Health and Social Care Bill

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Mr. Denham: I beg to move amendment No. 217, in page 54, line 7, at end insert `;

    (h) any other description of persons which appears to the appropriate Ministers to be a description of persons whose profession is regulated by or under a provision of, or made under, an Act of the Scottish Parliament or Northern Ireland legislation and which the appropriate Ministers consider it appropriate to specify.'.

The Chairman: With this it will be convenient to take Government amendments Nos. 213 and 216.

Mr. Denham: It may be helpful if I explain briefly how the next few clauses relate to one another. Clause 60, together with clause 44 and parts of clause 42, deals with the extension of prescribing rights. The remainder of clause 42 and clause 43 deal with the remote provision of NHS pharmaceutical services--home delivery, mail order and internet services. The genesis of these clauses is the final report of the ``Review of Prescribing, Supply and Administration of Medicines'', which was published in March 1999.

The review, by Dr. June Crown, made a number of recommendations relating to the prescribing and supply of medicines. One of its major recommendations was that legal authority to prescribe in the United Kingdom, including authorising NHS expenditure, should be extended beyond the current prescribers--doctors, dentists and some nurses. It also recommended that legal authority for new professional groups to prescribe should normally be limited to areas within the expertise and competence of each group. Two types of prescriber were recognised: independent prescribers, who would be responsible for the assessment of patients with undiagnosed conditions and for decisions about their clinical management, and supplementary prescribers, previously known as dependent prescribers, who would be responsible for the continuing care of patients who have been clinically assessed by an independent prescriber. The review also recommended that Ministers should receive advice on granting prescribing rights to new professional groups from a UK-wide advisory body, set up under the Medicines Act 1968.

The provisions in clauses 60, 44 and parts of clause 42 help us to implement the review's most important recommendations. Clause 60 amends section 58 of the Medicines Act 1968, and deals with the prescribing of prescription only medicines, whether privately or dispensed as a cost to the NHS. Clauses 42 and 44 make like changes to the National Health Service Act 1977, in respect of ordering drugs and other items on the NHS.

We consulted the NHS and relevant professional organisations before agreeing to implement the main recommendations of the review. A strong majority of the organisations consulted on the review's recommendations were in favour of extending prescribing rights to other health professionals. That is why we are now taking powers that will enable us to implement those recommendations through orders. I

was glad that on Second Reading the proposals were supported by both sides of the Chamber. Action to extend the rights to prescribe medicines will help to break down the divisions between health professions and play an important role in the introduction of more flexible team working throughout the NHS.

I shall give one or two examples of the potential benefits of extended prescribing rights. Physiotherapists may be able to prescribe non-steroidal anti-inflammatory drugs and analgesics rather than having to refer their patients to a GP, and optometrists could prescribe medicines for the treatment of conjunctivitis and other eye infections. However, the proposals will also mean better and speedier access for patients to the medicines they need, as envisaged in the NHS plan.

Clause 60 does not confer any prescribing rights. Instead, it makes it possible for Ministers to extend by order such rights to members of any recognised and regulated health profession. Patient safety will, of course, be paramount during implementation, particularly when considering whether to grant prescribing rights for specific medicines to a professional group. An advisory body under the Medicines Act will take account of concerns when considering the granting of prescribing rights to any specific group of health professionals. That advisory body will make recommendations to Ministers. More detailed proposals for granting prescribing rights for specific medicines to a particular group of health professionals will be subject to both informal and formal consultation with relevant organisations.

The Government amendments are related. Clause 60(3) lists the registered health professionals who may be considered for prescribing rights. Government amendment No. 217 extends that list to ensure that health professions, regulated under separate Scottish and Northern Ireland legislation, have the same potential right to prescribe as health professionals regulated under the specified Acts of Parliament.

Clause 42(3) lists the registered health professionals whose prescriptions may be dispensed under the NHS in England and Wales. Government amendment No. 213 extends that list to ensure that prescriptions of Scottish and Northern Irish regulated professionals will be able to be dispensed in England and Wales.

Finally, clause 44(3) lists the registered health professionals whose prescriptions may be dispensed under the NHS in Scotland. Government amendment No. 216 amends that list to make similar provisions in Scotland for health professionals regulated under Northern Ireland legislation.

Mr. Swayne: I have a number of questions for the Minister. First, how will the advisory body be constituted? Will it comprise members of the professions that are to obtain prescribing rights under the regulations? The Royal College of Nursing wants to know why midwives and nurses are not included in the list in amendment No. 213. He will be aware that the limited content of the current nurse prescribers formulary has proved frustrating, and that the royal college wants the full British national formulary to be accessible to all licensed nurse prescribers.

The electronic mail message that I received from the royal college states:

    ``The RCN calls on the Government to ensure that nurses who have specialist training can prescribe controlled drugs as well as having access to an increased range of other prescription only medicines. This would mean, for example, specialist pain control nurses could prescribe controlled drugs such as diamorphine for patients with a clinical need.''

