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Minutes

15 March 2006 | 21 June 2005 | 17 June 2002 | 12 March 2002 | 30 October 2001 | 31 July 2001

Confirmed Minutes of the New Prescribers Advisory Committee (NPAC)

Meeting held on 21 June 2005
Ministry of Health, 133 Molesworth St, Wellington
10am - 3pm

Present:

Associate Professor Margaret Horsburgh (Chair)
Ms Sue Driver
Professor Keith Grimwood
Ms Marion Hunter
Associate Professor Judy Kilpatrick
Professor John Shaw
Dr Michal Boyd
Dr Barnet Bond (Joined at 1pm)

Apologies:

Ms Beryl Anderson
Mr Alistair Brown
Dr John Edwards
Dr Dennis Thorburn
Mr Peter Glensor
Dr Stewart Jessamine

In Attendance:

Ryan McLean(Secretary)
Marion Clark, CEO Nursing Council (for part of meeting)
Annette Huntington, Chair Nursing Council (for part of meeting)
Vincent Bailey, Senior Nurse Advisor, Nursing Council (for part of the meeting)

ITEM 1 - Welcome and apologies

ITEM 2 - Minutes of the previous meeting held on 18 February 2005

Minutes were confirmed by Professor Keith Grimwood, seconded by Associate Professor Judy Kilpatrick.

ITEM 3 - Update on activities since the last meeting

Ryan gave the Committee an update on the status of the Optometrist regulations and the status of the expected application from the Pharmacists Association for the extension of prescribing rights to appropriately qualified pharmacists.

ITEM 4 - Discussion of the proposed model for extending prescribing rights to pharmacists

The Committee discussed the proposed framework for extending prescribing rights to pharmacists and noted that the current legislative environment (the Medicines Act 1981) would not support the model being proposed. The Committee suggested the proposed Therapeutic Products Bill, which will overhaul the Medicine Act 1981, should make provision to support the model being proposed to allow pharmacists to prescribe collaboratively.

ITEM 5 - Podiatrist's application

On the whole the Committee agreed there was evidence to support the extension of designated prescribing rights to podiatrists. However, it was felt clarification/strengthening of some points of the application was needed. The following points were made by Professor Keith Grimwood and formed the basis of discussion.

  • The Board has not adequately addressed issues surrounding quality of care and safety (especially in the use of non-steroidal anti-inflammatory drugs (NSAIDs), local steroid injections and the management of patients with complex systemic disease).
  • How common are complications arising from foot surgery performed by podiatrists and how does this compare with comparable procedures performed by orthopaedic surgeons? (page 20 of the application).
  • There needs to be an emphasis on the importance of "foot care" teams where they would play a primary role, as part of a multi-disciplinary team and where concerns over NSAIDs in the elderly could be safely addressed. This would also avoid the duplication of tests such as the testing of renal function and full blood count, etc.
  • It is apparent from the Boards application that there is a lack of understanding of the spectrum of activity, indications and dosages of common antibiotics (page 31 of the application).
  • For example, amoxycillin-clavulanate for coagulase -ve staphylococci, amoxycillin for penicillin-susceptible S. aureus strains and E.coli; cefaclor versus cephalexin (not subsidised) and phenoxymethylpenicillin. Fluoroquinolones are not included, but should be considered, while a special case could be made for prescribing terbinafine. The references quoted are more pharmacological than clinically based. Finally, short acting anxiolytics such as midazolam or lorazepam or other safer alterantives, should be explored instead of diazepam, especially for the elderly.
  • The postgraduate diploma does not appear to include learning in a clinical context where individual decision-making is practised. Initially, this could be difficult because of the lack of experienced podiatrists able to prescribe. However, this could be achieved in multi-disciplinary clinics, such as diabetes, vascular and orthopaedic clinics.
  • Much is made in response to the consultation of "prescribing clinical guidelines", but these are not presented, and should be, because of concerns over clinical safety.
  • No detail was given for assessment or ongoing audit of prescribing competency (page 51 of the application).
  • Two case histories are presented (page 66 of the application):
    1. The second case highlights how podiatrists may encounter difficulties once they start to address clinical problems outside their particular scope of practice (e.g. investigation of suspected SEA).
    2. A case describing management of the "diabetic foot" could have been discussed here, as this is an increasingly common condition where podiatrists should be playing a major role.
    3. The risks of local steroid injections are highlighted and give pause to whether podiatrists should in fact be using them independently.
  • There has been only limited consultation with the health practitioners currently prescribing in this area. The Podiatrist Board could consult the Royal Australasian College of Physicians (diabetes specialists, general physicians, infectious disease physicians and rheumatologists), the Royal College of Pathologists of Australasia (microbiologists), the Australasian Society for Infectious Disease (infectious disease physicians and microbiologists), the Royal Australasian College of Surgeons (general, vascular and orthopaedic surgeons), and to give the Royal New Zealand College of General Practice (including sports medicine specialists) a further opportunity to comment upon their proposal.
  • It would be of interest to learn why podiatrists lost access to "pathology lab service" on a no fee basis.

