently underway to the Prescription Only Medicines (POM) Order, NHS Pharmaceutical Services Regulations and NHS Charges Regulations, which will mean that, in future, it will not be necessary for the nurse to hold a district nurse or health visitor qualification to be approved for independent prescribing. In essence, any nurse will be eligible to undertake the programme for preparation provided they meet the legal criteria for eligibility outlined in Figure 2

Figure 2: Criteria for nurses legally eligible to prescribe from extended formulary following amendments to the POM Order and NHS Regulations (3)

		1st level Registered Nurse or Registered Midwife; and
		successful completion of the approved programme of preparation for extended nurse prescribing.

These guidelines drastically overhaul the traditional stranglehold on nurses developing autonomy to provide continuity of care and treatment and quality of service. Although long awaited, the Department of Health is providing £10m of central funding through the Workforce & Development Confederation until 2004 to prepare an estimated 10,000 nurse prescribers.

The Nurse Prescribers' Extended Formulary will enable those approved to prescribe GSL and pharmacy medicines currently prescribable by GPs with the exception of products which contain controlled drugs and a list of prescription only medicines. Details will be incorporated into the British National Formulary.

Selection of individuals for preparation will be a local decision, based on local needs. However, it is anticipated that the eligible group would include nurse consultants, nurse practitioners and specialist practitioners. In addition to the legal requirements outlined, candidates must fulfill the following specific requirements (4).

		Ability to study at academic level 3.
		Three-years post-registration clinical experience.
		A named medical practitioner to provide 12-days practice supervision.
		Support from their employer ensuring the candidate is a relevant post holder, will have access to continuing professional development, and have access to a prescribing budget (primary care only).

The Programme will be delivered over three-months. It will consist of 25 university-based study days. In addition there will be 12 days of supervised practice. The programme will be accredited with 20 credits at level 3.

A range of assessment strategies will be used within the programme of study, which were laid down by an Education Policy Letter in September 2001 (4) and include:

		submission of a portfolio;
		Objective Structured Clinical Examination (OSCE);
		satisfactory completion of the practice assessment; and
		written examination to include multiple-choice questions/short-answer questions and an essay.

Effect on the renal team

Undoubtedly, the new guidelines are welcome and provide the initiative to develop skills and a framework for decision-making paramount to delivery of a quality service. The forthcoming Renal Workforce Planning Document and the National Service Framework for Renal Services are to be published later this year and should support extended prescribing for renal nurses, pharmacists and dietitians.

The current regulations for supply and administration of medicines under patient group directions includes other health professionals working in renal services but, unfortunately, dietitians have been omitted. Care must be taken to ensure that this valuable group of professionals should be included in the development of future initiatives.

Patient Group Directions have traditionally been used to support nurses working within pre-treatment, transplant, dialysis, nephrology and Community Renal Services. However, these documents are difficult to develop because of the time and effort needed and bureaucracy encountered, and they limit practice boundaries to such an extent that many nurses working within renal specialities have not developed PGDs.

There has been much discussion within academic institutions about the number of credits awarded to the course and the amount of student effort demanded. Many argue that the credit rewards do not reflect the large amount of student effort needed to complete the course. But, to date, the English National Board of Nursing Midwifery and Health Visiting (ENB) has stood fast, refusing any negotiation on the allocation of 20 credits. This will need to be monitored in light of future student evaluation.

The course will be offered at academic level 3 only. Although this is in keeping with previous education provision for primary-care nurses, it could be argued that, in future, this course will need to be delivered at master's level to reflect the increasing educational needs of practitioners who need post-graduate degrees to work at advanced or consultant level.

It is hoped that the announcement of Supplementary Prescribing will be followed by further guidelines this year. But no date has been set and practitioners working in acute services should not be prepared to accept a protracted wait for these.

Development of Supplementary Prescribing will support those working within specialist services to enhance practice by empowering those who are best placed to make decisions regarding care and treatment for their patients.

It will be for Primary Care Trusts and Groups, NHS Trusts, and Health Authorities to decide which nurses in their area should undertake the preparation for prescribing from the extended formulary between 2002 and 2004 (3). There is no doubt that owing to the complex nature of both renal services and patient needs a combination of independent and supplementary prescribing will assist in meeting the future demands of an expanding patient population and for service delivery.