In April 2003, following a public consultation and after advice from the Committee on Safety of Medicines (CSM) and the Medicines Commission, Ministers agreed the implementation of supplementary prescribing.
Currently only registered nurses, registered midwives, pharmacists, podiatrists, physiotherapists, diagnostic and therapeutic radiographers and optometrists.may act as supplementary prescribers. A summary of supplementary prescribing arrangements is at Annex A and further details are available from the Department of Health’s website (external link). In brief, following diagnosis by a doctor or dentist (the independent prescriber), supplementary prescribers are able to prescribe prescription only medicines (POMs), pharmacy (P) medicines and general sale list (GSL) medicines as part of a clinical management plan (CMP) agreed with the independent prescriber for an individual patient. Supplementary prescribers are required to successfully complete a period of training and to have their name annotated to that effect on their professional register before they are eligible to practice as supplementary prescribers.
The concept of a supplementary prescriber (then called a “dependent” prescriber) was one of the recommendations of the report on the Review of Prescribing, Supply and Administration of Medicines1. That report did not place any restrictions on the range of healthcare professional that could become a supplementary prescriber. Ministers decided that supplementary prescribing would be introduced initially for nurses and pharmacists, and have subsequently agreed that an extension to other healthcare professions would follow.
Compliance with other relevant legislation
The sale and supply of medicines under supplementary prescribing have to comply with all other relevant legislative requirements relating to the supply of medicines.
The Department of Health (external link) has produced guidance, as an adjunct to the law, on the implementation of supplementary prescribing in the NHS in England. Similar guidance was made available to the health service in Wales, Scotland and Northern Ireland (NI). The independent healthcare sector has also had access to this guidance to encourage consistency of approach.
Supplementary prescribing (SP), then referred to as “dependent” prescribing, was one of the recommendations made in the report on the Review of Prescribing, Supply and Administration of Medicines. Following public consultation and advice from the Committee on Safety of Medicines, Ministers announced the implementation of SP and it came into effect on 4 April 2003. The legal requirements for SP are set out in the Prescription Only Medicines (Human Use) Order 1997.
What is SP?
SP is a voluntary partnership between the independent prescriber (IP-er) and a supplementary prescriber (SP-er), to implement an agreed patient-specific clinical management plan with the patient’s agreement.
Who are SP-ers?
Currently nurses, pharmacists, podiatrists, physiotherapists, diagnostic and therapeutic radiographers and optometrists. The legal definition of a SP-er is:
(a) a first level registered nurse or registered midwife,
(b) a registered pharmacist,
(c) a person whose name is registered in the part of the register maintained by the Health Professions Council in pursuance of article 5 of the Health Professions Order 2001 relating to
(i) chiropodists and podiatrists;
(iii) radiographers: diagnostic or therapeutic
(d) a registered optometrist
against whose name is recorded in the relevant register an annotation signifying that he is qualified to order drugs, medicines and appliances as a supplementary prescriber.
There are a number of key principles that underpin SP. These principles emphasise the importance of communication between the prescribing partners, and the need for access to shared patient records. It is also essential that the patient is treated as a partner in their care and is involved at all stages in decision making, including whether part of their care is delivered via SP. SP-ers should not enter into a prescribing partnership that entails them prescribing any medicine that they do not feel competent to prescribe.
Scope of SP
There are no legal restrictions on the clinical conditions which SP-ers may treat. As SP requires a prescribing partnership and a clinical management plan for the patient before it can begin, it is likely to be most useful in dealing with long-term medical conditions or with long-term health needs. However, it will be for the IP-er with the SP-er to decide, in drawing up the Clinical Management Plan, when SP will be appropriate. Unlike independent nurse prescribing, there is no specific formulary or list of medicines for SP. In the NHS, provided medicines are prescribable by the IP-er at NHS expense, and they are referred to in the patient’s clinical management plan, SP-ers are able to prescribe, at NHS expense:
- All general sales list (GSL) medicines, pharmacy (P) medicines, appliances and devices, foods and other borderline substances approved by the Advisory Committee on Borderline Substances.
- All prescription only medicines - but see below for specific provisions in relation to controlled drugs.
- Medicines for use outside of their licensed indications (i.e. ‘off label’ prescribing), ‘black triangle’ drugs, and drugs marked ‘less suitable for prescribing’ in the 'British National Formulary' (BNF).
- Unlicensed medicines
Amendments to the Home Office’s Misuse of Drugs Regulations 2001, which came into force in March 2005, allow supplementary prescribers to prescribe all Controlled Drugs (CDs), except those listed in Schedule 1 to the 2001 Regulations which are not intended for medicinal use.
The criteria that are currently set in regulations for lawful SP are:
- the IP-er must be a doctor (or dentist)
- the SP-er must be a registered nurse, midwife, pharmacist, podiatrist, physiotherapist, diagnostic and therapeutic radiographer or optometrist
- there must be a written clinical management plan relating to a named patient and to that patient’s specific conditions. Agreement to the plan must be recorded by both the IP-er and the SP-er before SP begins
- the IP-er and the SP-er must share access to, consult and use the same common patient record.
The particulars set out in regulations for clinical management plans are that such plans shall contain:
(a) the name of the patient to whom the plan relates
(b) the illnesses or conditions which may be treated by the supplementary prescriber
(c) the date on which the plan is to take effect and when it is to be reviewed by the doctor or dentist who is a party to the plan
(d) reference to the class or description of medicinal product which may be prescribed or administered under the plan
(e) any restrictions or limitations as to the strength or dose of any product which may be prescribed or administered under the plan, and any period of administration or use of any medicinal product which may be prescribed or administered under the plan
(f) relevant warnings about the known sensitivities of the patient to, or known difficulties of the patient with, particular medicinal products
(g) the arrangements for notification of -
(i) suspected or known adverse reactions to any medicinal product which may be prescribed or administered under the plan, and
(ii) suspected or known adverse reactions to any other medicinal product taken at the same time as any medicinal product prescribed or administered under the plan, and
(h) the circumstances in which the supplementary prescriber should refer to, or seek the advice of, the doctor or dentist who is a party to the plan.
1 The report on the Review of Prescribing, Supply and Administration of Medicines (external link), prepared under the Chairmanship of Dr June Crown, was published in March 1999 and is available on the Department of Health website.
Contact for further information
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