To seek views on possibilities for introducing independent … · 2013-07-16 · This engagement...

Engagement exercise

To seek views on possibilities for introducing independent prescribing responsibilities for podiatrists

distributed

DH INFORMATION READER BOX

Policy EstatesHR/Workforce CommissioningManagement IM&TPlanning/ FinanceClinical SocialCare/PartnershipWorking

Document purpose GatheringINFORMATION

Gateway reference 14691

Title ENGAGEMENTEXERCISETOSEEKVIEWSONPOSSIBILITIESFORINTRODUCINGINDEPENDENTPRESCRIBINGRESPONSIBILITIESFORPODIATRISTS

Author DepartmentofHealth

Publication date 3Sept2010

Target audience PPCTCEs,NHSTrustCEs,SHACEs,FoundationTrustCEs,MedicalDirectors,DirectorsofPH,DirectorsofNursing,DirectorsofAdultSSs,PCTChairs,NHSTrustBoardChairs,DirectorsofHR,DirectorsofFinance,AlliedHealthProfessionals,GPs,DirectorsofChildren’sSSs

Circulation list

Description Thisengagementexerciseprovidesbackgroundandinvitesviewsonpossiblechangestomedicineslegislation,whichwouldenablepodiatristtoprescribeindependently.ItmaytheninformandassistthedevelopmentofaformalpublicconsultationbytheMedicinesandHealthcareproductsRegulatoryAgency(MHRA)proposingamendmentstotherelevantlegislation.

Cross reference N/A

Superseded docs N/A

Action required Respondtothequestionsprovidedtothemailboxorinwriting

Timing Responses required by 26 Nov 2010

Contact details ShelaghMorrisAHPPLTRoom5E58QuarryHouse,QuarryHill,LeedsLS27UE01132546061

For recipient’s use

Engagement exercise – To seek views on possibilities for introducing independent prescribing responsibilities for podiatrists 222

Contents

About this engagement exercise 4

What is non-medical prescribing? 4

Who can respond to this engagement exercise? 5

How to respond 5

What podiatrists do Examples of podiatry roles

78

Where podiatrists work 10

How podiatrists are trained and regulated 10

How would podiatrist independent prescribers be trained? 11

What benefits would podiatrist independent prescribing bring? 13

Protecting the public 14

Governance and safeguards 15

Options for podiatrist independent prescribing 17

Engagement exercise – To seek views on possibilities for introducing independent prescribing responsibilities for podiatrists 3

Further considerations 22Controlled drugs 22Mixing prior to administration 23Prescribing of unlicensed medicines 24Off-label prescribing or supply of medicines 25Simultaneous prescribing and administration 26

Additional questions 27

Appendix 1 Non-medical prescribing and medicines supply mechanisms

2929

Appendix 2 Main conditions and medicines – podiatry

3131

Engagement exercise – To seek views on possibilities for introducing independent prescribing responsibilities for podiatrists

About this engagement exercise

What is non-medical prescribing?

Who can respond to this engagement exercise?

How to respond

What podiatrists do

Where podiatrists work

How podiatrists are trained and regulated

How would podiatrist independent prescribers be trained?

What benefits would podiatrist independent prescribing bring?

Protecting the public

Governance and safeguards

Options for podiatrist independent prescribing

Further considerations

Additional questions

Appendix 1

Appendix 2

44

About this engagement exerciseInJuly2009theDepartmentofHealth(DH)AlliedHealthProfessionalsPrescribingandMedicinesSupplyMechanismsScopingProjectrecommendedthatfurtherworkbeundertakeninordertoextendindependentprescribingtoappropriatelytrainedchiropodists/podiatrists(fromnowonreferredtoonlyaspodiatirsts),inordertoimprovethesafety,effectiveness,patientexperienceandproductivityofhealthcare.TheDHNon-MedicalPrescribingBoardacceptedtherecommendationsandagreedthatfurtherworkshouldbeundertakentoexploreindependentprescribingbypodiatrists.

Thisengagementexerciseprovidesbackgroundinformationandinvitesviewsonpossiblechangestomedicineslegislation,whichwouldenableappropriatelytrainedpodiatriststoprescribeindependently.Dependingontheoutcomeofthisexercise,andsubjecttoagreementbyMinisters,itmaytheninformandassistthedevelopmentofaformalpublicconsultationledbytheMedicinesandHealthcareproductsRegulatoryAgency(MHRA)proposingspecificamendmentstotherelevantlegislation.

Thisengagementexercisewillremainopenfor12weeks,endingFriday26November2010.

