Better Practice

196  Nurse Prescribing 2013 Vol 11 No 4

Nurse-led clinics:Accountability and practice

Richard Griffith

Abstract

The numbers of nurse-led clinics are continuing to grow in primary and acute

care, and they provide timely intervention for patients. The clinics provide exciting

opportunities for nurse prescribers but also carry an increased risk of exposure

to liability. In this article, some of the key areas of accountability underpinning the

duty of care of nurse prescribers working in nurse-led clinics are discussed.

Richard Griffith is a Lecturer at SwanseaUniversity specialising in healthcare and law 

Email: richard.griffith@swan.ac.uk 

Nurse-led clinics will continue togrow under the NHS reforms in

England, with commissioners beingactively encouraged to make better use ofnon-medical prescribers to achieve theirstrategic goals (Fittock, 2010). Research bythe RCN has shown the benefits of nurse-led clinics and their role in the effectiveoperation of the modern NHS (Leary andOliver, 2010). Without these clinics, patientswould not be seen in a timely manner,their conditions could worsen, and cost oftreatment would rise (Middleton, 2012).

Developments in the regulation ofnurse prescribing have enabled thecontinued expansion of nurse-led clinicsin primary and acute care. On the whole,nurse prescribers do an excellent job.Warnings from doctors that nurse-ledclinics were a threat to safety and wouldlead to patients being endangered by thereckless expansion of nurse prescribinghave proved to be unfounded (Cressey,2006). However, there is no room forcomplacency. Medication errors remainthe second most common reported errorin the NHS, behind slips, trips, andfalls (National Health Service LitigationAuthority, 2012). Increased responsibilityfor diagnosis and prescribing undertakenin nurse-led clinics also leads to increasedexposure to liability. In January 2012, the

‘the fulfilment of a formal obligation todisclose to reverent others the purposes, principles, procedures, relationships,results, income and expenditures for whichone has authority...’ 

Tis definition reveals thataccountability has its basis in law with aformal or legal relationship between nurseprescribers and the higher authoritiesthat hold them to account. Te extent ofthe scrutiny goes beyond conduct andencompasses competence and integrity. obe accountable is to be answerable for youracts and omissions. Te NMC (2008a)code states that:

‘You are personally accountable for your practice. Tis means that you are answerable for your actionsand omissions, regardless of advice ordirections from another professional.’ 

o provide maximum protectionfor patients in nurse-led clinics, fourareas of law are drawn together andcan individually or collectively holdnurse prescribers to account. Tey areaccountable to:

 ■ Society through the public law  ■ Patients through the law of negligence ■ Te employer through the lawof contract ■ Te profession through the provisionsof the Nursing and MidwiferyOrder 2001

Falling below the standards imposed bythese four areas of law can result in actionbeing taken against the nurse prescriber.Te need to preserve public and patientconfidence in nurse-led clinics means thatany misconduct by a nurse prescriber is

Royal College of Nursing (RCN) changedthe terms of its indemnity scheme toexclude practice nurses (RCN, 2012). TeRCN argued that the 40–50 annual claimsrelating to practice nurses, many of whichconcerned medication errors, accountedfor 90% of its indemnity scheme budgetamounting to five million pounds.

AccountabilityAccountability is fundamental to theprotection patients receiving careand treatment in nurse-led clinics.It is essential that nurse prescribersclearly understand the scope of theiraccountability, as it is the means bywhich the law imposes standards andboundaries on their practice. Nurseprescribers working in nurse-led clinicshave a considerable amount of autonomyto make decisions about the care andtreatment of patients, and this demandsthe highest levels of probity and a duty toact with honest and integrity at all times.A nurse prescriber in a walk-in clinicwas recently suspended for six monthsby the Nursing and Midwifery Council(NMC) who found his fitness to practiseimpaired when he prescribed fluconozole,erythromycin and cocodamol for his sisterin contravention of standard 11.2 of theStandards of proficiency for nurse andmidwife prescribers (NMC, 2012a).

