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Q: What is this new type of nurse prescriber called?

A: Nurse Independent Prescriber. The Nurse Prescribers’ Extended Formulary was discontinued from 1 May 2006. Nurses prescribing from the Nurse Prescribers’ Formulary for Community Practitioners (formerly NPF for District Nurses and Health Visitors) are called Community Practitioner Nurse Prescribers. Every nurse prescriber on the NMC register has had their “title” amended to reflect the changes in legislation.  This took place in time to be effective by 1 May 2006.

Q: What can Nurse Independent Prescribers prescribe?

A: Any licensed medicine for any medical condition within their competence, including some controlled drugs.

Controlled Drugs (CDs)

Q: Can Nurse Independent Prescribers prescribe CDs independently?

A:   Nurse Independent Prescribers (formerly Extended Formulary Nurse Prescribers) can prescribe the following CDs independently, solely for the specified medical conditions only:-

• diamorphine, morphine, diazepam, lorazepam, midazolam, or oxycodone for use in palliative care;
• buprenorphine or fentanyl for transdermal use in palliative care;
• diazepam, lorazepam, midazolam for the treatment of tonic-clonic seizures;
• diamorphine or morphine for pain relief in respect of suspected myocardial infarction, or for relief of acute or severe pain after trauma including in either case post-operative pain relief;
• chlordiazepoxide hydrochloride or diazepam for treatment of initial or acute withdrawal symptoms, caused by the withdrawal of alcohol from persons habituated to it;
• codeine phosphate, dihydrocodeine tartrate or co-phenotrope.

• Download table of substances and routes of administration (PDF, 8K)

N.B. Nurse Supplementary Prescribers can prescribe any CD that is included in a patient's clinical management plan and agreed by a doctor.

Borderline substances

Q: Can Nurse Independent Prescribers prescribe borderline substances independently?

A: Yes, but DH guidance recommends that Nurse Independent Prescribers restrict their prescribing to the substances on the Advisory Committee on Borderline Substances approved list, in Part XV of the Drug Tariff.

‘Off-label’ [also known as ‘off-license’] medicines

Q: Can Nurse Independent Prescribers prescribe medicines ‘off-label’ or ‘off license’ ?

A: Qualified Nurse Independent Prescribers are able to prescribe medicines ‘off-label’ or ‘off-license’. However, Nurse Independent Prescribers must take full clinical and professional responsibility for their prescribing and should only prescribe ‘off-label’ where it is best practice to do so.

Q: What can Community Practitioner Nurse Prescribers prescribe?

A. Community Practitioner Nurse Prescribers may only prescribe the dressings, appliances and licensed medicines listed in the Nurse Prescribers' Formulary for Community Practitioners.

Q: Can Community Practitioner Nurse Prescribers prescribe ‘off-label’?

A: No. Community Practitioner Nurse Prescribers do not undertake the same depth of prescribing training as Nurse Independent Prescribers and should not prescribe medicines 'off-label' apart from the exception listed below.

Nystatin – Prescribing off label

Community Practitioner Nurse Prescribers may exceptionally prescribe nystatin off-label for neonates. Where Community Practitioner Nurse Prescribers are absolutely clear that the diagnosis is one of oral thrush, they may prescribe nystatin at the dose recommended in the Childrens’ BNF. An exception for nystatin is allowed on the basis that there is no systemic absorption of the product and the use of the product in treatment of oral thrush is long-established.

This decision is without precedent and there are no other exceptions for off-label prescribing by Community Practitioner Nurse Prescribers.

Community Practitioner Nurse Prescribers who prescribe nystatin off-label must be clear that they accept clinical and medico-legal responsibility for prescribing that medicine. Community Practitioner Nurse Prescribers should only prescribe nystatin 'off-label' within their own competance and where they are clear that the diagnosis is one of oral thrush.

Unlicensed medicines

Q: Can Nurse Independent Prescribers prescribe unlicensed medicines?

A. No. However, Nurse Independent Prescribers who are also supplementary prescribers can still prescribe them as part of a supplementary prescribing arrangement, if the doctor agrees within a Clinical Management Plan.

Use of Botox® and Vistabel® in cosmetic procedures

Q: Can Nurse Independent Prescribers independently prescribe and administer Botox® for use in cosmetic procedures?

A: Yes. A Nurse Independent Prescriber can legally prescribe and administer licensed parenteral medicines such as Botox® in cosmetic procedures on his/her own initiative.
However, the use of Botox for cosmetic treatment is outside the product’s licensed indications.  Nurse Independent Prescribers may prescribe medicines independently for uses outside their licensed indications (so called ‘off-licence’ or ‘off-label’). They must however, accept professional, clinical and legal responsibility for that prescribing, and should only prescribe ‘off-label’ where it is accepted clinical practice.

Q: Can Nurse Independent Prescribers independently prescribe and administer Vistabel® for use in cosmetic procedures?

A: Yes. A Nurse Independent Prescriber can legally prescribe and administer licensed parenteral medicines such as Vistabel® in cosmetic procedures on his/her own initiative.

Q: Can Nurse Independent Prescribers order and receive supplies of Botox® and/or Vistabel®?

A: No. The law as it currently stands prohibits this activity and there is no intention to change this in the foreseeable future. The changes to legislation to introduce nurse independent prescribing were based on the long standing principle that a prescriber prescribes and that his/her prescription is then dispensed by a pharmacist.
Nurse Independent Prescribers can administer drugs themselves and authorise others to do so under their patient specific direction. The Department of Health and the MHRA do not consider that there are compelling grounds for reviewing the position.

