The final Crown 2 Report: implications for diabetes nurses

Now that the long awaited Final Crown 2 Review of Prescribing, Supply and Administration of Medicines (DoH, 1999) is with us, we need to think very carefully about where we want to go with it as a specialist nursing group.

The main recommendation is a new two-tier prescribing structure for health professionals, allowing for both independent and dependent prescribers.

Independent prescribers will be ‘responsible for the initial assessment of the patient and for devising the broad treatment plan, with the authority to prescribe the medicines required as part of that plan.’ Dependent prescribers will be authorised to prescribe ‘certain medicines for patients whose condition has been diagnosed or assessed by an independent prescriber, within an agreed assessment and treatment plan (page 3).’

Given that these are the recommendations of a team of experts, it is disappointing that the document is out for consultation until 7 June. Once this hurdle has been overcome, changes to primary legislation will be required – with a timescale of at least a year. It is anticipated that a New Prescribers Advisory Committee (NPAC) will be set up to authorise those wishing to gain prescribing powers. 

DSNs will need to petition the New Prescribers Advisory Committee
Whether diabetes nurses take advantage of one or other of the prescribing options will not be determined locally between DSN and diabetologist; rather, it will be up to us as a specialist group to petition the NPAC for prescribing rights. 

A key question we would be asked early in this process is whether ‘the professional group is adequately defined with appropriate training programmes’ (page 15, diagram 1). This is where we are going to need the education working party groups to help us to proceed.

There is much to be done and it is up to us to get moving with it. The good news is that DSNs are mentioned as possible early candidates for prescribing authority. We are recognised as ‘already skilled in advising patients with diabetes, training them in the use of insulin or other therapies, and assessing and changing the dose required.’ It is envisaged that following diagnosis by a hospital specialist we could ‘take over clinical responsibility at this point, assess the precise requirement for insulin or other medicines, prescribe as needed, and supervise continuing treatment, referring back to the doctor as necessary (page 51).’

How will nurses working in community clinics be affected?
One of the education working groups is attempting to redefine the role of the DSN. In the light of the above recommendations, this would appear to be an important exercise. Crown seems to assume that a DSN is a person working solely in the specialty of diabetes attached to a team headed by a diabetologist. The position of nurses working part time in community mini-clinics is less clear as far as prescribing is concerned. Would it be possible for them to work with group protocols to supply and administer under the authorisation of a GP or other independent prescriber?

This is all going to take some time, so how do we safeguard our practice in the interim? Given that many of us were already using protocols pre-Crown 2, it would seem best practice to ensure that these conform to the review team’s recommendations. The preliminary Crown report was published early in order to clarify the situation until out-of-date legislation could be changed.

If you are going to the BDA conference in Glasgow (28–30 April), do look in on the nurse prescribing working group led by myself and Mark Jones (RCN Primary Care Policy Adviser). It will be as interactive and as dynamic as you care to make it! 

Nobody is an expert on nurse prescribing at this stage, and your contribution to the debate will be greatly valued. The next nurse prescribing working group meeting is on 14 May, when we will be considering how to prepare a case for DSNs to become prescribers. We will report back then.