Decision relating to nurse prescribers

Medicines

Decision

PHARMAC is pleased to announce the approval of proposals to:

  1. Amend the Pharmaceutical Schedule rules to support the new prescribing rights that have been granted to Registered Nurse Prescribers.
  2. Amend the ‘Retail Pharmacy - Specialist’ restriction to support prescribing of these products by Nurse Practitioners.

This was the subject of a consultation letter dated 5 August 2016.

Changes were made to the proposal as a result of feedback that we received following consultation. In summary, the effect of this decision is that:

  • The definition of Nurse Prescriber in the Schedule will be removed from Section A General Rules and replaced with new definitions of Registered Nurse Prescriber and Nurse Practitioner. Associated rules, definitions and provisions will be modified accordingly.
  • Registered Nurse Prescribers meeting requirements for qualifications, training and competence will be able to prescribe from a list of medicines within their scope of practice and access subsidies for those medicines in accordance with Schedule rules and restrictions.
  • The definition of Specialist in Section A of the General Rules in the Schedule will be amended to include Nurse Practitioners. This means that Nurse Practitioners employed by DHBs working in secondary and tertiary care settings as part of specialist teams will have access to subsidies for medicines with a ‘Retail Pharmacy- Specialist’ restriction, within their scope of practice.

Feedback received

We appreciate all of the feedback that we received and acknowledge the time people took to respond. All consultation responses received were considered in their entirety in making a decision on the proposed changes. Most responses were supportive of the proposal, and the following issues were raised in relation to specific aspects of the proposal:

Theme

Comment

Some respondents sought clarification on the meaning of “appropriately authorised” (by the relevant DHB to prescribe Retail Pharmacy - Specialist products) and how the appropriate authority would be given and by whom

Appropriately authorised is currently interpreted as meeting the prescriber requirements specified and being employed by a DHB hospital. This has been in place for DHB doctors since 2000. The authorisation and verification required would be no different for Nurse Practitioners

Some respondents did not support amending the definition of Nurse Prescriber to include Nurse Practitioners and Registered Nurse Prescribers. The rationale for this was that the two terms are similar, yet they have different prescribing roles which could result in confusion and poor interpretation of the Schedule. It was also noted that Nurse Prescriber is not used in current medicines legislation or regulations

PHARMAC acknowledges that designated and authorised nurse prescriber roles and scopes are different. The approach proposed was considered pragmatic due to the existing multiple references to Nurse Prescribers throughout the Schedule rules. However, for clarity, the proposal was amended as suggested in the feedback

One respondent recommended that the definition of (and consequential references to) Diabetes Nurse Prescriber should remain on the Schedule until the revocation date of 30 November 2016

The proposal was amended as suggested in the feedback

One respondent was concerned the proposed changes to wording in the definition of Specialist from ‘Doctor’ to ‘Practitioner’ would have unintended consequences, resulting in a variety of other practitioners being able to access subsidy to ‘Retail pharmacy-Specialist’ medicines.  Alternative wording was suggested

PHARMAC staff considered this issue prior to consultation and concluded that using the mechanism of a change to the wording (to ‘Practitioner’) in part (d) of the definition should result in no change to the medicines that are currently able to be subsidised by a variety of other Practitioners. This is for two reasons:

  • these Practitioners are unlikely to be authorised to prescribe on DHB stationery; and
  • most of the medicines with a Specialist restriction would be outside the scope of practice of these other Practitioners.

For complete clarity, the proposal was amended using the alternative wording suggested

Two respondents proposed widening prescribing rights to nurses who support patients with neurological conditions in the community

Subsidy limitations sit on top of legislative prescribing constraints. PHARMAC cannot practically provide subsidy rights to someone who does not have legal prescribing rights

Some respondents were concerned that the proposal removes the ability of Registered Nurse Prescribers to prescribe medicines with Special Authority restrictions

Current designated prescriber groups (such as Pharmacist Prescribers and Diabetes Nurse Prescribers) are unable to apply for new Special Authority approvals or renewals. Pharmaceuticals with a Special Authority restriction may be subsidised when prescribed by these groups only after the initial prescription with Special Authority approval was dispensed. Registered Nurse Prescribers will have provisions consistent with these designated prescriber groups

Respondents raised issues of continuity and clarity around Practitioner and Specialist definitions and application of the rules.In a related matter, respondents noted the proposal in relation to Nurse Practitioners was intended to address some current patient access issues but would like consideration to be given to nursing roles in community and primary care and recommended:

    1. expansion of Specialist definition to include Nurse Practitioners working in private and community settings

    2. a review of medicines and other products included under the ‘Retail pharmacy-Specialist’ restriction

PHARMAC acknowledges that the Schedule rules framework requires a comprehensive review.  We expect next year to undertake a review of how we target access to medicines in the Schedule, including prescriber specific targeting methods, with the aim of building a fresh framework for the future. These issues will be addressed within this larger piece of work

One respondent sought clarification on whether a Nurse Practitioner will be able to apply for Special Authority approvals on medicines where application is limited to “relevant specialist or vocationally registered general practitioner”

Special Authority applications by Nurse Practitioners will continue to be limited to medicines where they meet the “relevant practitioner” or “Nurse Practitioner” applicant criteria. Special Authority applications for medicines that are limited to “relevant specialist or vocationally registered general practitioner” cannot be made by Nurse Practitioners at this time 

Respondents drew attention to possible need to review the definition of Specialist within “Hospital Pharmacy- Specialist” and “Retail Pharmacy – Specialist Prescription”

PHARMAC staff considered this issue prior to consultation and noted that these definitions are not in active use in relation to medicines currently listed on the Schedule.

PHARMAC expects next year to undertake a comprehensive review of how we target access to medicines in the Schedule, including prescriber specific targeting methods, with the aim of building a fresh framework for the future. These definitions will be addressed within this large piece of work

More information

If you have any questions about this decision, you can email us at enquiry@pharmac.govt.nz or call our toll free number (9 am to 5 pm, Monday to Friday) on 0800 66 00 50.