HEALTHCARE: THE NEW PRESCRIBERS - Nurses and pharmacists will be given new prescribing powers later this year

Nurses and pharmacists will be given new prescribing powers later this year, and PR will play a role in filling in the knowledge gaps. Adam Hill reports.

If pharmaceutical companies and healthcare PROs are not already rubbing their hands, they soon will be. Two audiences with which they already communicate, nurses and pharmacists, are about to be given wider responsibilities on prescribing medicines, and this will effectively create more opportunities for PR.

In March 1999, a Department of Health review team under Dr June Crown presented its findings on the prescribing, supply and administration of medicines. The Crown Report's radical recommendation was that doctors, who have always been responsible for prescribing drugs to patients, should be supplemented by nurses and pharmacists with the same responsibility.

A clinical management plan for a patient will be drawn up by the prescriber - a GP or consultant - and the supplementary prescriber - nurse or pharmacist - agreeing the best way of treating a patient. If the supplementary prescriber wanted to change dosage, they would be free to do so, yet if they wanted a different drug, the original prescriber would have to agree.

The changes will affect the professional status of both nurses and pharmacists, and this will affect the way the medical PR sector approaches communicating with these two audiences. PRWeek spoke to Colin Dale, an advisor of primary healthcare at the Royal College of Nursing and to Dr Peter Wilson, the lead on supplementary prescribing at the Royal Pharmaceutical Society to find out how far the new prescribing powers will affect their members (see boxes).

Nursing, says Dale, is facing the biggest change in 30 years, while Wilson holds that pharmacists will be qualifying as supplementary prescribers hopefully by the spring.

The specialist medical media for nurses and pharmacists are also making editorial adjustments to help their readers through the changes. PRWeek spoke to two senior editors at Nursing Times and Chemist and Druggist (see boxes) to find out what these changes are.

NT is adding new clinical pages, while Chemist and Druggist is hoping to provide training materials.

This year the first supplementary prescribers will be trained to enter the health system with extended remits and enhanced status. The move makes sense. Both groups are already heavily involved in the treatment of patients in disease areas such as diabetes, hypertension and asthma - nurses in recommending medicines that are often rubber-stamped by doctors, and pharmacists as OTC advisers to customers.

For pharma companies it looks like a huge opportunity.

According to the Association of the British Pharmaceutical Industry (ABPI), there will be no change to the rules governing how the healthcare PR sector operates since the new audiences are not members of the general public.

'There is no need to go back to the drawing board,' an ABPI spokesman says. 'The rules cover communication to healthcare professionals and nurses and pharmacists come under that heading. Companies are allowed to promote their products in a responsible and ethical manner.'

Yet pharma companes do not seem to be popping the champagne corks just yet, as the changes will take a while to work through the system.

Steve Hough, NHS relations advisor at Eli Lilly, says: 'It is fairly early days on the whole reorganisation of prescribing responsibility. We are holding a watching brief.' Richard Hollies, brand leader at Roche Consumer Health, says Roche is preparing its strategies now: 'With a number of the brands we have, we are targeting nurses and pharmacists more and more,' he says.

'If you are trying to get to an end user they are very important already. For example, with skincare they are probably our first port of call. It is a very important part of the marketing mix to get those people (nurses and pharmacists) on board.'

Cherry Wood, MD of Athena Medical, agrees the fallout from the Crown Report represents business as usual for the moment. 'We have been talking to nurses and pharmacists for years,' she explains. 'All supplementary prescribing is doing is formalising the process. We already see nurses in areas like asthma and diabetes as significant influencers.'

Rosemary Brook, director of Kaizo's food and health unit, adds that it will be the end of this year in her estimation before PROs have a clear idea of what they are looking at: 'Training courses haven't started yet which means target nurses aren't even identified yet.'

Though it may be early days at present, there are lessons to be learned before new PR strategies are hatched. Manning Selvage & Lee's director of European healthcare, Charlotte Ersboell, believes that caution must be exercised in communicating with both nurses and pharmacists.

'Pharma companies have already bombarded GPs and to some extent exhausted their options there. A common response from GPs is that they are fed up with the amount of material they receive, saying some companies don't understand their time limitations. People need to go about the new audiences with care and involve them as partners. A lot of pharma companies and PR agencies are hiring people from nursing and pharmacy backgrounds but I am not necessarily sure there is sufficient understanding of how to target these people in the right way.'