Defining accountability

Lewis and Batey (1982) defineaccountability as:

 

Nurse Prescribing 2013 Vol 11 No 4 197

Better Practice

taken very seriously. Sanctions are notmutually exclusive, and a nurse prescribercan expect to be punished by more thanone area of law. A nurse prescriber whoreceived a community punishment aerpleading guilty to the the of diazepamtablets from his place of work was alsodismissed by his NHS trust and madesubject to an interim suspension order bythe NMC (2012b).

Duty of careNurse prescribers in nurse-led clinics owetheir patients a duty of care. Te duty isa legal obligation to be careful, to takecare, and it underpins the prescriber’saccountability.

Te standard expected of a skilledprofessional, such as a nurse prescriber,is based on the test established by Bolam v Friern HMC (1957) confirmed by theHouse of Lords in Sidaway v BethlemRoyal Hospital (1985). It requires aprescriber to act in accordance witha practice accepted as proper by aresponsible body of professionals skilled inthat particular art. Tis standard rises themore the professional puts themselves outas an expert. A nurse prescriber employedto treat patients in a nurse-led clinicwill be subject to a high standard whendischarging their duty of care than more junior nurses working on wards or generalcommunity settings.

Although the law is generallycontent for the profession to establishthe standards expected of prescribers,in Bolitho v City and Hackney HealthAuthority (1998), the House of Lords heldthat any expert evidence used to supporta prescribers acts or omissions must standup to logical analysis. Terefore, it isessential that practice in a nurse-led clinicis evidence based and up to date. Courtswill not condone practice where otherstoo are negligent or common professionalpractice is slack (Reynolds v Northyneside Health Authority, 2002).

In England, common standards forquality and safety have been establishedunder the Health and Social Care Act2008 (Regulated Activities) Regulations2010. Te Care Quality Commission(CQC) regulates health and adult socialcare providers in England and imposes16 essential standards for quality andsafety. Nurse-led clinics are required to

dispensing, preparation, administration,monitoring, and disposal of medicines(CQC, 2009).

Failure to comply can result in awarning, fine, or even closure of the nurse-led clinic.

Te CQC has a memorandum ofunderstanding with the NMC and willpass on evidence of poor practice to theregulator for investigation of a nurse’sfitness to practice if they believe the nurseto be responsible for poor standards (CQCand NMC, 2010). A recent review of anurse-led clinic led to CQC enforcementaction when an inspection found that theclinic had failed to ensure that patientswere protected against the risk of unsafeor inappropriate care and treatment due toa lack of proper patient information. Teclinic was required to provide an actionplan for the improvement of this standardto the CQC, who would then check toensure the improvements were madebefore considering further enforcementaction (CQC, 2012).

Scope of duty of care

Lord Diplock in Sidaway v Bethlem RoyalHospital (1985) defined the duty as a:

‘Single comprehensive duty coveringall the ways in which a you are calledon to exercise skill and judgement in theimprovement of the physical and mentalcondition of the patient’.

Te scope of the duty is extremelybroad and covers all the direct andindirect ways nurse prescribers providecare and treatment for patients. It includesdirect care, history taking, diagnosis,recordkeeping, advice giving, the standardof prescribing including the standard ofhandwriting as well as recognising thelimits to the scope of practice, and whento seek more senior assistance (Gold vHaringey Health Authority, 1987). Teduty arises when a nurse prescriber in anurse-led clinic agrees to take a case andcontinues until the patient is discharged,refuses further treatment or is hand overinto the care of another practitioner.

Medication errorsSharing or transferring the care of apatient to another service or prescriber isa situation where nurse-led clinics need

contribute to the achievement of theseessential standards, and the CQC has far-reaching powers to take action if the clinicfails to meet those requirements.

