Is it safe for medicines to be prescribed after a third-party assessment ? (indirect prescribing)

Objectives:

·??????? To clarify the risks associated with prescribing based on an assessment conducted by another person. (This is sometimes referred to as ‘proxy-prescribing, ‘informal prescribing, or ‘indirect prescribing’).

·??????? To explain ‘medical’ and ‘non-medical’ prescribing and how this type of proxy-prescribing fits in with it.

·??????? To promote a deeper understanding of this practice, and the safety implications.

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What is ‘proxy prescribing’ in this context:

This article concerns the situation where a health care worker, who may or may not be a registered professional, sees a patient and then recommends a medicine to a prescriber (who has not seen the patient), who then writes a prescription.

Legally the person who signs the prescription (the prescriber) is the one who is accountable for that prescription.

The safety of this practice depends on the skills and competency of the person undertaking the assessment of the patient, and on the governance related to the process. This practice may present a risk for patients prescribed medicines such as benzodiazepines, NSAIDs, and antipsychotics. There are different scenarios in which this occurs, ranging from a prescription based on a verbal handover from a non-registered member of staff to a prescription written following an assessment by a secondary care specialist, accompanied by full documentation.

How does this process differ from nurse prescribing, also called ‘non-medical prescribing’:

It is different. Under UK law nurses, pharmacists and specific other health professionals can undertake additional learning (most often at master’s level), and if they pass can register to become ‘independent prescribers,’ (sometimes referred to as IPs). The scope of medicines they are allowed to prescribe varies by profession.

Nurses and pharmacists who are registered as independent prescribers can prescribe any medication from the BNF, including off-label and high dose medicines. The caveat which applies to non-medical prescribers is that these prescribers must be able to demonstrate that they are prescribing within their field of competency and undertake regular prescribing Continuous Professional Development.

Non-medical prescribers have the same status as medical prescribers. They are legally accountable their prescribing in the same way as doctors (medical prescribers) are.

There is a competency framework for all prescribers which has been in place since 20121.

How does this proxy-prescribing process work:

Typical scenarios include:

·??????? A GP practice nurse, Physician Associate or District Nurse (not qualified as a prescriber) sees and assesses a patient, decides they need a prescribed medicine and asks the GP to write the prescription. The GP has not seen and assessed the patient. This applies equally if the recommendation to stop a medicine or change the dose. These are also prescribing decisions.

·??????? A mental health practitioner (often not qualified as a prescriber) assesses a patient and contacts the patient’s GP to ask them to write a prescription. The GP has not seen and assessed the patient.

·??????? A substance misuse worker (who may not be a registered professional) sees and assesses the patient, then requests the prescription from a prescriber colleague or the patient’s GP. The GP, or the prescriber colleague, has not seen and assessed the patient.

What are the advantages:

·??????? It is claimed that some services would not be able to operate without this practice.

·??????? It avoids the risks associated with multiple prescribers2.

·??????? It avoids the delays and having to see two people for the same problem2.

·??????? Where the prescribing is limited to a specific clinical area or specific diagnosis, and safety considerations are included in the policies, shared care guidelines and local practices, this may be an efficient and safe way of working. Providing other options, including using a Patient Group Direction3 are not appropriate.

What are the risks:

·??????? ‘Proxy prescribing’ (as described here) is an informal unregulated process.

·??????? The Royal Pharmaceutical Society Prescribing Competency Framework and professional standards (such as the GMC Guidance for Prescribing4) does not apply to those proxy-prescribers who are not registered as prescribers.

·??????? ‘Proxy prescribers’ may not be trained in the art and science of prescribing.

·??????? Clinical governance, including policies and procedures, around the practice may be weak or even absent.

?A safe prescribing assessment includes:

? Assessing the presenting complaint.

? Assessing mental capacity and looking for any safeguarding issues.

? Assessing any ‘red flags.’

? Forming a diagnosis.

? Taking a medical history.

? Taking a medicines history (including allergies, sensitivities, and adverse reactions).

? Taking a social history (including smoking, alcohol, OTC & bought drugs, recreational drugs).

? Reviewing options with the patient.

? Agreeing on the option and considering previous adherence.

? Safety netting, follow up actions and signposting.

? Documenting the decision, including duration of treatment & review dates.

? Communicating the prescribing decision with the multi-disciplinary team.

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References:

1.????? Royal Pharmaceutical Society (2021) Prescribing Competency Framework (for all prescribers) WWW: https://www.rpharms.com/resources/frameworks/prescribing-competency-framework/competency-framework (accessed 01.09.2023)

2.????? NHS England (2018) Responsibility for prescribing between Primary & Secondary/Tertiary Care WWW: https://www.england.nhs.uk/wp-content/uploads/2018/03/responsibility-prescribing-between-primary-secondary-care-v2.pdf (accessed 4.09.2023)

3.????? Medicines and Healthcare Products Regulatory Agency (2023) Patient group directions: who can use them WWW: https://www.gov.uk/government/publications/patient-group-directions-pgds/patient-group-directions-who-can-use-them (accessed 01.09.2023)

4.????? General Medical Council [GMC] (2021) Good practice in prescribing and managing medicines and device WWW: https://www.gmc-uk.org/-/media/documents/prescribing-guidance-updated-english-20210405_pdf-85260533.pdf (accessed 04.09.2023)