Prescription forms

Q: What prescription forms should Nurse Independent Prescribers use?

A: Over the next two to three months (May – July), EFNP/SP prescription forms will change to be headed “Nurse Independent / Supplementary Prescriber”.  Meantime Nurse Independent Prescribers should continue to prescribe using their Extended Formulary Nurse Prescriber prescription forms.  The NHS Business Services Authority (formerly PPA) is aware of and supports the need for a period of transition.  We are also working closely with NHS Connecting for Health and suppliers of GP computer software to make the necessary amendments to their systems.

Training

Q: What extra training, if any, will existing Nurse Independent Prescribers need to undertake?

A: None.  Prescribers and employers should address any additional individual training needs through Continued Professional Development.

Q:  Who will decide which nurses are eligible to be trained as prescribers?

A:  Nurses must first meet the eligibility criteria as determined by the NMC. Once this is met, it is a matter for local decision, in the light of local NHS needs and circumstances. No nurses will be required to undertake training for prescribing unless they wish to do so.

Q: Can nurses employed by prisons or charitable and private organisations outside the NHS undertake prescribing training?

A: Yes – nurses employed outside the NHS may also apply to undertake prescribing training.  Nurses employed by charitable organisations and who provide the majority of their services to NHS patients can also be considered for centrally-funded prescribing training. Other non-NHS nurses will need to identify an alternative source of funding.
The NMC “Standards of proficiency for nurse and midwife prescribers” is available on the NMC website from

Accountability

Q:  Who will bear legal and professional responsibility for the actions of nurse prescribers?

A:  Nurse Independent Prescribers are professionally responsible for their own actions. Where a nurse is appropriately trained and qualified as an independent prescriber, and prescribes as part of his or her nursing duties with the consent of the employer, the employer may also be held vicariously responsible for the nurse's actions. In the Department's Guide to Implementation of Nurse Independent Prescribing, we advised all nurse prescribers to ensure that they have professional indemnity - for example through membership of a professional organisation or trade union.

Funding

Q: What funding will be provided to support prescribing training in the future?

A: DH central budgets have not yet been determined for 2006-7.  An announcement will follow in due course.  Guidance for Strategic Health Authorities will identify funding to support non-medical prescribing training for 2006/07.

Miscellaneous

Q: What effect will the changes have on Community Practitioner Nurse Prescribing and Supplementary Prescribing?

A: The current Nurse Prescribers’ Formulary for Community Practitioners will continue in its current format and is still available to nurses working in that setting.
Nurses will continue to be able to train and act as supplementary prescribers, and in some settings, supplementary prescribing will continue to be the best option. This will also enable them to prescribe Controlled Drugs for other medical conditions, eg drug abuse, in partnership with a doctor.

Q: Are nurses able to issue private prescriptions?

A:  Nurse Independent Prescribers can issue private prescriptions for any licensed medicine, except most Controlled Drugs.  Supplementary prescribers may also issue private prescriptions for any medicines covered by a patient’s clinical management plan.

Q:  Are Nurse Independent Prescribers able to give directions to a non-prescriber for the administration of a medicine ?

A:  Yes. A qualified Nurse Independent Prescriber may give directions for the administration of any product they are legally allowed to prescribe (ie a licensed medicine within his/her competence, or in the clinical management plan). The prescribing nurse will clearly need to be satisfied that the person to whom s/he gives the instructions is competent to administer the medicine concerned.

Q: How do nurse prescribers obtain copies of the BNF, NPF and Drug Tariff?

A:  All nurse prescribers receive a copy of the Nurse Prescribers’ Formulary, which is published biennially.

Nurses who are qualified as Nurse Independent Prescribers should also receive six monthly copies of the British National Formulary, except for those occasions when publication of the BNF coincides with that of the Nurse Prescribers’ Formulary (NPF) when they will receive only the NPF.

The NHS Business Services Agency (formerly the Prescription Pricing Authority) also sends all nurse prescribers six-monthly copies of the Drug Tariff – usually the May and November editions. Copies of all of these publications are distributed through a central contact point in each PCT or NHS Trust. Nurse prescribers who do not have a copy should contact the nurse prescribing lead in their PCT or NHS Trust. SHA non-medical prescribing contacts are responsible for co-ordinating requirements of PCTs and Trusts within the area covered by the SHA.

• The latest list of SHA contacts is on the section homepage for the Non-Medical Prescribing Programme

Q:  Are nurses able to prescribe or supply blood or blood products on the NHS?

A:  Blood, including the cellular elements that are packaged for use as "packed cells" and platelets,  is not considered to be a medicinal product and is therefore outside the ambit of the Medicines Act and its subsequent amending Regulations. The "prescribing" of blood for a patient is not therefore appropriate for nurse independent prescribing or for supply under the terms of a Patient Group Direction (PGD). Nurses should discuss the current local policy regarding ordering of these products with their Trust's haematology department. Consideration could be given to developing local guidelines for the ordering and supply of blood, based on the format of a PGD.

However, products derived from the plasma component of blood such as blood clotting factors, antibodies and albumin are considered to be medicinal products and are required to have marketing authorisations. These products may be prescribed by nurses under a supplementary prescribing arrangement , provided they are included in the necessary clinical management plan.

If a plasma substitute is a licensed medicine, then it is also prescribable by a nurse independent prescriber independently. However, it would also be very sensible to discuss this in advance with the Trusts Haematology Department.