The undoubted success of primary diabetes care over the past 5 years has been built on effective team working in general practices. In the following article (pages 97–100), Dr Molly Courtenay and Nicola Carey highlight a new and potentially important facet which has been added to this teamwork, allowing appropriately qualified and trained nurses to prescribe in diabetes care.
Since 1 May 2006, UK legislation has permitted independent prescribing from a full formulary for nurses and pharmacists, although there will be differences in how the legislation is applied between the four Nations in the NHS (Department of Health, 2006). There will be two types of non-medical prescribing: independent prescribing, which is carried out by a practitioner who is responsible and accountable for the assessment of patients; and supplementary prescribing, where there is a partnership between a nurse independent prescriber and the supplementary prescriber, who work to an agreed protocol.
Combining nursing and medical skills may provide a more comprehensive and flexible service for people with diabetes than that provided by general practitioners alone. Practice nurses can spend more time with patients, and both anecdotally from practice questionnaires and from evidence from nurse practitioners (Centre for Health Services Research), patients report a high level of satisfaction with practice nurses. In the context of diabetes care, nurses often follow patients up across a range of conditions, from early diagnosis through opportunistic screening, to follow-up at practice diabetes clinics and on to dressings for complications such as foot ulcers. Frequently there are prescribing decisions.
Some medical practitioners may be apprehensive about this development, basing their concerns on the limited training nurses have in diagnosis. However, nurse independent prescribers tend to prescribe for relatively minor conditions and medically trained assessors found that they generally prescribed appropriately, with few obvious differences in the pattern of prescribing between doctors and nurses (Latter et al, 2005).
There has been an impression that this development in nurse prescribing will be a revolution, but the training and qualifications required for nurse prescribing will make the development more of an evolution during the next 5 years. Nurses will want to ensure that they have access to patients’ complete medical record as well as the computerised prescribing prompts which ensure accuracy and recording in prescriptions. GPs will retain their clinical governance requirements for the practice and will want to ensure appropriate indemnity for this non-medical prescribing.
Many GPs report that the targets required for the Quality and Outcomes Framework have meant that they are increasingly prescribing in a more formulaic way to achieve these rigorous goals. This means that many people with diabetes are now on a comprehensive regimen of anti-hypertensive, lipid-lowering and hypoglycaemic agents. To ensure the success of nurse prescribing, practice nurses will want to follow clear practice prescribing protocols, and a patient-specific clinical management plan, to initiate therapy and use their increased prescribing skills to ensure better concordance with the complex therapeutic regimens used in contemporary diabetes care.