What is non-medical prescribing?Overrecentyearschangestothelawhavepermittedanumberofprofessions,otherthandoctorsanddentists,toplayanincreasingroleinprescribingandmanagingmedicinesfortheirpatients.Therearenowover16,000qualifiednurseindependentprescribersandaround1000qualifiedpharmacistindependentprescribers.Morerecently,Optometristshavebeenaddedtothelistofprofessionsabletoprescribeindependently.Evidencefromevaluationofnurseprescribingin20051andarecentevaluationofnurseandpharmacistprescribingbytheUniversitiesofSouthamptonandKeele(dueforpublication2010)indicatesthatsuchprescribingisvaluedbypatientsandgivesthemquickeraccesstothemedicinesthattheyneed.

1UniversityofSouthampton(2005)Evaluationofextendedformularyindependentnurseprescribing–ExecutiveSummary,DepartmentofHealth,London.





How to respond

What podiatrists do










Appendix 1

Appendix 2

5

Podiatristshavebeeninvolvedinthedirectcareofpatientsformanyyears.PodiatristshaveexperienceinthetreatmentofconditionswithmedicinesthroughtheuseofExemptions–whichenablealimitedlistofPrescriptionOnly(POM)andPharmacy(P)plusallGeneralSales(GSL)medicinestobesold,suppliedoradministeredinthecourseoftheirprofessionalpractice.TheseExemptionssitalongsidePatientSpecificDirections2andPatientGroupDirections3.Since2005,experiencedpodiatristshavebeenabletotrainasSupplementaryPrescribers(Appendix1containsfurtherdetailaboutthevariousnon-medicalprescribingandmedicinessupplymechanisms).

Thisengagementexerciseseeksviewsonpossibilitiesforintroducingindependentprescribingresponsibilitiesforpodiatrists.

Who can respond to this engagement exercise?Everyoneiswelcometorespond.Wehopetohearfromthepublic,patients/patientrepresentativegroups,healthcareproviders,commissioners,doctors,pharmacists,regulators,non-medicalprescribers,theRoyalCollegesandotherrepresentativebodies.

How to respondYoucanrespondinoneoftwoways:

• Byusingtheelectronicresponseform.Typeyouranswerstothequestionsintotheboxesprovided.Whenyouhavecompletedthefinalquestion(question11)andenteredyourdetailsbelowit,clickon‘Saveform’.Thiscreatesapdffilewhichyoushouldsavetoyourcomputerdesktop.Youcanthenemailthepdffiletousatahpprofessionalleadershipteam@dh.gsi.gov.ukusingthe‘Attachtoemail’optioninthe‘File’menuofthepdf.

• Alternatively,youmayprinttheformandsenditinhardcopyto:ShelaghMorris,ProfessionalLeadershipTeam,DepartmentofHealth,QuarryHouse,LeedsLS27UE

2Theterm“PatientSpecificDirection”isnotdefinedinlegislation.Itreferstothewritteninstructionofaprescriberwhichenablesapersontosell,supplyoradministeramedicinetoanamedpatient.

3Theterm“PatientGroupDirection”andtheassociatedlegalrequirementsaredefinedinmedicineslegislation.

mailto:[email protected]





How to respond

What podiatrists do










Appendix 1

Appendix 2

6

IfyouhaveanyqueriesorrequirefurtherinformationinrelationtothisengagementexercisepleasecontactAlexHill,[email protected].

Confidentiality of Your ResponseWemanagetheinformationyouprovideinresponsetothisengagementexerciseinaccordancewiththeDepartmentofHealth’sInformation Charter.

Informationwereceive,includingpersonalinformation,maybepublishedordisclosedinaccordancewiththeaccesstoinformationregimes(primarilytheFreedomofInformationAct2000(FOIA),theDataProtectionAct1998(DPA)andtheEnvironmentalInformationRegulations2004).

Ifyouwanttheinformationthatyouprovidetobetreatedasconfidential,pleasebeawarethat,undertheFOIA,thereisastatutoryCodeofPracticewithwhichpublicauthoritiesmustcomplyandwhichdeals,amongstotherthings,withobligationsofconfidence.Inviewofthisitwouldbehelpfulifyoucouldexplaintouswhyyouregardtheinformationyouhaveprovidedasconfidential.Ifwereceivearequestfordisclosureoftheinformationwewilltakefullaccountofyourexplanation,butwecannotgiveanassurancethatconfidentialitycanbemaintainedinallcircumstances.AnautomaticconfidentialitydisclaimergeneratedbyyourITsystemwillnot,ofitself,beregardedasbindingontheDepartment.