Te essential standards of quality andsafety include:

 ■ Care and welfare of people who

use services ■ Assessment and monitoring of thequality of service provision ■ Safeguarding people who use services ■ Cleanliness and infection control■ Management of medicines ■ Safety and suitability of premises ■ Safety, availability, and suitabilityof equipment ■ Respecting and involving people whouse services ■ Maintaining nutritional needs ■ Privacy, dignity, and independence ofservice users ■ Consent to care and treatment ■ Complaints ■ Records ■ Requirements relating to workers ■ Staffing ■ Supporting workers ■ Cooperating with other providers.

Te standards are an essential yardstickagainst which the clinic service ismeasured.

Managing medicines is a regulatedactivity under the Health and Socialcare Act 2008 and nurse-led clinics havea duty to protect service users againstrisks associated with unsafe use andmanagement of medicines. o achieve thisstandard nurse-led clinics must ensurethat the medicines given to service usersare appropriate and person centred bytaking account of the age, choice, lifestyle,conditions, allergies and disabilitiesof a person when prescribing andadministering medicines. Medicines mustnot be prescribed or administered in thesame arbitrary way to every service user.Te most appropriate medicine, route andform of the drug must be considered ineach person’s case. Prescriptions must bekept up to date, reviewed and changed asthe person’s needs change and risks mustbe managed through effective proceduresfor medicines handling.

Tis includes procedures to be followedfor obtaining, safe storage, prescribing,

 

Better Practice

198  Nurse Prescribing 2013 Vol 11 No 4

to discharge their duty with particularcare. Medication errors at transitions incare have been identified by the WorldHealth Organization (WHO) (2005) asone of nine key patient safety areas thatmust be improved. Te WHO arguesthat over 40% of medication errors occurwhen prescriptions are issued on patientadmission or discharge and they urgea system of medication reconciliationto reduce these errors. Tis requiresprescribers in nurse-led clinics to ensurethey create a complete and accuratelist of all the medicines—includingprescription-only, over-the-counter, andherbal medicines—the patient is taking.Keeping this list under review and up todate to reflect changes in medication andto communicate this list to the next careprovider to minimise error (Institute forHealthcare Improvement, 2005).

Prescription-only drugsAuthority to authorise the supply ofprescription-only medicines can onlygenerally be given by an appropriatepractitioner under the provisions of theHuman Medicines Regulations 2012.

Te Human Medicines Regulations2012 were introduced in August 2012and consolidate the wide range andoen piecemeal orders, regulations, andEuropean directives that had built upover 40 years since the enactment ofthe Medicines Act 1968. Tese are nowlargely drawn together into a singlelegal framework set out in the2012 regulations.

Although medicines law generallyremains unchanged, the 2012 regulationsdo make some provisions clearer andextend the authority of non-medicalprescribers, including those who work innurse-led clinics.

Supplying prescription-only drugs

As a general rule, prescription-onlymedicines must be supplied andadministered in accordance with thedirections of an appropriate practitioneras set out in a valid prescription (HumanMedicines Regulations 2012: regulation214(1)(a)).

Tis strict regime protects patientsfrom the harmful effects of medicines butcan delay treatment because of the needto visit an appropriate practitioner or a

pharmacy before the medicine can besupplied or administered.

o overcome this inflexible processwhile still ensuring the safety of patients,nurse-led clinics can take now takeadvantage of amendments introduced bythe Human Medicines Regulations 2012that allow prescription-only medicines tobe supplied for administration throughpatient-specific directions (PSDs).

Patient-specific directions

PSDs are written instructions forprescription-only medicines to be suppliedfor administration to a named patientwithout a prescription. PSDs have routinelybeen used in hospitals through the patient’sdrug chart and administration record.

Prior to the introduction of the2012 regulations the Prescription OnlyMedicines (Human Use) Order 1997,article 12 allowed any appropriatepractitioner, including non-medicalprescribers, to authorise the supply of aprescription-only medicine in a hospitalfor the purpose of being administered(whether in the hospital or elsewhere) to aspecific person.

For other NHS settings article 12A ofthe 1997 Order limited the exemption todoctors and dentists. Nurse prescriberscould not authorise the supply of aprescription-only medicines in nurse-ledclinics at a health centre, surgery, or othercommunity setting through a PSD, theyhad to issue a prescription.

