Deposited in DRO : 31 March 2014 Version of attached le : Published Version Peer-review status of attached le : Peer-reviewed Citation for published item

Background: Supplementary prescribing for mental health nurses was first introduced in the UK in 2003. Since then, a number of studies have reported stakeholders’ perceptions of the success of the initiative. However, there has been little experimental research conducted into its effectiveness. This paper reports findings from the first known study to compare the cost and clinical impact of mental health nurse supplementary prescribing to independent medical prescribing. Methods: A post-test control group experimental design was used to compare the treatment costs, clinical outcomes and satisfaction of patients in receipt of mental health nurse supplementary prescribing with a matched group of patients in receipt of independent prescribing from consultant psychiatrists. The sample comprised 45 patients in receipt of mental health nurse supplementary prescribing for a minimum of six months and a matched group (by age, gender, diagnosis, and chronicity) of patients prescribed for by psychiatrists. Results: There were no significant differences between patients in the nurse supplementary prescribers’ group and the independent prescribers’ group in terms of medication adherence, health status, side effects, and satisfaction with overall care. Total costs per patient for service use were £803 higher for the nurse prescribers’ group but this difference was not significant (95% confidence interval -£1341 to £3020). Conclusions: No significant differences were found between the health and social outcomes of patients in the mental health nurse supplementary prescribers’ group, and those prescribed for by the independent medical prescribers. The cost appraisal also showed that there was no significant difference in the costs of the two types of prescribing, although the pattern of resources used differed between patients in the two prescriber groups. The results suggest that mental health nurse supplementary prescribers can deliver similar health benefits to patients as consultant psychiatrists without any significant difference in patients’ service utilisation costs. Background In 2001 suitably trained nurses were permitted to prescribe from an extended formulary that included 120 different medicines within the areas of minor injury and illness, palliative care, and health promotion [1]. However, it was not until 2003 that mental health nurses were permitted to prescribe through the introduction of supplementary prescribing [2]. Supplementary prescribing is described by the Department of Health (DH) [2] as “a voluntary prescribing partnership between an independent prescriber (a doctor or dentist) and a supplementary prescriber (a pharmacist, nurse or midwife) to implement an agreed patient-specific Clinical Management Plan, with the patient’s agreement. ” In order to be registered as a supplementary prescriber, nurses attend a 26-day university-based training programme, followed by a period of supervised practice by an experienced doctor. * Correspondence: ian.j.norman@kcl.ac. uk † Contributed equally King’s College London, Division of Health and Social Care Research, London SE1 8WA, UK Norman et al. BMC Health Services Research 2010, 10:4 http://www.biomedcentral. com/1472-6963/10/4 © 2010 Norman et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Since 2006, the extended Nurse Prescriber Formulary has been discontinued and qualified independent nurse prescribers can now prescribe all licensed medicines from the British National Formulary including some controlled drugs [3]. This latest development, was described in a British Medical Journal (BMJ) editorial as “one of the most far reaching extensions of prescribing by nurses and pharmacists anywhere in the world” [4]. The British Medical Association responded to this new policy of opening up the entire formulary to nurses with dismay, expressing concerns about safety, and emphasising the importance of diagnostic training to prescribing. Avery and Pringle [4] were more positive, noting that training in diagnosis for non medical health professionals is becoming more widespread. They pointed to findings from an influential study [5] which showed that independent nurse prescribers prescribed for relatively minor conditions and that medically trained assessors had found that generally, they prescribed appropriately. However, the BMJ editorial also pointed out that the evidence base to support the current policy of non medical prescribing was weak, and that it was “worrying that the policy was launched by the Department of Health before waiting for further evidence to accumulate, including studies that it has only recently commissioned. ” This paper reports on findings from one of these Department of Health (England) (DH)) commissioned studies; a national evaluation of supplementary prescribing by mental health nurses. Much of the early literature on mental health nurse supplementary prescribing in the UK consisted of expert opinion, sometimes with the benefit of the authors having visited mental health care settings in the USA, in which nurses have exercised prescriptive authority for over 20 years [6,7]. Within this anecdotal literature there have been debates on: whether mental health nurses have sufficient psychobiological knowledge to undertake prescribing [8]; whether the legal protection of nurses undertaking the role is adequate [9]; and whether nurse prescribing has been introduced primarily as a cost cutting measure [10], given the lower salaries of nurses compared to doctors. Although there have also been concerns regarding nurse prescribers’ academic knowledge and clinical experience [4], a recent national survey by Courtenay et al. [11] suggested that the qualifications and experience of many nurse prescribers exceeds the training guidance stipulated by the Nursing and Midwifery Council [12]. Nurse prescribers have been widely surveyed regarding their experiences of their new role. On the whole, they have been found to have positive views about the initiative [13-16]. Although early surveys suggested that some nurses were anxious about obtaining sufficient knowledge and skills to carry out prescribing [17], practicing non medical prescribers report gaining greater confidence and knowledge of medicine management through prescribing, as well as greater job satisfaction and increased credibility with other professionals [16,18]. In addition, despite some of the negative commentary voiced by the medical profession [4], those studies which have sought the views of NHS doctors on nurse prescribing have found that they are broadly supportive of the initiative if the nurse prescribers are well qualified and experienced, and aware of their own limitations and of the context in which they are prescribing [15,18]. Studies within mental health settings which have examined psychiatrists’ views of nurse prescribing also suggest that they are largely supportive of the nurse prescribing role [15,19,20], with consultant psychiatrists appearing to be less concerned about independent nurse prescribing than their junior staff [19]. This is encouraging as the relationship between the nurse supplementary prescriber and consultant psychiatrist is likely to be key to the success of non medical prescribing. Perceived benefits of mental health nurse supplementary prescribing were that it would provide quicker and more efficient patient access to medication, would increase patient choice, and would make better use of nurses’ skills and knowledge [21]. However, the effectiveness of supplementary prescribing has been difficult to ascertain. Recent case studies of nurse prescribers (both supplementary and independent) working in non mental health settings [22,23] suggest that staff perceive that prescribing has helped them to provide more streamlined packages of care, involve patients more in prescribing decisions, be more responsive to patient needs, and to work more holistically. Specifically Courtenay et al [23] reported that nurse prescribers in dermatology services felt able to spend longer in consultations discussing medicines, and were able to make prescribing decisions that were better tailored towards their patients’ lives. There has been little comparable published research conducted within mental health. However, mental health patients’ expectations of prescribing have been found to be positive, although tempered with uncertainty with regard to nurses’ prescribing skills [24]. One study of patients’ views of supplementary prescribing found that patients, on the whole, valued the nurses’ holistic approach to medicine management [25]. Nurse prescribing has also been identified as a potential way of improving medication management for patients. Latter [26] suggests that prescribing medicines provides a new opportunity to affect the way patients take their medicines through maintaining good relationships and providing appropriate information on medicines. Certainly non compliance with medication in mental health care is a substantial problem which has Norman et al. BMC Health Services Research 2010, 10:4 http://www.biomedcentral. com/1472-6963/10/4 Page 2 of 9