Finding the right path to nurses and pharmacists is an issue that Sante Communications is already working towards. The agency has a background of work with high street chemist Boots, and is to go one step further by setting up a specialist unit targeting the future prescribers in the pharmacy community. Sante MD Liz Shanahan says: 'We have got a lot of expertise in this area and I would see a lot of educational opportunities.

The pharmacy media is quite well-established and already covers the background on products and diseases. However, historically there has been a limited focus on pharmacists, thus many companies will require advice on how they can reach them.

'While the approach may be similar, ie running advisory boards or regional meetings, the emphasis needs to focus on the specific needs of this group. For certain conditions, pharmacists will soon become the key healthcare advisor in the management of a patient's medication in a not dissimilar way to GPs or other clinicians. Healthcare companies therefore, need to carefully consider how they can influence and advise pharmacists through their communication and medical education programmes.'

For PROs not yet putting resources directly into new means of communication, there is a lot to think about. Nick May, chairman, healthcare and pharmaceuticals, Hill & Knowlton London, agrees there is a key role for agencies to play with supplementary prescribers.

'It strikes me that the crucial question is how much freedom of prescribing they will have,' he says.

'It could be that you will get a pocket, a practice where everyone is enthusiastic (about the new initiatives).' Logically, the opposite could also be true in some areas, he adds.

Getting information to flow between supplementary prescribers and GPs or hospital doctors will also be important.

May continues: 'With the people we do most of our work with we are supporting one good brand against another: how do we get more of that trust in good experiences (with products) back up the line to GPs? It is important to give people simple, clear training with clear markers for when things are going well and when they are not. What are the signs for when they want to change therapy or increase/decrease dosage? When do you go back to the principal prescriber to say things should change? And what's the guidance to the patient? When do I talk to this person (the supplementary prescriber) and when do I talk to this person (your GP)?'

However, comms opportunities are definitely there now, according to Dr Jasmine Zidane, head of bioscience communications at Edelman Health. 'Pharma companies and agencies can help fill in gaps in knowledge,' she says.

'Nurse or pharmacist prescribing can't be in isolation. There are problems with "polypharmacy", it is not just that "A leads to B". It's the bigger picture that GPs have, whereas nurses and pharmacists have specialist expertise in other ways. There is the opportunity for pharma companies to sponsor programmes targeted at nurses, community practices and pharmacists and a whole need for regional, practical initiatives and education, using websites and linking in with people like the Royal College of Nursing (RCN) and the Royal Pharmaceutical Society.'

Pharmacia claims to be doing that with an initiative at Lanarkshire PCT.

It has sponsored nurses' training in Cumbernauld, allowing a pain clinic to be set up which in part led to its leader, senior district nurse Rosemary Showell, being chosen as the RCN's Community Nurse of the Year. Pharmacia's Celecoxib is used in the treatment of osteoarthritis at the clinic and Showell, in nursing since 1967, is set to become a supplementary prescriber later this year.

The Government has made no secret of wanting radical changes to the boundaries of prescribing responsibility to improve the performance of the NHS and is confident the Crown recommendations can provide that, particularly in palliative care. This should take pressure off doctors, freeing their time up to allow further treatment of patients. An ageing population means more chronic disease leading to greater chronic pain - areas in which the putative supplementary subscribers are already expert.

Whatever way pharma companies eventually choose to communicate to their new audiences, Rosemary Brook has a word of caution. Pharmacists and nurses are highly trained health professionals. 'Perhaps nurses are a slightly different target group (to doctors), but pharma companies should not be too patronising about this,' Brook says. 'Nurses have been managing patient prescribing - while not allowed to prescribe themselves - for years. People should be aware that there is not a need for highly simplistic information.'

The next few months will be a learning experience for the new supplementary prescribers and healthcare PR.


Colin Dale, advisor of primary healthcare, Royal College of Nursing

'Nursing will be seen as a much more autonomous profession. This is probably the biggest change in nursing in 30 years. There has been a long-standing stagnation in the professions that needed to be challenged and (health secretary Alan Milburn) has been prepared to ask the difficult questions, like why should it always be a doctor (who prescribes)?

'The requirement to do additional training will continue to be a need for any prescriber and at last year's RCN Congress Milburn saw prescribing being put on nurses' pre-registration curriculum. Training for nurse prescribing is done by higher education establishments but we will make recommendations on it.

