Legislation Application And Patient Centric

Legal basis for supplementary prescribing: Definitions of supplementary prescribing and clinical management plans CMP

According to Root (2003), supplementary prescribing refers to a voluntary prescribing partnership between an independent prescriber mainly the doctor of a patient and a nurse or pharmacist also referred to as a supplementary prescriber in order to effectively implement an agreed patient specific clinical management plan with an agreement made with the patient. The development of supplementary prescribing was made possible with the passing of Health and Social Care Act in 2001 after which numerous further legislations and regulations have been developed with regards to defining a legal basis for supplementary prescribing. Currently the Medicinal Products: Prescription by Nurses and Others Act 1992 informs the primary legislations that enable nurses, Midwives and pharmacists to prescribe medicinal drugs (Watterson, 2009). This legislation defines a supplementary prescriber as any registered nurse midwife or health visitor approved with relevant training in handling, prescribing and administering drugs to patients. This essay aims to explore the various issues regarding supplementary prescriptions the legislations that effect the prescription as well as its application in relation to the use f the Clinical Management Plan with a chosen patient.

The main aim of supplementary prescribing includes improvement patient experience, efficiency and effectiveness in receiving treatment through access to better quality of care and improved patient safety (Hobson, 2010). Given the duties of diagnosis and treatment weighing down on doctors, supplementary prescription comes in to ease the burden for doctors and ease access of patients to their medication. Cooper et al (2008) highlights that the department of Health has enabled nurses, pharmacists, optometrists and some Allied Health Professions (AHPs) physiotherapists, chiropodists or podiatrists and radiographers to train as supplementary prescribers so that they can prescribe medicines, within an agreed Clinical Management Plan for a patient.

Given the complicated and lengthy treatment that a patient may have with relation to the kind of illness they suffer and are undergoing treatment for, and the inability of doctors to be able to keep up the treatment program with their patients and at the same time attend to new patients in the aim to serve each person singularly and equally, a Clinical Management Plan is developed for the patient after which a registered nurse and a supplementary prescriber can take over the continuation of the patients treatment ( Berry, Courtenay and Bersellini, 2005)

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The development of a written individual Clinical Management plan which must be agreed upon by the patient, the independent prescriber and the supplementary prescriber, Access to the same common patient record as well as effective communication between the independent and supplementary prescriber are some of the key principles that underpin supplementary prescription(Root, 2003).

Despite there being no scope of illnesses strictly defined for supplementary prescription, the development of a simple acceptable Clinical Management Plan can be quite an investment in terms of time consumption, as such Courtenay, Carey and Burke (2007) highlight that supplementary treatment is reserved for long term illnesses such as asthma, hypertension, Diabetes as well as neurological diseases. However for Acute conditions that require a regular input of the independent prescriber due to the need for frequent changes in medication, Supplementary subscription is highly unlikely to be solely used.

Before endeavoring in supplementary prescription, development of clinical Management Plan of the patient with regards to the specific condition being managed as well as the secluded date for the commencement of the plan is essential. Health professionals offer the expertise of scientific knowledge in relation to the patients’ condition and potential treatment but the patient offers their personal expertise of themselves and how they cope with illness (Weiss and Britten, 2003)

Miss X for instance is 26 years old single woman presented at the private clinic with severe hyperhidrosis and had been successfully treated by the aesthetic doctor for two years. Appendix 1 highlights the Clinical Management Plan used and aimed at providing medication to control sweating and allow patients well being by preventing isolation and psychological impact of the condition.

The independent prescriber sets within the Clinical Management Plan the relevant range of discretion consistent with the patient’s safety. The CMP also includes relevant warnings of known sensitivities to particular medicines as well as including procedures and arrangement for notification of adverse drug reactions (Jones, 2010).

Miss X reports that she always had been over sweating since her young ages. She has no relevant past medical history, but a left knee arthroscopy 2 years ago. She is not taking any medication expect sometimes paracetamol for her migraine. Miss X is not aware of any allergy. She doesn’t smoke but spend almost every Friday evening at the local bar celebrating the end of the working week with her office colleagues. She denied the use of illegal drugs. Family history and social history reveal that Miss X lives with her depressed mother, never known her father and that her brother complains of excessive sweating on the axillary. This background already suggest a possibility of trauma that has a potential of effecting her social exclusion as well as public embarrassment for her condition, despite the record showing positive outcome from the treatment that relieve her from social embracement and isolation.