TheDepartmentwillprocessyourpersonaldatainaccordancewiththeDPAandinmostcircumstancesthiswillmeanthatyourpersonaldatawillnotbedisclosedtothirdparties.However,theinformationyousendusmayneedtobepassedontocolleagueswithintheUKHealthDepartments.

What podiatrists doPodiatristsarestatutorilyregisteredhealthprofessionalswhofocusonthediagnosis,managementandtreatmentoffootandlowerlimbdisorders.Theirkeyroleistohelppreventorcorrectdeformityandmaintainnormalmobilityandfunction.Podiatrists’managegaitproblemsandidentifyassociatedmedicalorsurgicalconditionsthatmayrequirefurtherreferralandmanagement.They






How to respond

What podiatrists do










Appendix 1

Appendix 2

7

alsohelptorelievepainfulfootconditions,treatfootinfectionsandotherdisordersoftheskin,nail,softtissueandconnectivetissues,oftenworkinginconjunctionwithothermembersofthehealthcareteam.Podiatristscanalsogiveexpertadviceonfootwear.Specialistpodiatristsseemanypatientsathighriskofamputation,forexamplethosewhosufferfromimpairedbloodsupplytothelowerlimb,footulcersandwounds,orthoserequiringsurgery,forexampletocorrectbunions.Podiatristsareactiveinhealthpromotion,preventativehealthcare,treatmentandrehabilitationusingphysicaltreatments,medicinesandsometimessurgery.

Followingpre-registrationtraining,mostpodiatristsgainexperienceingeneralpractice,mainlyintheNationalHealthService(NHS),orintheprivatesector.Manypodiatriststhengoontospecialise,orworkexclusivelywithaspecificclientgroup.Perhapsthemostwellknownfieldsofspecialisationincludemusculoskeletal(suchasfunctionalfootandgaitproblems,alsoknownasbiomechanics,andsportsinjuries),diabetescare(assessingtheriskofandmanagingfootulcersandwounds)andrheumatology.Otherspecialismsareindermatology,footwear,surgeryandchildren’slowerlimbproblems.

Advancedandconsultantpodiatryroleshaveledthedevelopmentofpodiatrytoincreasinglevelsofresponsibilityfordiagnosis,onwardreferralandprovisionofspecialistinterventions.ThepublicincreasinglyuseNHSandindependentsectorpodiatristsdirectly(egself-referral)fordiagnosisandtreatment,withoutcontactingadoctor.

SincetheMedicinesAct(1968)wasintroduced,somepodiatristshaveusedmedicinessafelyandeffectivelyintheirprofessionalpracticethroughPatientSpecificDirectionsissuedbyadoctor.From1980,somepodiatristshavealsohadaccesstocertainmedicinesviastatutoryexemptions,allowingthemtosell,supplyandadministerfromalimitedlist.Forexample,since1980theuseofinjectablelocalanaestheticagentshasbecomeacommonpartofpodiatricpracticeforthosepodiatristsqualifiedtousethem.Today,thesepodiatristsareidentifiedontheHealthProfessionsCouncil’sregisterbyaspecialannotation,referredtoas‘localanaesthesia’.ReviewsofExemptionsovertheyearshaveextendedpodiatristsaccesstoawiderrangeofmedicinesforsupplyandsale,includingsomeanti-inflammatorymedicines,anti-fungalagentsandantibioticsforthetreatmentof





How to respond

What podiatrists do










Appendix 1

Appendix 2

8

infections.Accesstotheseadditionalmedicinesrequiresafurtherqualification,andthosepodiatristsinpossessionofthisqualificationarealsoannotatedontheHPCregister,asthe‘POM’qualification.In2000,specialistpodiatristsweregrantedrightstosupplyandadministeranevenwiderrangeofmedicinesviaPatientGroupDirections.Allthesemechanismsareusedinabroadarrayofcommunityandacutesettings,witharangeofmedicinesused,spanningmusculoskeletaldisorders,diabetescare,skindisorders,footsurgeryandinthecareoftheelderly.

Examples of podiatry rolesMusculoskeletal conditionsPodiatristshaveaprimeroletoplayintheassessmentandmanagementofmusculoskeletalfootandanklepathology.Advancedpractitionersandconsultantpodiatrists,assess,diagnoseandmanagecomplexlowerlimbmusculoskeletalpathology/pain,includingtheprovisionofspecialistfootwearandin-shoecorrectivedevices.Theymayuseinjectiontherapyandrequestinvestigationssuchasultrasound,MRI,X-rayandbloodtests.

