Evaluate the non medical influences on prescribing practice

In the UK, nurse prescribing was born out of the need to increase efficiency in the NHS by making best use of its resources. Nurse-led services are one means of improving healthcare provision and a string of legislative change has gradually broadened the scope of nurse prescribing in the UK. (Courtenay et al 2007). The role expansion of nurses to meet efficiency targets has meant that nurse-led services in the healthcare setting are expanding as one means of coping with a growing, increasingly ageing population.

For those nurses running nurse-led services the focus for that reason, needs to be on treatment that improves the quality of someone’s life and represents an effective use of NHS resources.

Prescribing is therefore one stage in making a rational treatment decision. If prescribing is to be effective, the practitioner must be able to: •Identify the problem in terms of the patient’s needs and the ultimate goal of any treatment •Break the problem down into more explicit questions, such as ‘what are the treatment options?’; ‘how well do they work?’; ‘what are the resource implications?’ •Check the evidence

In order to do this, the efficacy of treatment options must be considered.

This involves considering efficacy and clinical effectiveness, which are quite different. Efficacy is when a drug is proven to have a pharmacological effect greater than a placebo which does not necessarily translate into improved clinical outcome. Clinical effectiveness is when that efficacy results in a proven clinical outcome.

Knowing that a drug represents value for money is as much a part of evidence-based prescribing as clinical effectiveness.

If two drugs have the same clinical effect then it makes sense to prescribe the cheapest alternative – known as cost minimisation – without any other coercement being involved. The pharmaceutical industry has traditionally denied attempts to influence prescribing behaviour, instead insisting that marketing efforts are simply intended to educate physicians on new products in order to ensure that their prescribing choices are well informed and based on the latest available evidence. (Cruddas and Gannon 2009)

However, an increasing number of studies are also revealing that pharmaceutical marketing does impact on prescribing habits (Kravitz et al 2005; Grande et al 2009) and there is some evidence that these studies are beginning to exercise the minds of nurses as well as doctors. Lakeman and Cutcliffe (2009) propose that:

‘Now, more than ever, nursing needs to examine its relationship to the pharmaceutical industry and (if it is to maintain its integrity and impartiality) maintain some considerable distance.’

There are 53, 813 nurse prescribers in the UK who have recorded their qualification on the NMC register (NMC Register 2010, unpublished data) With more than 912 million prescriptions dispensed in the NHS in 2007, prescribing remains one of the most common therapeutic interventions. (The Association of the British Pharmaceutical Industry 2010) The impact of the global economic downturn on public spending is likely to make the need for cost-effectiveness in prescribing even more acute in the future and the need to influence nurse prescribers a higher priority for the pharmaceutical industry.

Evidence already exists to suggest that the pharmaceutical industry actively seek out nurse prescribers through workplace visits and the offer of special events ( Kessenich 2000) and with the growing number of nurses able to prescribe this controversial aspect of professional practice is becoming more prevalent. Lipley (2000) claimed that three quarters of nurse prescribers would change their practice for a ‘glossy leaflet or sandwich’. Bearing this in mind nurse prescribers need to be aware of the potential influences on their prescribing. These may include: •Patient expectation and knowledge

•Drug company promotional activities
•Hospital prescribing patterns and policies (hospital led prescribing) •Nursing colleagues attitudes and opinions
•The relevant GP policies
•Local formularies, national and local guidelines

The principles outlined in the range of standards, guidance and advice from the NMC are part of effective governance for prescribing practice, and form an essential tool kit for nurse prescribers to assist them in protecting those in their care. The NMC Code of Professional conduct (2008) gives clear direction regarding actions and responsibilities:

•You must ensure that your registration status is not used in the promotion of commercial products or services •Where you recommend a specific product, you must ensure that your advice is based on evidence and not on commercial gain

•You must refuse any gift, favour or hospitality that might be interpreted now or in the future as an attempt to obtain preferential consideration.

There is little question that the development of independent nurse prescribers will serve the greater public good, but the primary obligation of the individual nurse must continue to be the health and wellbeing of his or her patients. Crigger (2005) identifies that nowhere in medicine today is the potential for conflict of interest greater than in the interaction between health professionals and private industry. These industries include pharmaceutical companies, medical device manufacturers, and makers of other products such as baby formulas. In short, any private interest whose income depends on the prescription or approval of their product.

The Association of the British Pharmaceutical Industry (ABPI) Code of Practice is the means by which the promotion of prescription medicines is regulated in the UK. The code and its operation were recently reviewed following wide consultation with stakeholders. This review resulted in modernisation and a number of changes. It is worth noting that not all drug companies are a member of the ABPI and therefore are not obliged to abide by their recommendations. The changes which are of relevance to nurse prescribers are the greater provision of information and limitations on advertising. In order to increase confidence within the non medical prescriber group better understanding of the ABPI code of practice is necessary.

