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Supplementary prescribing: sustainable or not
Supplementary Prescribing – community or acute in-patient setting
Supplementary Prescribing: A long way to go
Supplementary Prescribing
Supplementary Prescribing - is it a new way of working?
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L S Choong, consultant psychiatrist MRCPsych
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steve.choong{at}worcsmhp.nhs.uk L S Choong
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Many teams and services are now operating on similar lines to this report. Unfortunately it does change the nature of consultant-patient interaction. Consultants under this model will do even less face to face contact. Will this satisfy them? Additionally, are patients ever offered a real choice, ie to see their consultant as often as they might choose to? |
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Rahul Tomar, Consultant Psychiatrist Hertfordshire Partnership Foundation NHS Trust
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rahul.tomar{at}hertspartsf.nhs.uk Rahul Tomar
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I read with interest the recent article by Giles Harborne and Adrian Jones (Psychiatric Bulletin April 2008, 32, 139-142). Nurse supplementary prescribing has the potential to improve patient care. It can provide increased patient choice and a better use of nurses’ skills and knowledge (National Prescribing Centre, 2005). What is not clear is where supplementary prescribing will be most useful? Community settings, i.e. crisis team or memory clinics, seem the most appropriate places where supplementary prescriber could work. In these settings the nurse prescriber could, based on the clinical management plan, repeat prescriptions, adjust doses and even switch and stop medications. This view was expressed by Directors of Nursing of Mental Health Trusts in England (Gray et al, 2005). The role of nurse prescribing in an acute in-patient setting is more complex. New ways of working suggest consultants should focus on more complex cases, where delegation of medical work would fall outside the competence of even the most highly trained nurse. Only the most complex cases are now admitted to acute psychiatric in-patient units and management of such patients should surely be a consultant’s responsibility? The shift towards the functional model of working has led to in-patient units having a dedicated consultant and that could limit the role of nurse supplementary prescriber who may take over some of the duties of the psychiatric trainees. This can lead to role confusion within clinical practice. There is also a risk that, in the in-patient units, supplementary prescribing may be used as a way of making up for reductions in junior doctor hours or even replacing traditional roles of junior medical staff. The complex shift patterns on in-patient units are another issue. In order to ensure 24 hour nurse prescribing cover, larger numbers of qualified nursing staff will need to be trained, and that may not be feasible. NATIONAL PRESCRIBING CENTRE (2005) Improving mental health services by extending the role of nurses in prescribing and supplying medication: Good practice guide. NPC, Liverpool. GRAY R, PARR A. & BRIMBLECOMBE N (2005) Mental health nurse supplementary prescribing: mapping progress 1 year after implementation. Psychiatric Bulletin, 29,295-29. Rahul Tomar, Consultant Psychiatrist, Gossoms End Elderly Care Unit, Berkhamsted, Herts HP4 1DL email – rahul.tomar@hertspartsf.nhs.uk Ph- 01442-876441 Fax- 01442- 865915 |
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Vineet Padmanabhan, Speciality trainee- 3 Mrcpsych
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vinidoc1{at}aol.com Vineet Padmanabhan
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I read with interest the paper by Giles Harborne and Adrian Jones (Psychiatric Bulletin April 2008, 32, 139-142). The authors have put forward an interesting model of working. However, I see possible problems arising including, for example, confusion about who deals with medical complications or side effects arising from psychotropic drugs. In addition, the authors mentioned the need to rule out medical problems at the time of admission but failed to explain what would actually happen if there was an acute medical problem. Further, I see the possibility of confusion for patients in who is actually responsible for specific aspects of his or her care. And finally, I believe there is the problem that the role of the junior doctor may be duplicated by the nurse consultant. |
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Imran Mushtaq, Associate Specialist-Child & Adolescent Psychiatrist Specialist-CAHMS, Eaglestone Centre, Standing Way, Milton Keynes MK6 5AZ, Salman A Mushtaq, Sanjay Khurmi
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imranmushtaq{at}doctors.org.uk Imran Mushtaq, et al.