Diabetes Care Podiatristsareimportanttothemultidisciplinaryprovisionofdiabeticfootcareinlinewithlocalandnationalrequirements.Podiatrymanagementofcomplexdiabeticfootproblemsincludeswoundcare(includingdebriding4wounds),theselectionofappropriatedressings,physicaltreatmenttoremoveexcessivepressurefromvulnerablepartsofthefootandthemanagementofinfection.Timelyprescriptionofmedicinesfordiabeticfootinfectionsiscrucialinordertostoptheinfectionworsening,reducetheriskofamputationandavoidunnecessaryhospitaladmissions.Podiatristsalsoplayanimportantroleineducatingotherhealthprofessionalsinthescreeningofpatientsfordiabetesrelatedfootproblemsandadvisingupontreatmenttominimisetheriskofseriousfootproblems.

General podiatry carePodiatristsingeneralpracticeworkinarangeofclinicalsettingsdeliveringfootcaretoallages.

4Debriding–cleansingtopreventinfectionandpromotehealing.





How to respond

What podiatrists do










Appendix 1

Appendix 2

9

Footproblemscanseriouslyaffectqualityoflifebyreducingaperson’smobility,independenceandincreasingtheriskoffalls.Podiatristsrecogniseanddiagnosecommonfootdisorderssuchasskindiseaseorinfection,naildisordersaswellasrecognisingcausesoffootpain.Thismayincludeafullclinicalassessmentcomprisingahistoryandclinicaltests.Effectivepromptmanagementofmostcommonfootproblemsisessential.Footinfectionsrequirepatientadviceandinmanycasesaccesstothecorrectanti-microbialdrugssuchasantibioticsoranti-fungalagents.Managementofacutefootpainoftenrequiresanalgesiaaspartofthetreatmentplan.

Foot surgeryPodiatristsworkinginthisfieldofpracticewillhavesignificantexperienceofworkingwithpatientswithcomplexmedicalconditions.Theymaybeinvolvedintheconservativeandsurgicalmanagementoffootandanklepathologyacrossabroadpatientgroup.Correctivefootsurgeryisusedtoreducethepainandimmobilityofproblemssuchasbunions,hammertoesandtraumatisednerves.Patientsmayrequiremedicationssuchasanalgesia(forpainmanagement),antibiotics(inmanaginginfection),anticoagulants(followingsurgery),sedativesforpre-operativeanxietyandinjectablecorticosteroids.





How to respond

What podiatrists do










Appendix 1

Appendix 2

10

Where podiatrists workThereareatpresent12,581podiatristsregisteredinUK(2010figures)andtheirworkspansasignificantcross-sectionofthehealthcaresystem.MostworkintheNHS.Theyworkinhospitalsandinawidevarietyofcommunitysettings,includingbothGPpracticesandindependentpractices.Somepodiatristsprovidecareforpatientsintheirownhomes,innursinghomesordaycentres,inschoolsandinhealthcentres.TheSocietyofChiropodists&Podiatristsestimatesthataround55%ofpractisingmembersundertakeanelementoftheirworkintheprivatesector,andpodiatristsalsoworkinavarietyofoccupationalhealthsettings,inprisons,schools,industry,sportsclubsandfortheArmedForces.

How podiatrists are trained and regulatedPre-registrationtrainingofpodiatristsconsistsofanapprovedthreeorfour-yearuniversitycourseleadingtoaBSc(Honours)degreeinpodiatry.StudentswhoalreadyholdaBScinarelatedsciencesubjectcanalsofollowapre-registrationMScinpodiatry.GraduatesofboththeBScandMScpre-registrationcoursesareeligibleforstatutoryregistrationwiththeregulator–theHealthProfessionsCouncil(HPC).Registrantsareentitledtousetheprotectedtitles‘podiatrist’and‘chiropodist’.TheHPCsetsstandardsforpodiatrists’education,training,competence,conduct,behaviourandhealth.AnypersonwhowishestopractiseasapodiatristintheUKmust,bylaw,havetheirnameregisteredwiththeHPC.TheHPCalsoregulatesthefitnesstopracticeandre-registrationofthosealreadyontheregisterandhasthepowerstoremoveindividualsfromtherelevantregisteriftheyfallbelowthestandardsrequiredtoensurepublicsafety.