Action: It was thought appropriate that Ryan prepare a letter to be sent to the Podiatrists Board requesting clarification/strengthening around a number of points

ITEM 6 - Nursing Council Application

Some time was spent clarifying the intent of the Nursing Council submission. The Nursing Council (the Council) attended for part of the Committee meeting to give the Committee members an opportunity to ask for clarification on some points of the Council's application.

It is evident to the Committee that the Council considered that consultation around registration as a Nurse Practitioner prescriber had previously been undertaken and that Nurse Practitioners with prescribing rights was now covered by a scope of practice in the HPCAA. The Committee understood that consultation around scopes of practice for the HPCAA had been with registration bodies only. The Committee accepted that the submission under consideration by NPAC was solely around how to implement Nurse Practitioner prescribing. The Committee were disappointed in the lack of detail around this, in particular around ongoing monitoring and evaluation of nurse prescribing.

The Committee was also disappointed that the collaborative nature of health practice with understanding that Nurse Practitioners work as part of interdisciplinary teams was not made evident in the submission. Collaborative practice is critical to safe clinical decision making.

  • The time allowed for consultation had been six weeks; this has meant the range of submitters was not broad. The Ministry has received letters from the College of General Practitioners and the Society of Anaesthetists outlining their concerns around this issue. The Society of Anaesthetists has alluded to the potential for a judicial review if their concerns are not considered.

Action: Ryan is seeking advice from the Ministry's legal team on the implications of a judicial review for the NPAC.

  • The Council did not include a list of those individuals/organisations who were consulted.
  • The Committee considered the level of qualifications and experience required by the Council of those Nurse Practitioners wishing to gain prescribing rights to be appropriate although it was not clear at the time the Committee considered the application, how many programmes were now approved for preparation of Nurse Practitioner prescribers.
  • The Council had not presented the training requirements including the assessment and supervision in clinical practice of Nurse Practitioners preparing for prescribing in the submission.
  • The Council clarified a number of issues at the meeting - there are five programmes approved to prepare Nurse Practitioners for prescribing. These programmes are offered at the University of Auckland, Auckland University of Technology, Massey University, Otago Polytechnic and the Eastern Institute of Technology.
  • While the process of training and education, including clinical supervision and assessment of Nurse Practitioners preparing to prescribe had been presented to the Committee in previous submissions it would have been helpful to have provided an update of education and training.
  • Supervised clinical practice and clinical decision-making are critical to safe prescribing and the Committee discussed this issue both in the context of the Council's application and the broader preparation of health professional prescribers. The Committee felt that there would be value in generic prescribing courses being developed at a University level.
  • There was a lack of detail around the audit process the Council proposes to use to monitor nurse prescribing (the submission indicated that the Council intended to include Nurse Practitioner prescribers in random audits of all nurses). The Committee considers this inadequate. The Committee would like to see a stand-alone process for monitoring Nurse Practitioner prescribers. Council indicated this would be acceptable. It was felt that there was potential to develop collaborative approaches to monitoring prescribing with medical colleagues.
  • The exclusion list was not considered helpful and the Committee consider that this adds no value to the submission

Action: Ryan to seek clarification around the legal requirement for a 'list'

Recommendations:

The NPAC recommends that the Minister of Health:

  • Agree to proceed with the application for Nurse Practitioner prescribing rights subject to:
    The Council satisfying the Committee that monitoring of Nurse Practitioner prescribing will be appropriate and that the process, analysis and documentation of consultation in respect of Nurse Practitioner prescribing has been adequate.

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