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The benefits of nurse prescribers in primary care diabetes services

Molly Courtenay describes her research into the role of non-medical prescribers in primary care.​

Non-medical Prescribing (NMP) was introduced as a means to increase service efficiency and medicines access (Department of Health, 2006) and it is now well established in the UK. Around 28 000 nurses are now able to prescribe the same medicines as doctors, provided that it is within their level of competence (Nursing and Midwifery Council, 2006). Most of these nurses work at an advanced or specialist level (Courtenay and Carey, 2008a; Courtenay et al, 2012) and it is evident that this successful policy initiative has enabled faster medicines access, with flexible, patient-centred care and service efficiency gains (Courtenay et al, 2009; Stenner et al, 2010; Carey et al, 2014). It is also safe and acceptable to both clinicians and the people that they treat (Courtenay et al, 2010; Latter et al, 2010; Courtenay et al, 2011).

Diabetes service delivery
Primary care teams provide routine care for about three quarters of the population with diabetes and most general practices have a nurse with diabetes training (Audit Commission, 2000). Practice nurses run a third of diabetes clinics (National Audit Office, 2012) and have become increasingly involved in medicines management activities for people with diabetes (Courtenay and Carey, 2008b; James et al, 2009). These nurses also provide invaluable education and support so that people with diabetes can self-manage their condition. Nurse-led services have been shown to result in improved outcomes (Carey and Courtenay, 2007; Cook-Johnson et al, 2012).

How different types of nurses impact the health of patients with diabetes
A recent study by Courtenay et al (2015) reports on the added value of nurse prescribers, compared to those without prescribing capability, working in general practice. The study adopted a case study design and compared six general practices in which care for people with diabetes was provided by a practice nurse with a prescribing qualification, with six practices in which care for people with diabetes was provided by a practice nurse without a prescribing qualification. Data collected included patient-reported outcomes (self-care and satisfaction), clinical indicators (body mass index and HbA1c), nurse activities and processes of care, resource implications and cost.

There was a significant decrease in HbA1c across patients of both prescribing and non-prescribing nurses, and self-care was high across the whole sample. However, there were no differences in these outcomes between nurses with and without prescribing capability.

All patients were satisfied with their care, however, patient perceptions of nurse’s knowledge of symptoms, confidence in treatment, the provision of useful advice, and support to cope with the disease, were aspects of care rated more highly by patients of nurse prescribers, compared to non-prescribers. It is important to consider that nurse prescribers were generally a higher band than non-prescribers and incurred extra costs due to their longer consultation times (by an average of 7.7 minutes).

Although practice nurse prescribers in this study were a more expensive resource than practice nurses without prescribing capability, findings from this study provide reassurance that these nurses are able to deliver complete episodes of care for patients with diabetes (including the prescription of medicines) and achieve health outcomes. Furthermore, patients are very happy with the care they receive. Given the increasing prevalence of people with diabetes and associated comorbidities, and the strain this is putting on the current health system, practice nurse prescribers would seem ideally placed to lead the care of these individuals.

Although there were no differences in patient-reported self-care and HbA1c between the patients of prescribing and non-prescribing nurses, the six months follow up period was limited, given the context of the long time period during which most of the patients in the study had been managed. Differences may have been seen had the follow-up period been longer.

Audit Commission (2000) Testing Times: A Review of Diabetes Services in England and Wales. Audit Commission, London. Available at: http://bit.ly/1MQB1EJ (accessed 27.10.15)
Carey N, Courtenay N (2007) A review of the activity and effects of nurse-led care in diabetes. J Clin Nurs 16: 294–304
Carey N, Stenner K, Courtenay M (2014) An exploration of how nurse prescribing is being used for patients with respiratory conditions across the east of England. BMC Health Serv Res 14: 27
Cook-Johnson R, Parker D, Clifton K et al (2012) The effectiveness of nurse-led care in general practice on clinical outcomes in adults with type 2 diabetes. Best Practice 16: 1–4
Courtenay M, Carey N (2008a) Nurse independent prescribing and nurse supplementary prescribing: Findings from a national questionnaire survey. J Adv Nurs 61: 291–9
Courtenay M, Carey N (2008b) The prescribing practices of nurse independent prescribers caring for patients with diabetes. Practical Diabetes International 25: 1–6
Courtenay M, Carey, N, Stenner K (2009) Nurse prescriber-patient consultations: A case study in dermatology. J Adv Nurs 65: 1207–17
Courtenay M, Stenner K, Carey N (2010) The views of patients with diabetes about nurse prescribing. Diabet Med 27: 1049–54
Courtenay M, Carey N, Stenner K et al (2011) Patients’ views of nurse prescribing: effects on care, concordance and medicine taking. Br J Dermatol 164: 396–401
Courtenay M, Carey N, Stenner K (2012) An overview of non medical prescribing across one strategic health authority: A questionnaire survey. BMC Health Serv Res 12: 13
Courtenay M, Carey N, Gage H et al (2015) A comparison of prescribing and non-prescribing nurses in the management of people with diabetes. J Adv Nurs doi: 10.1111/jan.12757
Department of Health (2006) Independent prescribing by nurses and pharmacists within the NHS in England. A guide for implementation. Department of Health, London. Available at: http://bit.ly/1WfyOgq (accessed 27.10.15)
James J, Gosden C, Wincourt C et al (2009) Diabetes specialist nurses and role evolvement: A survey by Diabetes UK and ABCD of specialist diabetes services 2007. Diabet Med 26: 560–5
Latter S, Blenkinsopp A, Smith A et al (2010) Evaluation of nurse and pharmacist independent prescribing. University of Southampton and Keele University. Available at: http://bit.ly/1FAt06J (accessed 27.10.15)
National Audit Office (2012) The management of adult diabetes services in the NHS. National Audit Office, London. Available at: http://bit.ly/1RVQxDu (accessed 27.10.15)
Nursing and Midwifery Council (2006) Standards of proficiency for nurse and midwife prescribers. NMC, London
Stenner, K, Carey N, Courtenay M (2010) Implementing nurse prescribing: A case study in diabetes. J Adv Nurs 66: 522–31

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