Thescopeofpodiatryisverywideandcoversavarietyofphysical,pharmaceuticalandrelatedinterventionsaimedatimprovingfoothealthandmobility.Apodiatrist’sscopeofpracticewillchangeovertimebecauseofexperience,specialisationinacertainclinicalareaorwithaparticularclientgroup,oramovementintorolesinmanagement,educationorresearch.Apodiatristmustundertakethenecessaryongoingtrainingandexperiencetodemonstratethattheyarecapableof





How to respond

What podiatrists do










Appendix 1

Appendix 2

11

workinglawfully,safelyandeffectivelywithintheirgivenscopeofpracticeandmustnotpractiseinareaswheretheyarenotproficient.TheHPCapprovesthetraining,setsthestandardsrequiredofpodiatristsupplementaryprescribersandannotatestheirnamesontheregister.

Thisregulatoryprocesswouldalsoapplytopodiatristindependentprescribers.

How would podiatrist independent prescribers be trained?Thepresentmultiprofessionaltrainingisprovidedasanintegratedprogrammeforindependentandsupplementaryprescribers.Itisthelegislativeframeworkwhichdefinesthemechanism(s)availabletoeachprofessionandtheassessmentofcourseparticipants.Forexamplenursesandpharmacists,whosuccessfullycompletetheprogrammeareabletopracticeasbothindependentandsupplementaryprescribers.However,podiatristswhosuccessfullycompletetheprogrammeareonlyabletopracticeassupplementaryprescribers.Appendix1providesfurtherdetailsaboutindependentandsupplementaryprescribing.

TheHPChasalreadyapprovedanumberofcoursestoprovidetrainingforpodiatristsassupplementaryprescribers.AnoutlinecurriculumframeworkforpodiatristindependentprescribingwouldneedtobedevelopedandtheHPCwillhavetheauthoritytoapprovecoursesfortheprovisionofpodiatristindependentprescribingtraining.Podiatristsalreadyqualifiedassupplementaryprescribersmayberequiredtoundertakeadditionaltraininginordertopracticeasindependentprescribers.





How to respond

What podiatrists do










Appendix 1

Appendix 2

12

Eligibility for training as a podiatrist independent prescriber

Notallpodiatristswouldneedtotraintobecomeindependentprescribers.Itissuggestedthatallentrantstothetrainingprogrammewouldneedtomeetthefollowingrequirements:

• BeregisteredwiththeHealthProfessionsCouncil

• Bepractisinginanenvironmentwherethereisanidentifiedneedfortheindividualtoprescribeindependently

• Haveatleastthreeyearsrelevantpostqualificationexperience

• Havesupportfromtheiremployer

• Haveanapprovedmedicalpractitionertosuperviseandassesstheirclinicaltrainingasaprescriber.

PodiatristindependentprescriberswouldhaveanannotationontheHPCregister.ThiswouldalsorequirethemtoundertakeappropriatestepstomaintaintheirskillsandcompetenceinkeepingwiththeHPCregulatorystandards.TheHPCwouldneedtoamendtheirstandardsforpodiatrists,toreflectpodiatristindependentprescribingandtheyhaveindicatedtheirwillingnesstodothisinduecourseifproposalsmoveforward.

QUESTION

1. Do you have any comments on these eligibility criteria?





How to respond

What podiatrists do










Appendix 1

Appendix 2

13

What benefits would podiatrist independent prescribing bring?Independentprescribingwouldimproveoutcomesforpatients,whilstalsoprovidinggreatercost-effectivenessandchoiceforpatientsandcommissioners.Podiatristswoulduseindependentprescribingwhereautonomyinmedicinesusewouldfacilitateeffectivecareforthepatient,wherethetimelyinstigationofappropriatemedicinesmanagementwouldpreventadeteriorationinapatient’shealthstatusandwheretheappropriateuseofmedicineswouldenhancetheaimsoftheprogrammethathasalreadybeenestablishedforthepatient.Forexample:

• Timelymanagementofmusculoskeletalandrheumatologicaldisorderswouldreduceunnecessaryorinappropriatewaitingtimesfortreatment,hastenrecovery,andimprovepatientoutcomes.Presentlycarecanbedelayedwhenpatientshavetomakeadditionalvisitstodoctorsforprescriptions,ordoctorsarenotavailabletosupportsupplementaryprescribing.Viaindependentprescribing,podiatristswouldbeabletoimmediatelyandsafelyprescribethemedicinesneeded,adaptingandtailoringapatient’smedicinesalongsidetheirphysicaltreatment.

• Timelyprescriptionofmedicinesfordiabeticfootinfectionsiscrucialinordertohalttherapidprogressionofinfection,reducetheriskofamputationandavoidunnecessaryhospitaladmissions.Independentprescribingwouldallowthepodiatristtoplayacentralroleinalleviatingdelaysintimelyaccesstomedicinesinthecommunity.Servicecommissionerswouldalsohaveagreaterrangeofoptionsinmeetingtheneedsofpatientsinthesecircumstances.