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Harborne and Jones five step model of supplementary prescribing led by consultant nurse is yet another example of new ways of working (Psychiatric Bulletin, April 2008, 32, 136-139). No one can deny the unsettling rapid changes in NHS culture, equally affecting clinicians and patients. We feel that the government’s desperate move to cut services and privatise the NHS in a rather subtle way is inadvertently encouraged by the doctors in general and psychiatrists specifically through adopting new ways of working, without challenging the validity and by not demanding evidence for long term outcomes. Christine Vize et al (1) acknowledged that it could be used as escape goat for service cuts which appears to be the case in the current reconfigurations that we are seeing as a result of new ways of working. Harborne and Jones model raises few concerns. It will reduce face to face consultant-patient interactions, possibly compromising patient care and encouraging government’s vision of reducing number of doctors due to financial reasons. A consultant is trained and paid to primarily treat complex cases and with the availability of Crisis Resolution and Home Treatment teams, only complex and high risk cases are admitted in hospitals. Supervising nurse consultants who do ward rounds may raise ethical issues as well as concerns regarding clinical care. The idea of nurse prescribing was initially introduced to fill certain gaps and the legislation passed in 1992 and guidance announced by government in May 2001 included specific medical conditions in four main areas: Minor illness, Minor injuries, Health promotion and maintenance and Palliative care (2). However it can be exploited by the hidden agenda behind the new ways of working at the expense of compromised patient care, more stress for nurses as they are asked to do jobs they are not qualified to do and increased responsibility for consultants which include supervising nurse prescribers and ultimately spending less time with patients. Finally in the whole model from making management plan to prescribing and doing complex ward rounds, there doesn’t seem to be mention of trainee doctors? What’s happening to the training of doctors? Another important aspect of a consultants’ job is to train junior doctors. References: (1) Vize C, Humphries S, Brandling J, and Mistral W. New Ways of Working: time to get off the fence. Psychiatr Bull 32: 44-45. (2) Maintaining competency in prescribing, An outline framework to help nurse prescribers, 2001 Authors: Imran Mushtaq Associate Specialist-Child & Adolescent Psychiatrist Specialist-CAHMS, Eaglestone Centre, Standing Way, Milton Keynes MK6 5AZ Salman A Mushtaq Staff Grade Psychiatrist Crisis Resolution and Home Treatment team, Coventry, Swanswell Point, Stoney Stanton road, Coventry. CV1 4FH. Email: ghazalizee@hotmail.com Sanjay Khurmi, Specialist Registrar. Crisis Resolution and Home Treatment team, Coventry, Swanswell Point, Stoney Stanton road, Coventry. CV1 4FH Declaration of Interests:None declared |
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Dr.Arvind Sharma, Consultant Psychiatrist and Medical Lead Hollylodge Community Mental Health Team,45 Church Lane,Cheshunt,Hertfordshire EN8 0DR
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arvind.sharma{at}hertspartsft.nhs.uk Dr.Arvind Sharma
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I have read the article by Harborne et al, Psychiatric Bulletin (2008), 32, 136-139 and would like to share my experience and opinion. The delegation and distribution of responsibility is core to New Ways of Working. This principle is driven by the fact that consultants are overburdened with clinical work and need to be able to free up more time to contribute to service development and function in a consultative role. Most of the services are now gradually adopting a functional model with dedicated consultants for the inpatients and community. The south east locality of Hertfordshire Partnership Foundation Trust adopted the functional model of care approximately two years ago. The inpatient unit benefits from sufficient medical input from the consultant, ward rounds, timely assessment by the consultant of all new admissions, regular reviews of inpatients and their medication, easy accessibility of consultations and advice from the consultant, as well as a timely discharge from the ward. The supplementary prescribing has the potential to improve patients’ outcome and is more relevant in the community setting where the patient is usually stable and regularly monitored by nurses. However, in the inpatient setting most of the patients are complex and delegating and distributing the responsibility for prescribing and reviewing the mental state can pose several risks. |
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