Coster, Samantha

Faulker, Alison

Florence Nightingale School of Nursing and Midwifery at King’s College London

McCrone, Paul

Norman, Ian

Rosenbloom, Karen

Sibley, Andrew

Wade, Tiffany

While, Alison

Whittlesea, Cate

Southampton (e-Prints Soton)

  Evaluation of mental health nurse supplementary prescribing _____________________________________________________________________ Executive Summary Project team  Ian Norman Alison While Cate Whittlesea Samantha Coster Andrew Sibley Karen Rosenbloom Paul McCrone Alison Faulkner Tiffany Wade  October 2007  Funded by the Department of HealthFlorence Nightingale School of Nursing and Midwifery at King’s College London    2 Executive Summary: An evaluation of Mental Health Nurse Supplementary Prescribing BACKGROUND Following publication of the Review of Prescribing, Supply and Administration of Medicines (Department of Health (DH), 1999) the DH announced plans to introduce supplementary prescribing for pharmacists, nurses and midwives in 2002.  Prior to this present study, supplementary prescribing by mental health nurses had not been evaluated for its safety or effectiveness nationally, with most available literature being anecdotal or based on expert opinion. This summary reports on findings from a 12 month national evaluation commissioned by the DH. AIMS AND OBJECTIVES The main aims of the evaluation were to:  • Describe the implementation of mental health nurse supplementary prescribing (MHNSP) and its present state of development in the NHS in England;  • Explore the impact of MHNSP on interprofessional working and services; • Compare the health and social outcomes of a group of patients (service users) in receipt of MHNSP with those of a matched group in receipt of independent medical prescribing (IMP); • Explore patients’ experiences of MHNSP; • Compare the safety of MHNSP to established independent medical prescribing practice; • Provide a tentative appraisal of the costs of MHNSP. METHODS • Two national questionnaire surveys of: non-medical prescribing leads in all NHS trusts in England providing mental health services (n=35); and all mental health nurses registered as supplementary prescribers with the Nursing & Midwifery Council (NMC) (n=224). • Case studies of six “leading edge sites” incorporating interviews with mental health nurse supplementary prescribers (MHNSPr), independent medical prescribers (IMPr) and non-medical prescribing leads (NMPL) (n=29). • A post-test control group experimental design in the leading edge sites to compare the treatment costs, clinical outcomes, and satisfaction of patients in receipt of MHNSP for at least six months, compared to a matched group in receipt of independent medical prescribing. Outcomes were collected using validated scales.  The design incorporated a record audit to evaluate the safety of prescribing (n=90).  3 • Interviews with a sub-sample of patients in the experimental study to explore their experiences of MHNSP (n=17). • A national conference at King’s College London on 9th March 2007 to disseminate and discuss the findings of the study with key stakeholders.  MAIN FINDINGS OF THE EVALUATION The present state of development of MHNSP within the NHS in England: • Two thirds of trusts that responded to the survey reported having mental health nurse supplementary prescribers working within their organisation, with an even greater proportion reporting that they were in the process of training MHNSPrs.  Most MHNSPrs who were qualified or in the process of qualifying were experienced mental health nurses of ten years or more and almost all were on pay band six or higher. The majority (58.1 per cent) of current prescribers qualified in 2004.  Nearly two thirds of the current prescribers commenced prescribing in 2005, approximately one year after qualifying.  More than half prescribed for service users diagnosed as suffering from schizophrenia and depression, with the majority prescribing for multiple conditions. The two classes of drugs most frequently prescribed by the MHNSPrs were anti-psychotics and anti-depressants.  Challenges of implementing, developing and sustaining MHNSP services  • The most common reasons for developing MHNSP services, as reported by both survey respondents and interviewees, were to: develop the contribution and role of nurses; increase access and choice for patients; and to increase service efficiency, particularly in the light of shortages of senior medical staff and reduction in junior doctors’ hours. Important to successful implementation of the service was the presence of influential trust staff, usually consultant psychiatrists or nurses, who championed MHNSP.  Once appointed, the non-medical prescribing leads played a key role in establishing and developing the service.  Frequently cited barriers to development included: unsupportive behaviour of key medical staff; organisational failures resulting in delays in adopting policies and procedures to regulate MHNSP; and the reluctance of MHNSPrs to engage with the initiative due to perceptions of inadequate pay for assuming additional responsibilities.   The impact of MHNSP upon professionals’ roles • Over half of all survey respondents and the majority of interviewees thought that MHNSP had fostered greater levels of mutual respect and better working relationships between nurses and psychiatrists.  A number of staff perceived that consultant psychiatrists’ time may be saved by the transfer of more stable service users to the care of the MHNSPr.   4 However, doctors may have unmet training needs with respect to their mentorship and supervision of nurses.    