Opinion Article - Journal of Primary Care and General Practice (2019) Volume 2, Issue 1
Good governance in drug and alcohol services.Jeff Fernandez*
Camden and Islington NHS Foundation Trust, Greater London, United Kingdom
- *Corresponding Author:
- Jeff Fernandez
Camden and Islington NHS Foundation Trust Camden
London, Greater London
E-mail: [email protected]
Accepted Date: March 13, 2019
Citation: Fernandez J. Good governance in drug and alcohol services. J Prim Care Gen Pract. 2019;2(1):6-7
In line with the new NMC guidance that has come out outlining safe prescribing, there are many challenges this will present to drug and alcohol services in primary care in the UK . This will be relevant for all nurses who are currently prescribing in the field. To ensure prescribing is safe, the process of assessment, follow-up and review needs to be essential. These concepts are important as they ensure safe and effective prescribing and also good clinical governance. However, due to a very challenging time for drug and alcohol provision in the UK with budget cuts to service provision, this has led to services operating with redesigned clinical care. One of these re-designs has been the introduction of ‘batch’ prescribing that becomes very common in drug and alcohol services in the UK. This is where prescriptions are signed in bulk without seeing or reviewing the patient, like a repeat prescription . This has presented a challenge to many nurses working in the field of drug and alcohol provision trying to safe prescribing for themselves and their patients in the prescribing of controlled drugs.
Batch prescribing for NMP’s needs good clinical governance structures such as a review process to ensure contact with patients. Nurses and other NMP’s cannot replicate the ‘doctors’ role of batch prescribing with no follow up of the patients unless indicated by other multi-disciplinary staff. NMP’s are not doctors but experienced prescribers in their field. Good prescribing in drug and alcohol services by NMP’s and nurses should always be followed up with a review of the patient in order to prove that prescribing has been positive for the patient and it is effective .
As mentioned, batch prescribing has grown the field of substance misuse. Particularly as funding has reduced the number of nurses and in particular reduced their role to Non-medical prescribers. This is limited and at odds with the NMC prescribing guidance for nurses and is in urgent need of nurses to address this fact.
The six main frameworks which are expanded upon in the NMC guidance are :
1) Assessment of the patient
2) Consider the options
3) Reach a shared decision
5) Provide information
6) Monitor and review
7) Prescribe safely
8) Prescribe professionally
9) Improve prescribing practice
10) Prescribe as part of a team.
The introduction of nurse prescribing in drug and alcohol services in the UK have used the NMP function to prescribe for patients with key-worker (Drug workers) ensuring the monitoring and review of patients. However, this system is often not robust enough to monitor and review patients effectively and therefore ensure services prescribe safely and professionally. In many drug services the process Batch prescribing (repeat prescribing) for patients they are often not seen, assessed and reviewed in a uniform process. In the services in the UK this is often the case and it does make the position of the NMP very vulnerable. However, the system can be effectively made safer with an organised review process with a minimum review period of a year but ideally every six months. This would review the prescribing of the NMP systematically ensuring the prescribing was safe and professional. This needs the NMP’s to promote this framework that will make the process more effective and safe with a little more organisation. Below is how the services for drug and alcohol for nurses and other NMPs can be made safer and ensure that adherence to the new guidance is provided.
The Review Process
As mentioned, prescribing by nurses is completed in batches of prescriptions being signed with often no review process being conducted. This can limit the overall control the clinical staff may have on making safe decisions and compromise safety. Indeed some services but not all in the UK have initiated review process so the Non-Medical Prescribers do have contact with patients and can review the prescribing with a patient feedback and review. A process like this can enable effective and safe prescribing and all drug services need to recognize this as an essential part of any service re-design. Therefore, the review process for Non-medical prescribers can ensure safety for patients and nurses and maximize safe and effective care. Importantly, the assessment and follow up of the patient must be cornerstones of any re-design as, without this how prescribing can be evaluated as safe and in the interests of the patient. A follow up by a key-worker or another member of staff who is not a Non-medical prescriber often weakens the governance and lead to errors which work against the patient interest. Therefore, the review process has to be conducted and owned by NMP’s to ensure accountability and effective clinical governance. The review can be fast and simple and below is an example of a review for prescribing in the drug and alcohol field that can be practical and quick.
6 Monthly Reviews of Non-Medical Prescribing Patients
Date of birth:
Date of review:
• Current dose of medication and dispensing arrangements:
• Co-morbidities physical and mental health (include any risk issues identified):
• Concurrent medication:
• Control of drug use and alcohol use (including recent UDS and breathalyzer if indicated):
• Any problems with attending appointments at ISIS or at pharmacy:
• Plan for reduction/maintenance or onward referral over next 6 months.
• Record of GP registration (Shared Care / Non Shared Care):
• Risk Identified / Safeguarding issues:
Date of presentation:
Independent Prescriber decision:
Also, with a robust review system other innovative prescribing for patients in substance misuse can happen such as, Alcohol detoxification for patients on methadone and buprenorphine; Benzodiazepine clinics looking at reductions for patients who struggle with diazepam and lorezepam for instance. Therefore, enabling creative and effective practice. Important cornerstones of the new NMC guidance for nurse prescribers which should ensure and encourage service innovation.
This is also a very important structure to have to ensure safe and effective prescribing. The role of supervision often falls upon nurses who are the level of band 6 and band 7. This often has enough experience to understand that good reflective practice can enhance learning and improve practice. This can often be achieved by good clinical supervision. There are two effective ways this can be delivered in services:
This can be effective as it is not time-consuming or hard to plan for individuals to take part. Often group supervision can enable a fruitful discussion to that place where the group as a whole can be very supportive and effective in creating an effective space for learning and reflection. This can also be planned with regular times arranged and gives nurse the potential to get regular and effective supervision.
This is what most nurses prefer in the way they receive supervision from a senior member of staff that can encourage learning and reflection. However, in a very streamlined system this can often be difficult to arrange and can often be delayed due to the day-to-day functioning of services. I would argue that in modern day health care this is often a difficult task to meet. Group supervision seems to be the way forward as at least supervision can be regular and effective for nurses in the modern streamlined NHS.
This may all seem very obvious points of the process for nurses to ensure safe and effective prescribing practice. However, in the current NHS and particularly in substance misuse services with limited nursing numbers these structures are being compromised often in service re-designs. It is important that these structures are maintained and boosted as they are essential to enhance nursing care and make patients confident they are receiving the best care possible. Nurses need to argue collectively to commissioners through the RCN and NMC that these structures should not be compromised for austerity measures. And the new guidance needs to the cornerstone of safe prescribing.
I would argue these are small but important measures that can be easily adapted into services and it is important for prescribers. It ensures they prescribe to patients effectively and safely and protects them in the process of prescribing. It also ensures that NMP’s are adhering to the monitor and review process outlines in the guidance.
• Establishes and maintains a plan for reviewing the patient’s treatment.
• Ensures that the effectiveness of treatment and potential unwanted effects are monitored.
• Detects and reports suspected adverse drug reactions using appropriate reporting systems.
• Adapts the management plan in response to on-going monitoring and review of the patient’s condition and preferences.
It is important to meet this to ensure good clinical governance in prescribing is maintained and that services can improve their prescribing practice. Nurse in drug and alcohol services need to embrace this guidance and drive it forward to embed good and safe prescribing for patients and nurse prescribers.