• Ingeneralpodiatryclinics,effectivemanagementofcommonfootproblemsoftenrequiresspeedyaccesstoantibiotics,effectiveuseofanti-fungalagents,oranalgesiatomanagefootpain.Whereitissafetodoso,independentprescribingwouldallowpodiatriststopromptlysupplythenecessarymedicinestotheirpatients.Prompttreatmentwouldhelptoalleviatepatients’symptoms,encourageamorerapidrecoveryandavoidtheneedforpatientstomakeadditionalappointmentswithotherprescribers.





How to respond

What podiatrists do










Appendix 1

Appendix 2

14

• Patientsreceivingfootsurgeryfromapodiatristmayrequiremedicinessuchasanalgesia(forpainmanagement),antibiotics(inmanaginginfection),anticoagulants(followingsurgery),sedativesforpre-operativeanxietyandinjectablecorticosteroids.Prescribingofthesemedicinesbypodiatristindependentprescriberswouldenablerapidpatientcare,withareductionindelaysinreceivingnecessarymedicines,andwouldbeconsistentwiththeimplementationofnationalandlocalguidelines.

Independentprescribingwouldenableinnovativeserviceredesigntomakegreateruseofpodiatrists’skillsinareassuchasdiabetescare,toensurepatientsreceivethemedicinestheyneedatthetimetheyneedthem.Forexample,inareasasdiverseasdiabeticfootwoundcare,footsurgery,fungalskininfections,independentprescribingwouldenablepatientstoreceiveimmediateappropriatepharmacologicalmanagementalongsideotherphysicaltreatments,whilstavoidingdelaysassociatedwithadditionalappointmentswithotherprescribers.Independentprescribingcouldalsoprovidegreaterchoiceforpatientsandofferswideroptionsforservicesandcommissioners,reducingdelaysinaccessingtreatmentandimprovingoutcomes.

Independentprescribingwouldalsoenhancetheflexibilityandexpertiseoftheworkforceandtherebyimprovecareforpatientsnowandinthefuture.

Protecting the publicPodiatristindependentprescribinghasthepotentialtoimprovepatientsafetybyimprovingmedicinesmanagement,reducingthedelaysinreceivingcareandpotentiallyreducingavoidablehospitaladmissions.

Safeguardsareofutmostimportancebecauseindependentprescribingbyanyprofessioncarriesinherentrisks.Thetwomainriskswhichmustbeconsideredare:

• thepotentialrisktopatientsafetyofinappropriateprescribingofmedicines;and

• therisktopatientsafetyoffailuretoshareinformatione.g.iftheGPrecordwasnotupdatedinatimelymanner.





How to respond

What podiatrists do










Appendix 1

Appendix 2

15

Thefollowingprincipleswouldunderpinprescribingresponsibilitiesforpodiatrists:

• Patientsafetyisparamount.Prescribingresponsibilitiesshouldonlybeenablediftheywilldeliversafe,effectiveandmoreconvenientcareforpatients

• Prescribersshouldonlyprescribeandpracticewithinthelimitsoftheirclinicalcompetenceandscopeofpractice

• Prescribingmustbeunderpinnedbyrobustgovernancestructures

• Independentprescribersmusttakefullclinicalandprofessionalresponsibilityfortheirdecisions.Prescribersneedtobeabletorecognisewhentheyneedtoaskforsupportinrelationtoapatient’scare

• Trainingshouldbedeterminedlocally,withinanationallyagreedoutlinecurriculumforprescribingtraining

• Dispensingpharmacistsandthosechargedwithreimbursingprescriptionsneedtobeabletoidentifyprescriberseasilythroughanannotationontheprofessionalregister

• Asisthecaseforexistingprescriberswhoindependentlyprescribe,thesamestandardsoftraining,practice,governanceandregulationwillapplyregardlessofwhetherthepodiatristisworkingintheNHS,independentorothersettings.

Governance and safeguardsTheHealthProfessionsCouncil(HPC)wascreatedbytheHealthProfessionsOrder2001andisthestatutoryregulatorof15healthprofessions,includingpodiatry.Aspartoftheirdutytoprotectthepublic,theHPChasastatutoryresponsibilitytosetstandardsofproficiencyforpodiatrists.Thiswouldincludesettingstandardsforindependentprescribing.TheHPCwouldalsohaveadutytoassessandaccrediteducationalinstitutionsasrecognisedprovidersoftrainingforpodiatristindependentprescribing.