Te Human Medicines Regulations2012 remove that limitation forindependent nurse prescribers. Regulationsfor the supply of a prescription-onlymedicine do not apply to NHS bodies,including community and primary caretrusts, where the product is suppliedfor the purpose of being administeredto a person in accordance with thewritten directions of doctor, dentist, orindependent non-medical prescriber.

A PSD differs from a prescription. obe lawful, a prescription must meet therequirements of the Human MedicinesRegulations 2012: regulation 217. Incontrast, a PSD is valid when it:

 ■ Is in writing ■ Relates to the particular person towhom the medicine is to be suppliedfor administration; and

 ■ Is issued by a person who is anappropriate practitioner with authorityto issue a PSD in that setting.

Liability for harm rests with theindependent nurse prescriber who willbe accountable for the appropriateness ofthe PSD and the appropriateness of anydelegation of the administration of themedicine to another person.

Te need for a prescription or aPSD to be issued by an appropriatepractitioner with authority is alsoa requirement of the Standards of proficiency for nurse and midwife prescribers and the Standards ofmedicines management  (NMC, 2006,2008b). Failing to meet those standardswill call the nurse prescriber’s fitness topractice into question and they will beheld to account. A nurse who workedat several military health centres wasrecently given an 18-month interimsuspension order by the NMC whilethey conclude their investigation intoa series of incidents where he heldhimself out to be a nurse prescriberand prescribed medication to patientswhen he was not a nurse prescriber(NMC, 2012d). In another case, acommunity matron was subject to an18-month interim suspension orderby the NMC aer investigations foundher to have written prescriptions inadvance of seeing patients and of issuingprescriptions without assessing patients(NMC, 2012c).

ConclusionsNurse-led clinics allow patients toreceive timely care from specialistnurse prescribers and their numbersare set to expand under the NHSreforms in England. Te clinics offernurse prescribers an opportunity todevelop advanced practice and managea caseload of patients with relativeautonomy. With this autonomy comesincreased accountability and exposure tothe risk of liability. o ensure maximumprotection for patients, nurse-led clinicsare subject to legal and professionalstandards that hold the service and itspractitioners to account for the qualityof care delivered in the clinic and thedischarge their duties in law. Failing tomeet the standards imposed by the law

 

Nurse Prescribing 2013 Vol 11 No 4 199

Better Practice

will result in nurse prescribers in nurse-led clinics being held to account and calledto justify their actions. It is essential thatnurse prescribers in nurse-led clinicsare aware of the legal and professionalstandards expected of them and that theydischarge those standards when caring forpatients in their clinics. In this way, theywill ensure the safety of their patients andthe continued development of their nurse-led clinic.

Bolam v Friern HMC (1957) 1 WLR 582

Bolitho v City and Hackney Health Authority (1998)AC 232

Care Quality Commission (CQC) (2009) Essentialstandards of quality and safety. CQC, Newcastle

Care Quality Commission (CQC) (2012) Review ofcompliance at University Hospitals Bristol NHSFoundation rust Central Health Clinic. CQC,London

Care Quality Commission (CQC) and Nursing andMidwifery Council (NMC) (2010) Memorandumof understanding between the Care Quality

Commission and Nursing and MidwiferyCouncil. CQC and NMC, London

Cressey D (2006) Nurse prescribing ‘a threat tosafety’. Pulse October 5th: 1

Fittock A (2010) Non-medical prescribing by nurses,optometrists, pharmacists, physiotherapists,podiatrists and radiographers. A quick guide forcommissioners. National Prescribing Centre,Liverpool

Gold v Haringey Health Authority (1987) 1 FLR 125

Health and Social Care Act 2008 (RegulatedActivities) Regulations 2010 (SI 2010/781)

Human Medicines Regulations 2012 (SI 2012/1916)