The pharmaceutical industry is therefore seen as an intoxicating force within prescribing. (Davies and Hemmingway 2004). Non medical prescribers have a duty of care to the organisation they are a part of, themselves and the patient.

In my current practice I am not allowed to meet with drug representatives. If they are promoting a product they are instructed to arrange an appointment with pharmacy or the Consultant whose speciality they believe their product to be best targeted towards. If accepting favours in any way shape or form from the pharmaceutical industry compromises the individual nurse prescriber’s own morals, values or beliefs, then they must be clear as to where their interests lie. Reference to the recommendations that are set out in the Code of Professional conduct should provide clear direction.

The pharmaceutical industry insists that the provision of information to doctors and nurses is not intended to influence prescribing behaviour but intended to educate. Unfortunately such marketing efforts can be biased, inaccurate and intended to portray the target product in a favourable light. ( Cruddas and Gannon 2009). Research in this area does appear to be focused on medical concerns, but in terms of the extant literature four studies stand out as being relevant in this context:

•An Argentinian study concluded that 46% of refernecse given in literature distributed by industry representatives did not concur with the claims made in the companys lioterature. (Meija and Avalor 2001)

•In the United States, two articles examined how doctors and drug companies are ‘twisted together like tha snake and staff’, and claimed that approximately 90% od doctors see drug representatives and receive gifts and attend events which highlight the sponsors drug. (Moynihan 2003a; 2003b) •A German study found that 94% of the information in brochures for doctors had no basis in scientific eveidence. (Tuffs 2004) •A Spanish study revealed that 44.5% of the information provided by pharmaceutical representatives to GP’s is factually erroneous and is biased toward their own product. (Rivera et al 2005)

This mounting body of evidence only serves to reinforce the argument that the pharmaceutical industry has, at times, an ulterior motive in seeking out doctors and nurse medical prescribers. Conversely the opposite to the evidence researched above must also be true, otherwise new drugs would never be tried, tested and prescribed for patients! Ultimately non medical prescribing must improve care for patients.

It requires a high level of skill, expertise and judgement, not only in deciding what to prescribe, but in deciding what not to prescribe, what to discontinue and when, and an awareness of medicines knowledge and individual limitations. Prescribing decisions will also be influenced by formularies, of which one is national and others locally based. Although the British National Formulary provides

Shaughnessy and Slawson (1996) presented the acronym ‘STEP’ as a way to evaluate the information presented by drug representatives: -Safety
-Tolerability
-Effectiveness
-Price suggesting that the four attributes should be considered when weighing the purported advantage of one drug over another. I believe this acronym to be a useful reference point when considering the prescription of any drug over another. Certainly in my practice each Consultant appears to have a favoured drug to treat the same symptom. If I am able to rationalise my choice of drug by using this acronym it would give me increased confidence in selecting which drug to prescribe. In this ever increasing age of technology access to information is greater than it has ever been.

Subsequently patients’ knowledge or awareness of medical problems has increased along with their expectations, increasing the difficulties of resisting pressure to prescribe. Patients may try to influence prescribing decisions by telling you what happened when they saw one of your colleagues, intimating that they will return to see another health professional or even threatening to complain.

Consequently there is peer pressure, patient pressure and the pharmaceutical industry all exerting pressure on prescribing. There is little written about the impact that other healthcare professionals have on the prescribing decisions of non medical prescribers. Lewis and Tully (2009) studied interactions between teams and team members and how these influenced prescribing.

The study used the critical incident technique and in-depth interviews. Prior to indepth interviews forty-eight doctors of varying grades were asked to remember any uncomfortable prescribing decisions that they had recently made. These ‘incidents’ were discussed in depth. There were 193 critical incidents described in the interviews. Of these one third were related to the difficulties of prescribing within a team environment. Discomfort frequently arose because of factors relating to hierarchical structure; in particular, junior doctors described their discomfort when they were uncertain of seniors’ prescribing decisions. Discomfort also arose from a perceived pressure to prescribe from the nursing team.

Overall this study demonstrated that hospital doctor’s prescribing decisions were strongly influenced by relationships with other team members.

The impact of the multidisciplinary team cannot be underestimated. I currently run a nurse-led clinic as explained in outcome one. Certainly prescribing responsibility, pressure on the decision to prescribe and prescribing to facilitate the radiographer team will affect the physical act of writing a prescription. The wide range and complexity of advanced clinical decision making and some of the ethical problems and dilemmas faced on a daily basis may make the process stressful and difficult. Ensuring that the benefits outweigh the risks when prescribing, assessing patient safety and the non medical prescribers’ integrity and belief that they are prescribing appropriately must be foremost considerations.

Conversely the intricacy of nurse prescribing may make them more aware of what other members of the multidisciplinary team are doing and the unique skills and resources of other practitioners. (e.g. Pharmacists) Potentially at least, nonmedical prescribing is a powerful catalyst for change, enhancing collaborative working and promoting greater awareness of commercial enterprise among health professionals.