Health and social outcomes of patients in receipt of MHNSP • No significant differences in health and social care outcomes were found between matched service users who had been prescribed for by either a nurse or doctor for at least six months. MHNSP appeared to increase levels of satisfaction, with service users generally reporting better relationships with the nurse than with their doctor.  However, there were no differences found in service users’ satisfaction with the information provided by their prescriber about medication or their perceived adherence to medication regimes.    Patients’ experiences of MHNSP  • Patients with experience of MHNSP were generally positive about the initiative when interviewed, but they did not express a strong preference for being prescribed for by a nurse or a doctor. Practical advantages of MHNSP cited by informants included: convenience of obtaining their prescriptions and medication, greater continuity of care, and an increase in the time devoted to providing information about their medication.  However, patients who were positive about MHNSP were not always able to disentangle the nurse’s prescribing function from the rest of the service that they received from their nurse.   The safety of MHNSP  • The record audit showed no significant difference in the safety of prescribing between MHNSPrs and independent medical prescribers using NICE audit parameters. However, the quality of documentation was generally poor, with a substantial amount of information relevant to safe prescribing practice absent in the records of service users prescribed for by both MHNSPrs and consultant psychiatrists.  Fewer than two-fifths of all records included a diagnosis and clinical management plans were not accessible for over half the patients managed by MHNSPrs. However, there was no evidence that patient care provided by the MHNSPr was compromised due to inaccessible documentation.  There was limited evidence of formal communication between different care agencies or between agencies and patients.    The cost of MHNSP • The difference between the costs of MHNSP and independent medical prescribing was not statistically significant.  More patients in the MHNSP group spent slightly more time as psychiatric inpatients during the previous 12 months, than those patients in the independent  5 medical prescribing group, with the result that nurse supplementary prescribing appears to cost more, although not significantly more, than independent medical prescribing. There are several possible explanations for this difference in resource use, but given the small number of patients involved in the analysis, the most likely explanation is that this is a chance finding.   IMPLICATIONS FOR POLICY AND PRACTICE Evidence from this evaluation suggests that MHNSP fulfils several important functions, which are important to different groups of stakeholders:  • An attraction of supplementary prescribing for health service managers is its potential to deliver efficiency savings by, for example, freeing up the time of consultant psychiatrists and other medical staff to undertake other work.  Time and money saved in this regard would need to be offset against the time required from doctors for supervising nurse supplementary prescribers.  This evaluation found no significant difference between the costs of MHNSP and independent medical prescribing. However, it seems possible that medical supervision costs will decrease over time as nurses become more experienced and confident in their prescribing role.   • Patients interviewed were generally positive about the introduction of MHNSP but did not hold strong views about who should prescribe their medication.  There would not appear to be any difference in the health status, social functioning, and satisfaction with the way their medicines were prescribed of patients prescribed for by a MHNSP or a doctor.  However, interviews indicated that the acceptability of MHNSP reflects patients’ perceived quality of the relationship with their mental health nurse.  Given this, it might be that MHNSP would be less acceptable to patients in settings where the nurse-patient relationship may sometimes have a coercive element, for example within inpatient psychiatric wards.   • For mental health nurses, supplementary prescribing is: a mechanism for recognising existing practice of nurses who are already involved closely with the prescribing decision but by virtue of an informal and unregulated relationship with the doctors with whom they work; a vehicle which allows nurses to develop a role which gives due regard to the increasing importance of good medication management to the health of people with long term mental health problems, and so enables nurses to offer a more comprehensive and holistic service to patients; and provides a training platform for those nurses who aspire to be independent prescribers to develop their skills, knowledge and confidence within a well regulated training framework, which assures them of medical supervision and protection.    6  Reference: Department of Health (1999) Review of Prescribing, Supply and Administration of Medicines (Chair: Dr J Crown).   London: Department of Health.                                                  Correspondence to:  Professor Ian Norman Florence Nightingale School of Nursing and Midwifery at King’s College London London SE1 8WA 

Evaluation of mental health nurse supplementary prescribing: executive summary

Evaluation of mental health nurse supplementary prescribing: executive summary

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