Institute for Healthcare Improvement (2005) Te casefor medicine reconcilliation. Nursing Management  September 22nd: 22

Leary A, Oliver S (2010) Clinical nurse specialists:Adding value to care. Royal College of Nursing,London

Batey MV, Lewis FM (1982) Clarifying autonomy andaccountability in nursing service: part I. J Nurs

 Adm 12(9): 13–8

Middleton J (2012) Recognising the value of all rolesin nursing. Nurs Times November 27th: 1

National Health Service Litigation Authority(NHSLA) (2012) NHSLA risk management

standards 2012–13 for NHS trusts providing

acute, community, or mental health and learning

disability services and non-NHS providers of

NHS care. NHSLA, London

Nursing and Midwifery Council (NMC) (2006)

Standards of proficiency for nurse and midwife

prescribers. NMC, London

Nursing and Midwifery Council (NMC) (2008a) Te

code: Standards of conduct, performance and

ethics for nurses and midwives NMC, London

Nursing and Midwifery Council (NMC) (2008b)

Standards for medicines management. NMC,

London

Nursing and Midwifery Council (NMC) (2012a)

Conduct and Competence Committee substantive

hearing on 8 and 9 November 2012. NMC,

London

Nursing and Midwifery Council (NMC) (2012b)

Conduct and Competence Committee substantive

hearing on 8 and 9 November 2012 at the NMC

Aldwych, London, WC2B 4EA. NMC, London

Nursing and Midwifery Council (NMC) (2012c)

Investigating Committee interim order hearing

on the 28 February 2012 at 85 ottenham Court

Road, London, W1 4Q in respect of Dawn

Elizabeth Williams. NMC, London

Nursing and Midwifery Council (NMC) (2012d)

Investigating Committee new interim order

hearing on the 1 August 2012 at the NMC, 61

Aldwych, London, WC2B 4EA in respect of

David Maxwell Mwenitete. NMC, London

Nursing and Midwifery Order 2001 (SI 2002/253)

Reynolds v North yneside Health Authority (2002)

Lloyd’s Rep Med 459

Royal College of Nursing (RCN) (2012) A briefing

from the Royal College of Nursing on changes to

its indemnity scheme. RCN, London

Sidaway v Bethlem Royal Hospital (1985) AC 871

World Health Organization (WHO) (2005)

Collaborating Centre for Patient Safety: Nine life-

saving patient safety solutions. WHO, Geneva

Key Points

 ■ Nurse-led clinics will continue to grow under the NHS reforms in England

 ■ Increased responsibility for diagnosis and prescribing undertaken in nurse-led

clinics also leads to increased exposure to liability

 ■ Nurse prescribers working in nurse-led clinics must act with the highest levels

of probity and have a duty to act with honest and integrity at all times

 ■ Nurse-led clinics must meet the essential standards for quality and safety

imposed by the Care Quality Commission

 ■ Human Medicines Regulations 2012 now allows independent nurse prescribers.

In nurse-led clinics in health centres and community setting to issue patient

specific directions for the supply and administration of prescription-only medicines

Call for Authors

Email the editor: np@markallengroup.com Website: www.nurseprescribing.com

Nurse Prescribingis looking for prescribing professionals and academicsto write medical education articles for the journal.

If you would like to be considered, please contact the editor in the firstinstance with a brief CV and details of your particular areas of expertise

or interest.

 

C o p y r i g h t o f N u r s e P r e s c r i b i n g i s t h e p r o p e r t y o f M a r k A l l e n P u b l i s h i n g L t d a n d i t s c o n t e n t    

m a y n o t b e c o p i e d o r e m a i l e d t o m u l t i p l e s i t e s o r p o s t e d t o a l i s t s e r v w i t h o u t t h e c o p y r i g h t    

h o l d e r ' s e x p r e s s w r i t t e n p e r m i s s i o n . H o w e v e r , u s e r s m a y p r i n t , d o w n l o a d , o r e m a i l a r t i c l e s f o r    

i n d i v i d u a l u s e .