Introduction

Medicines make a huge impact on the health and wellbeing of individuals and populations. They enable people to: live longer; help prevent the onset and adverse effects of acute illness; effectively manage long-term conditions; prevent and treat infection and promote health. Not surprisingly, medicines are the most common clinical intervention used in the NHS today (National Prescribing Centre 2008). However, there are also significant costs associated with medicines. There are human costs, resulting from unwanted side-effects or the inappropriate use of medicines, which can lead to serious illness or death. There are also huge financial costs for the health service in paying the medicines bill, which includes medicines that are dispensed and never used. As life expectancy increases and new treatments enter the market, the medicines bill will continue to rise.

Medicines management can be described as:

Medicines management aims to enable people to get the maximum benefit from the medicines they take, not only by ensuring that they are appropriate and clinically effective but also by balancing safety, cost, tolerability and choice. The term covers a wide range of activities involving doctors, pharmacists, nurses, other members of the health and care team and most importantly, the person and their family. However, the nursing team plays such a pivotal role, that medicine management has been included in the NMC Standards for Pre-registration Nursing Education as one of the five Essential Skills Clusters (ESC) (NMC 2010), Consequently, medicines management underpins a number of your nursing programme learning outcomes.

Medicines management in the community

The safe and effective use of medicines is essential in all healthcare settings. However, there are additional challenges in the community that make it even more important to get medicines management right. For example, people have a great deal more responsibility for managing their own medicines in the community than they would in an inpatient setting. They not only have access to a wide range of medicines on sale in shops, pharmacies and on the internet, but also any medicines that are prescribed. In most cases, the responsibility for the administration of medicines and the day-to-day monitoring of their effect rests with the individual and carer.

When the health and care team is involved in home care, the emphasis is on educating, supporting and empowering people to manage their medicines safely and effectively. The primary care team manages increasingly complex medication regimens for people who would once have been treated in hospital. Older people with multiple health problems, those with long-term conditions and children with very complex healthcare needs are now cared for at home for as long as possible. To be effective therefore, medicines management must involve a wide range of people in a wide range of activities namely:

Why is medicines management so important?

Safety, effectiveness and cost underpin medicines management. Medicines aim to control symptoms, help improve a person’s health and wellbeing and prevent ill-health of individuals and populations, for example through immunisation programmes. However, we know that people do not always use medicines in the way that was intended by the prescriber. NICE (2009) have estimated that up to 50% of patients do not take their medicines as prescribed. Sometimes, people choose not to take their medicines at all. They may be unclear about their purpose or they may have a physical or psychological problem which prevents them from following the directions they have been given. As a result, far from getting benefit from the medicine, people continue to experience poor health or may be affected by the harmful effects of taking medicines incorrectly. This has a huge personal cost to the individual and family. There is also a cost to the health service, as money wasted in one part of the health service means denying services in other areas.

The overriding reason for effective medicines management is safety. The safety of medicines relates to two different effects: an adverse drug incident and an adverse drug reaction.

An adverse drug incident refers to an unsuitable or incorrect procedure. The National Patient Safety Agency (2009) identified three incident types accounting for 71% of the serious harm or fatal outcome of medication incidents. These were:

Four groups of drugs account for more than 50% of the drug groups associated with preventable drug-related hospital admissions: antithrombotics (e.g. aspirin); anticoagulants (e.g. warfarin); non-steroidal anti-inflammatory drugs (e.g. ibuprofen); and diuretics (e.g. hydrochlorothiazide) (Howard et al 2007).

Garfield et al (2009) reviewed the UK literature and found a prescribing error rate of around 7.5% and showed that approximately one in 15 hospital admissions were related to medication, with two-thirds of these being preventable. Barber et al (2009) reviewed the medication of older people living in 55 care homes in England and found that 70% of the residents they studied had one or more medication error.

Adverse events are reported through local and national risk management systems. The National Patient Safety Agency (NPSA) National Reporting and Learning System (NRLS), collects information on reported patient safety incidents from local risk management systems in England and Wales. Scotland has the National Patient Safety Programme coordinated by Healthcare Improvement Scotland, an organisation that directly promotes patient safety within NHS Scotland.

An adverse drug reaction (ADR) is defined on the MHRA website as:

Pirmohamed et al (2004) studied hospital admissions in the UK and found that:

Reporting adverse drug reactions

The Medicines and Healthcare Products Regulatory Agency (MHRA) is a UK government agency whose role is to ensure that medicines and medicinal devices are effective and acceptably safe. The MHRA is responsible for licensing new medicines and monitoring the use of existing medicines in the UK. Yellow card reporting is the main reporting scheme for suspected adverse drug reactions. Without this scheme, it would be very difficult to monitor the safety of new medicines and also established medicines when they are used in new ways. It relies on the voluntary reporting of suspected adverse drug reactions by healthcare professionals and the public from all over the UK by completing a yellow card.