How to respond

What podiatrists do










Appendix 1

Appendix 2

16

TheSocietyofChiropodists&Podiatrists(SCP)andtheInstituteofChiropodistsandPodiatrists(ICP)aretheprincipalprofessionalbodiesrepresentingtheUK’sregisteredpodiatrists.Togethertheywillproducedetailedguidanceforpractitionersrelatingtogoodpracticeforindependentprescribing,ifthisisintroduced.Ashasbeenthecasefornurses,pharmacistsandoptometrists,theNationalPrescribingCentreofferedtoproduceacompetenceframeworkforpodiatristindependentprescribers.However,thedevelopmentofasinglegenericcompetencyframeworkforallprescribersiscurrentlybeingconsidered.

Employerswillretainresponsibilityforensuringadequateskills,safetyandappropriateenvironmentsforpodiatristindependentprescribing.Employerswouldalsoberesponsibleforensuringthatthereisaneedforapodiatristtoundertakeprescribingresponsibilitiesbeforetheyembarkontraining–aswellasensuringthatthereisanopportunitytoprescribepost-training.ThesamestandardswouldapplyregardlessofwhetherthepodiatristisworkingintheNHS,independentorothersettings.

Continuing Professional Development (CPD):Allpodiatristsarerequiredtokeepup-to-dateintheirpracticeandarerequiredtorenewtheirregistrationeverytwoyears.TheHPCsetsstandardsforCPDwhichallregistrantsmustmeet.TheHPCundertakesarandomsampleauditeverytwoyearsaspartofthere-registrationprocess,toensurethatitsregistrantsaremeetingitsstandardsforCPD–thuskeepingup-to-dateandmaintainingtheirfitnesstopractise.Ifintroduced,podiatristindependentprescriberswouldhaveasimilarresponsibilitytokeepup-to-datewithclinicalandprofessionaldevelopmentsinmedicinesusetomaintaintheirregistration.

Access to the medical record:Ifindependentprescribingisimplementeditisessentialthatprescribingpodiatristshaveup-to-daterelevantandproportionateinformationaboutapatient’smedicalhistoryandmedicines.Thisisachievedbypatientconsent,togaineitherbydirectaccesstothepatientsfileinsecondarycare,GPrecordinprimarycareorthecommunityandviareferrallettersinoutpatientsettings.Individualprescribersmustassurethemselvesthattheyhaveallrelevantinformationandifthereisanydoubt,furtherinformationshouldbesoughtbeforeprescribingtakesplace.





How to respond

What podiatrists do










Appendix 1

Appendix 2

17

Updating the medical record:Itisessentialthatanyprescribingactivitybypodiatristsisknowntootherhealthcareprofessionalscaringforthesamepatient,suchasthepatient’sGPandpatientsinformedofthis.Nurseprescribersandexistingpodiatristsupplementaryprescribersarecurrentlyexpectedtoupdateapatient’snotescontemporaneouslyifpossibleandinanyeventwithin48hoursoftheepisodeofcare.Thismaybedoneelectronicallywherepossible,viaanemailorelectronicupdatetotheGP’sofficewherethepatient’snotesareheld,orbyfaxtotheGP’ssurgery,ensuringgoodinformationgovernanceproceduresaretakentoensureitssafetransfer.Therewillbearequirementonprescribingpodiatriststoupdatethepatient’srelevantmedicalrecordsinatimelymanner.

Options for introducing podiatrist independent prescribingIndependentprescribingbypodiatristscouldtakevariousforms,suchasthoseoutlinedintheoptionsbelow.Appendix2outlinesthemainconditionsandmedicinespertainingtopodiatrypractice.

Option 1. No changeHighlyskilledandexperiencedpodiatristswouldcontinuetobeeligibletotrainassupplementaryprescribers.Dependinguponlocalemploymentarrangements,appropriatelytrainedpodiatristswouldcontinuetosupplyand/oradministermedicinesunderPatientGroupDirections(PGD),patientspecificdirections(PSD),orexistingstatutoryexemptions.

Benefits

Theexistingarrangementshaveprovedsafeandinsomesettings,theyenablepodiatriststosupplypatientswiththemedicinesthattheyneed.





How to respond

What podiatrists do










Appendix 1

Appendix 2

18

Limitations

Recentscopingwork5hasindicatedthattheexistingarrangementsdonotbestsupporttheneedsofpatients,particularlywhenapodiatristisprovidingselfreferral,firstcontact,diagnostic,orcommunitycare.Wherepatientsrequiremedicinesmanagement,outsidethatspecifiedinaPatientGroupDirectionorexistingstatutoryexemption,theywouldcontinuetohavetovisitanotherprofessional.Theexistingarrangementsaredifficultandcostlytoadminister.