Miss X is now a functional member of society with a job and friends but she remembers how her clothes would become soaked from the axilla down to her waist, sweat run down her arms and dripping out the sleeves of her shirt. Over the counter antiperspirants were not of much help to her until her general practitioner recommended treatment with Botulinum toxin type A with a dose usage of 50 Units for each axillae. Being able to treat Miss X and prescribe her medication that will greatly help her reduce sweating and as such improve self confidence and esteem is critical for the patients well being, however it requires a lengthy period highlighting the need for a Clinical Management Plan and a supplementary prescriber to help her go about her regular treatment.

According to Scamoni et al. (2012) Primary Hyperhidrosis refers to an idiopathic and chronic disorder of uncontrollable sweating without any distinct recognizable cause. Despite its classification as primary and secondary hyperhidrosis, primary Hyperhidrosis is much more common and accounts for up to 90% of the cases diagnosed within the UK. Karpinski (2016) further highlights that Hyperhidrosis of all kinds can be exacerbated by stimulant containing foods especially caffeine and theobromine highlighting that dietary restrictions make up part of the Clinical Management Plan in being able to manage the condition.

Scamoni et al. (2012) further highlights that up to 1 % of the population within the UK are diagnosed with Primary auxiliary. One third of these individuals that they experience continuous and intolerable sweating that occur frequently and profusely during the day thereby effectively interfering with their daily activities. As such, patients with this condition experience increased chronic stress and depressive symptoms, with axillary disease carrying the highest morbidity.

Among the symptoms developed by patients suffering axillary hyperhidrosis include copious volumes of watery sweat despite environmental or physical conditions, staining of cloths and on a rare occasion softening of the skin. Most of these symptoms are experienced by patients as early as puberty or in the adolescence stage of life. Psychological issues such as low self-esteem and interpersonal difficulties have also been reported causing a negative impact on daily activities and impaired performance and productivity at work. This results in higher rates of depression (Hamm, 2014).

Anxilliary Hyperhidrosis is further accentuated and manifested through Bromhidrosis. According to Greenberg, Shaw and Reuman (2016) Bromhidrosis is a condition of abnormal and offensive body odour that is to a large extent determined by apocrine and/or eccrine gland secretions. The condition is further aggravated by poor hygiene or underlying disorders promoting bacterial overgrowth, including diabetes, and obesity.

While a wide range of treatment exist that can be adopted to manage the condition, Karpinski (2016) highlights that these medications seek to decrease sympathetic stimulation, block sweat gland openings or produce neuro-acinar blockade, all of which are temporary solutions and at best highlight the patience reliance of the medication throughout their lifetime to control the disorder. In addition the first line medication is not quite efficient and effective in all cases. Topical Aluminum chloride works by obstructing sweat ducts, but fails and/or is not tolerated in 20% of cases. Anti‐cholinergic like oxybutynin, are often limited by adverse effects which outweigh benefit in around 60%. Thoracic sympathectomy retains high complication rates both intra‐ and post‐operatively, including up to 90% compensatory hyperhidrosis (Stewart, 2018).

However the first line of therapy for axillary hyperhidrosis and which Miss X applied unsuccessfully involves the use of topical antiperspirants. Treatment with prescription antiperspirants, such as aluminum chloride hexahydrate, may provide adequate therapy for patients who fail to respond to non-prescription antiperspirants. Aluminum chloride, known for its hemostatic properties, activates the extrinsic coagulation pathway and causes vasoconstriction. The afterward development of the Clinical Management Plan to enable the supplementary prescription involved the use of Botulinum toxin A.

Botulinum toxin A is a highly effective treatment for hyperhidrosis and within the UK relevant legislations approve of it for the treatment of severe axillary hyperhidrosis. Heckman et al. (2001) highlights its mechanism of action to be inhibiting the release of acetylcholine from the neuromuscular junction and sympathetic nerves that innervate the eccrine sweat glands. Botulinum toxin A is reported to have an efficacy greater than 90% for hyperhidrosis treatment and has greater improvements within the first 22 weeks of treatment. However since the Neuromuscular joints to which the treatment is injected are synthesized the drugs effect only lasts a maximum of up to 9 months. In addition to this the painful nature of the Injections are also limiting consequently necessitating the need for a supplementary prescriber to administer the drug to the patient on a regular basis based on the parameters as well as the guidelines set out on the Clinical Management Plan designed by the independent prescriber.

According to Miss X’s CMP, she is scheduled to take 50 units of the drug Botulinum Type A on each axillae to help with the control of excessive sweating. While the CMP does not specify the actual interval for the medication administration, it highlights specific indications for referral back to the independent prescriber. These include: development of any new symptom related to the condition, the occurrence of important changes in patient life style such as pregnancy planning, that could greatly impact the treatment and signs of developed resistance to the Boitulinum Type A medication.