Yellow card reports enable the MHRA to identify risk factors for certain medicines and evaluate these together with other sources of evidence. As a result, actions can be taken to improve the safety of the medicine, such as making additional information available to prescribers and the public or in cases where the evidence suggests the drug is unsafe. The MHRA has the authority not to license the drug following the trial period or to suspend or withdraw a licensed medicine from the market.

How people get their medicines in the community

The ways in which people access medicines relate to the three main groups of medicines defined by the Medicines Act 1968. This is shown in Table 12.1.

Prescription-only medicines (POMs)

The vast majority of POMs are prescribed by the GP. However, there are other methods of obtaining POMs in the community which enable people to get easier and quicker access to the treatments they need, without having to rely on a doctor being present.

Prescribing and prescribers

Changes in prescribing legislation have given an increasing number of healthcare professionals eligibility to prescribe prescription-only medicines (POMs) under certain conditions. Legislation and professional regulation strictly control prescribing rights and determine who can prescribe and what they can prescribe. This can be confusing for everyone and particularly patients. Essentially there are:

Medical prescribers are doctors (and dentists) who are licensed to prescribe when they complete their training. Non-medical prescribers must successfully complete a specific course of preparation which meets the standards of their professional regulatory organisation, for the type of prescribing they are eligible to undertake. Table 12.2 lists the practitioners who are currently eligible to become non-medical prescribers. However, further changes in legislation will extend prescribing roles further, particularly in relation to allied health professionals.

Independent prescribers are responsible for assessing the person’s healthcare needs, making a diagnosis and using prescribing as one potential component of the treatment plan. They make prescribing decisions independently within their area of competence and are not required to refer to another practitioner.

Supplementary prescribers do not make the initial assessment of the patient. The doctor assesses the patient, makes the diagnosis and then draws up with the patient and supplementary prescriber a clinical management plan for their care. Supplementary prescribers are responsible for continuing care, which includes ongoing evaluation and by prescribing as directed by the clinical management plan. Supplementary prescribing is a voluntary partnership between the independent and the supplementary prescriber and agreed by the patient. Case study 1 illustrates the role of the supplementary prescriber.

Legal restrictions apply to each professional group regarding the items they can prescribe, either as an independent or supplementary prescriber. For example, community practitioner nurse prescribers are only permitted to prescribe from the Nurse Prescribers Formulary for Community Practitioners. This contains dressings and appliances and a limited number of medicines, including some POMs, which have been selected to support community nursing interventions. Nurse independent prescribers can select items from the British National Formulary (BNF). Table 12.3 summarises the scope of prescribing for each type of prescriber.

From nurse prescribing to non-medical prescribing

Community nurse prescribing has led the way for a much wider group of health professionals, namely, midwives, pharmacists, radiographers, podiatrists, physiotherapists and optometrists, collectively known as non-medical prescribers, to gain prescribing rights. As long ago as 1989, the Report of the Advisory Group on Nurse Prescribing (the Crown Report) advised Ministers how patient care in the community could be improved by introducing nurse prescribing. The report identified a number of clear benefits that could arise from nurse prescribing including:

In 2001, extended nurse prescribing was introduced and included other categories of nurses and midwives. A new course was developed in accordance with NMC standards, which was more lengthy and in-depth and prepared practitioners for independent and supplementary prescribing. Although the range of prescribable items was much broader than in the formulary for community nurses, prescribing was restricted to specific items for specific conditions and consequently, not applicable to all areas of clinical practice. Not until 2006 did new legislation allow Nurse Independent Prescribers to prescribe from the entire BNF and include allied health professional groups in non-medical prescribing. Although there were limitations regarding controlled drugs at this time, in April 2012, legislation was enacted to allow Nurse Independent Prescribers to prescribe schedule 2–5 controlled drugs for any medical condition within their competence. Nurses continue to be the largest professional group who are qualified to prescribe. In England, 2–3% of the registered nurse and pharmacist workforce are independent prescribers (Latter et al 2011).

Government policy in all four UK countries continues to promote non-medical prescribing as an important method of improving the quality of patient care, giving people easier access to treatments and services they require and making best use of the knowledge and skills of the professionals involved. An evaluation of nurse and pharmacist independent prescribing in England, commissioned by the Department of Health, reported prescribing to be safe and clinically effective, increased the quality of services and was very acceptable to patients (Latter et al 2011).