That description seems consistent with what the Minister said about different groups with different expertise being able to prescribe in a particular way. Will he respond to that point when he answers the debate?

Concern has been expressed about the degree of restriction that regulations may place on legitimate prescribing powers. If regulations are to specify in detail what drugs can be prescribed and in what circumstances, they will rapidly become cumbersome and out of date. It will be difficult for dispensing pharmacists to keep abreast of changes in products and what is available for patients. The benefits that those patients may obtain from those products, and the most up-to-date clinical practices will be constrained by regulation . How quickly can we expect the regulations to be reviewed to accommodate pharmaceutical developments?

3.15 pm

There must be absolute clarity about where clinical responsibility lies. Perhaps the Minister will say something about that. Will it lie with those who gain the new prescribing rights? The Minister commented on the independence of those people, but the implications were not clear. Will the new prescribing rights be independent of the existing prescribers—general practitioners and consultants—or will they be dependent on an existing prescriber, who will take full responsibility?

What safeguards does the Minister plan to provide to ensure communication between multiple prescribers, to avoid interactions between the drugs prescribed for a patient by several eligible professionals?

Dr. Peter Brand (Isle of Wight): The Minister is right to attempt to outline the professional groups that should have prescribing rights and to consider specific drugs in relation to those groups. I also invite him to consider the specific settings or circumstances under which prescribing takes place. I share some of the concerns expressed by the hon. Member for the nicer bit of the New Forest—the hon. Member for New Forest, West (Mr. Swayne)—as accountability and teamwork should be strengthened rather than confused by the provisions.

Let us deal with dependent prescribers—that is not a happy term—in a hospital. I imagine that a specialist diabetic nurse would prescribe according to protocols accepted by the diabetic team, which would include a consultant. If so, there should be shared accountability within that team for what happens to the patient. If prescribing occurs outside that unit, the nurse practitioner would become responsible by himself or herself.

It would be nice if the Minister gave some thought to the possible conflicts within a team. A specialist asthma nurse may be keen to follow the guidelines of the British Thoracic Society--which are excellent, although some eccentric asthma physicians do not hold by them. The nurse prescriber would have a good basis to act independently as a prescriber, but would be in a difficult position if the consultant, who was part of an asthma team in a hospital, was not prepared to back up the prescriptions that had been issued.

In primary care, teamwork has probably evolved more than in hierarchical, hospital-based structures. However, there is sometimes wooliness as to who is a member of the core primary care team and who is an adjunct, and therefore important but not integral. Where does the definition of dependent and independent prescriber begin and end?

Clearly, independent practitioners—physiotherapists, ophthalmologists and others who rightly have wider prescribing rights—would not necessarily fit into a primary care team on a day-to-day basis. It is more difficult for them to share local protocols on how to deal with particular diseases. In the relevant circumstances, the practitioner would be totally responsible for the prescribing, in the same way as a practitioner, a nurse practitioner or a pharmacist in a walk-in centre should be responsible for a prescription that he or she has issued. I am, however, slightly concerned about the lack of a clear mechanism by which the responsibility could be passed on to members of the team caring for the patient.

General practitioners are worried about the case law covering what could happen once a hospital pathology department or diagnostic imaging department had obtained abnormal results, in a process that had been initiated by a hospital consultant, and had sent a copy to a general practitioner. If the hospital failed to act on the abnormal results, and things went amiss, and if the GP had not acted on the results that were copied to him or her, there would be joint liability. I am slightly concerned, given the proliferation of agencies that are now involved with the care of patients, that that could become an increasing problem.

Out-of-hours co-operatives have established a fairly tight regime of information sharing and handing over of responsibilities. When an out-of-hours service ceases to operate at 8 o'clock in the morning and passes over the notes of the events of the night, liability for the patients transfers immediately back to the GP with whom the patient is registered. In a walk-in clinic matters are not so clear. The GP may not receive notification. There is no statutory responsibility to share information.

Information may be shared in the form of a fax that arrives at 11 o'clock on a Saturday morning, which may not be seen until 11 o'clock on a Monday, after the Monday morning rush, when people begin to look at the faxes that have arrived. In the meantime, for a day and a half the patient concerned may have been on inappropriate treatment, or may have needed further treatment, without follow-up. Would that situation impose a liability on the practitioner, who had not sought the information but on whom it had been thrust? Would responsibility be thrust upon the practitioner?

My difficulty with clause 60 is that all such matters are left to regulations. Issues of accountability are very important, and I wonder whether the Government are being unwise in not specifying in the Bill where responsibility will lie for the actions of the professional groups that they are rightly including in the provisions. The need for insurance and legal accountability can of course be discussed under amendment No. 278, which will no doubt be moved by the hon. Member for New Forest, West, but I should like the Minister's response on the general points.

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