The designed CMP hugely benefits the patient Miss X in a range of ways including enabling her be able to plan for her future. Given that Miss X is a young woman, future plans of having children is a most likely thought that the CMP accounts for by developing a lee way for revisiting the independent prescriber at the opportune time. In addition to this having Just secured a job and therefore forward looking in the development of her life, Miss X is prone to high social activity which would be a challenge in her condition minus the treatments, an annual review of her treatment plan therefore comes to her advantage in being able to psychologically coup with her situation. From an aesthetics clinic prospective it helps to ease the Aesthetics doctor amount of work.

According to Brodsky et al. (2012) the greatest variables that affected migration or spread of botulinum toxin from the target site included dose, concentration and volume injection. The larger the volume of injection, the greater the risk of migration from the target site, due to greater extracellular toxin available. Higher concentrations of botulinum toxin allow for lower volume injections, increased precision and a reduced risk of toxin migration to non-targeted areas (Collier, 2013).

In addition to this a range of safety practices that are crucial in the effectiveness of the medication functioning and which are not included within the CMP include: avoiding deodorant sprays and skin ointments for at least two to three days after the treatment, avoiding strenuous exercises within 24 hours of the medication administration, and exposure to ultra violet Light (Sycha et al., 2007).

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References

  • Berry, D., Courtenay, M. and Bersellini, E. (2006). Attitudes towards, and information needs in relation to, supplementary nurse prescribing in the UK: an empirical study. Journal of Clinical Nursing, 15(1), pp.22-28.
  • Brodskey M. A. Swope D. M. And Grimes D. (2012). Diffusion of botulinum toxins. Tremor Other HyperkinetMov (N Y). 2:pii: tre-02-85-417-1
  • Carey N. and Stenner K. (2011) Does non-medical prescribing make a difference to patients? Nursing Times;107: early online publication.
  • Cooper, R., Lymn, J., Anderson, C., Avery, A., Bissell, P., Guillaume, L., Hutchinson, A., Murphy, E., Ratcliffe, J. and Ward, P. (2008). Learning to prescribe – pharmacists' experiences of supplementary prescribing training in England. BMC Medical Education, 8(1).
  • Courtenay, M., Carey, N. and Burke, J. (2007). Independent extended and supplementary nurse prescribing practice in the UK: A national questionnaire survey. International Journal of Nursing Studies, 44(7), pp.1093-1101.
  • Greenberg J. L., Shaw A. M. and Reuman L. (2016). Clinical features of olfactory reference syndrome: an Internet-based study. J Psychosom Res. 80(1), pp: 11–16.
  • Hamm H. (2014). Impact of hyperhidrosis on quality of life and its assessment. DermatolClin. 32(1) pp. 467–76.
  • Heckmann, M., Ceballos-Baumann, A. and Plewig, G. (2001). Botulinum Toxin A for Axillary Hyperhidrosis (Excessive Sweating). New England Journal of Medicine, 344(7), pp.488-493.
  • Hobson R. (2010) Pharmacists and nurses as independent prescribers: exploring the patient’s perspective. Family Practice; 27: 1, 110-120.
  • Jones M et al (2010) Nurse prescribing roles in acute care: an evaluative case study. Journal of Advanced Nursing; 67: 1, 117-126.
  • Karpinski, R. (2016). Surgical Treatment of Axillary Hyperhidrosis Treatment & Management: Medical Therapy, Surgical Therapy, Sympathectomy. [online] Emedicine.medscape.com. Available at:
  • Root G. (2003). Supplimentary Prescribing-A ground breaking Opportunity. The Pharmaceuticals Journal. 270(7230), pp 19-20.
  • Rosen R. and Stewart T. (2018). Results of a 10‐year follow‐up study of botulinum toxin A therapy for primary axillary hyperhidrosis in Australia. International medicine journal
  • Scamoni, S., Valdatta, L., Frigo, C., Maggiulli, F. and Cherubino, M. (2018). Treatment of Primary Axillary Hyperhidrosis with Botulinum Toxin Type A: Our Experience in 50 Patients from 2007 to 2010.
  • Sycha T., Kotzailias N., Kranz G., Trautinger F., Schnider P. And Auff E. (2007). UV-B irradiation attenuates dermal effects of botulinum toxin A: a randomized, double-blind, placebo-controlled study. Dermatol Surg. 2007;33 (1 Spec No):S92–S96.
  • Watterson A.(2009) An Evaluation of the Expansion of Nurse Prescribing in Scotland. Edinburgh: University of Stirling.
  • Weiss, Britten (2003). What is Concordance. Pharmaceutical Journal 271: 493-494

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