'For the RCN there is a capacity issue, making sure that there is a fair coverage of courses throughout the country. There is no reason why nurses aren't perfectly well-placed to manage some conditions, freeing doctors up from over-burden with the result that their valuable time can be better-used in longer consultations for other types of cases.

For example, virtually every surgery has access to a diabetes nurse specialist who now won't have to refer back to the GP to change an insulin dose.

For many prescriptions, the GP is only rubber stamping what the nurse said anyway.

'We understand the concerns (about pharmaceutical companies marketing indirectly to nurses), but there is nothing new in it: GPs are marketed to all the time. Section 7.2 of the code of conduct from the Nursing and Midwifery Council (the industry's registering body) says you must ensure your registration is not used in the promotion of commercial products. They would be in breach of the code if that happened.'


Dr Peter Wilson, lead on supplementary prescribing, Royal Pharmaceutical Society

'The Royal Pharmaceutical Sociey will accredit training programmes and register pharmacists who have achieved the status of supplementary prescribers. We have a curriculum which covers all the knowledge and skills required for prescribing, and although there are no programmes running as yet the Department of Health is keen to get them going by spring. They will be run by higher education institutions and some of the schools of pharmacy would be keen to put on programmes too.

'Payment for training places will come through the NHS via workforce development confederations and we are waiting to see what happens when the NHS publishes how many will be available. The problem (of pharmacists taking time off from work to train) has been recognised. We don't know what the solution is going to be or, indeed, if there is going to be one.

'There is also a section (in the curriculum) called "influences on prescribing" which covers communication. It talks about the awareness of influences that pharmacists need to take note of: these include national influences (such as NICE), local (such as the local area prescribing committees and the pharmaceutical industry's input to training) and personal.

'But we have no explicit concerns about pharmaceutical companies marketing their products to pharmacists. They are already working with PCTs and also with health authorities, and they are trained and competent.

'We expect pharmacists to understand the nature of a working relationship with the industry. There is a code of ethics and we expect pharmacists to use their professional judgment and take an evidence-based approach.'


Rachel Downey, editor, Nursing Times

'We relaunched the magazine in November and expanded our clinical coverage. We have increased staffing, brought in a new primary care editor and boosted the clinical team. For the first time there are new clinical news pages so we can keep readers up to date with drugs approved by NICE, for example. We are not writing "product news" but we are giving readers more news about research on drugs, studies and changes to nursing practice.

'The news desk was staffed by freelances but I have brought that up to strength and appointed a former nurse turned journalist as deputy news editor and a health reporter who was a former clinical reporter on GP magazine.

'Research told us that readers wanted more clinical information. The image of nurses as "caring angels" remains despite the fact that nursing is much more of a profession than a vocation these days and Nursing Times needs to reflect that.

'On 1 April, we will be running a cover story asking whether the Department of Health is going to reach its target number of nurse prescribers. Anecdotally, we know that nurses are confused (by the timescale of the recommendations). But this really is new ground.

'Drugs companies are doing roadshows and people who attend them are saying that they are not a plug for their products although there must be an issue over whether the Department of Health should be doing the training. (NT publisher) Emap Healthcare is considering opportunities although I am not saying we would provide those courses.'


Charles Gladwin, assistant editor, Chemist and Druggist

'Our readers are community pharmacists. At the moment, the priority (in terms of extending prescribing powers) is in primary care rather than high street chemists but we will respond as this moves into the community setting.

'Part of our job is to keep pharmacists abreast of new drugs and how we might tailor that will develop in time. We already do a number of continuing education courses looking at clinical aspects of pharmacy. We provide our own training through our weekly Pharmacy Update, which is a bound-in part of the book on clinical training. Thirty articles are accredited by the College of Pharmacy Practice, which means we are providing at least 30 hours of accredited training. But remember that pharmacists' training is in medicines - they are the specialists. We are also running business management courses.

'All sponsored training material we do is on the OTC side but there is scope for the branded prescriptions side to fit into that. For pharmacists running a pharmacy, getting out to do a month's training will be hard. You can't let the business slip.

'We can help provide some of the material through our own editorial or sponsored material but there is going to be far more to it than having an article in front of you. There will be a range of readers keen to take it up, others will feel it's not for them. Our editorial coverage will be alerting people to what's happening, and looking at how things should be done.'

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