Underthisoption,thecreationofinnovativenewcarepathwayswillcontinuetobelimited.creatinglesschoiceandongoingunnecessarycostsforcommissioners.Consequently,anopportunitytoimproveoutcomesforpatientswouldbemissed.

Option 2. Independent prescribing for specified conditions from a specified formularyAppropriatelytrainedpodiatristswouldbepermittedtoprescribeindependentlyfromalistofspecifiedmedicinesforaspecifiedlistofconditions.

Benefits

Thisoptioncouldbenefitpatientsprovidedthattheircondition,andthedrugstheyneed,arelisted.

Limitations

Patient’swhoseconditionormedicinesneedsdonotappearonthelistsofprescribablemedicinesandconditionswouldnotbeabletobenefit.Asthepodiatryprofessionspansalargerangeofpatientgroups,eitherthelistsofconditionsandmedicineswouldneedtobeextensive,orcertaingroupsofpatientswouldbeexcluded.Inaddition,alimitedformularyandlistofconditionswouldneedupdatingregularly,tosupportongoingcurrentbestpractice.Thiswouldrequirelengthyadministrativeandlegislativeprocessesandmaynotberesponsivetotheneedsofpatientsordevelopmentsinclinicalcare.

5DepartmentofHealth(2009).AlliedHealthProfessionalsPrescribingandMedicinesSupplyMechanismsScopingProjectReport.www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_103949.pdf

http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_103949.pdf





How to respond

What podiatrists do










Appendix 1

Appendix 2

19

Option 3. Independent prescribing for any condition from a specified formularyAppropriatelytrainedpodiatristswouldbepermittedtoprescribeindependentlyforanyconditionwithintheircompetencebutonlyfromalistofspecifiedmedicines.

Benefits

Awiderrangeofpatientscouldbenefitfromthisoption,thancouldunderoption2.

Limitations

Patientswhosemedicinesneedsdonotappearonthelistofprescribablemedicineswouldnotbeabletobenefitfully.Aswithoption2,thelistswouldbedifficulttoadministerandthisoptionwouldbepotentiallyunresponsivetotheneedsofpatientsandcurrentbestclinicalpractice.

Option 4. Independent prescribing for specified conditions from a full formularyAppropriatelytrainedpodiatristswouldbepermittedtoprescribeindependentlyanymedicinewithintheircompetence,butonlyforspecifiedconditions.

Benefits

Awiderrangeofpatientswouldbenefitfromthisoption,thancouldbenefitunderoption2.

Limitations

Patientswithaconditionthatdoesnotappearonthelist,wouldnotbeabletobenefitfully.

Aswithoption2,thelistswouldbedifficulttoadministerandkeepup-to-date,andpotentiallyunresponsivetotheneedsofpatientsandcurrentbestclinicalpractice.





How to respond

What podiatrists do










Appendix 1

Appendix 2

20

Option 5. Independent prescribing for any condition from a full formulary Appropriatelytrainedpodiatristswouldbepermittedtoindependentlyprescribeanymedicineforanycondition,withintheircompetence.

Benefits

Patientswouldbeabletomakedirectcontactwithappropriatelytrainedpodiatristsandreceivethecareandmedicinestheyneed,withouthavingtomakeadditionalappointmentswithotherprescribers.Agreaternumberofpatientscouldbenefitfromimprovedcare,fastercareandgreaterconvenience.

Limitations

Thisoptionhasnoobviouslimitations.Itisthemostflexibleoptionandstandstobenefitthemostpatients.

Option 6. A combination of the above options Appropriatelytrainedpodiatristswouldbeabletoprescribeindependentlybysomecombinationoftheaboveoptions.Thiscouldbeachievedinanumberofways.Forexample,prescribinganymedicinewithintheprescriber’scompetenceinahospitalsetting,butonlyfromalistofspecificmedicinesinacommunitysetting.

Benefits (based on the example above)

Thisapproachcouldbenefitpatients,providedthattheirconditionorthemedicinetheyneedwasonthelist,forthesettinginwhichtheircarewasbeingdelivered.

Limitations (based on the example above)

Thisapproachcouldbedifficulttoadministerandregulate,particularlyforindividualpodiatristswhoworkinacombinationofdifferentsettings.Patientswhoseconditionsormedicinesneedsvaryfromthedefinedlistwouldnotbeabletobenefitfully.Thisoptionwouldalsocreateariskthatpatientsmovingbetweensettingswouldbeunabletoreceiveconsistentcare.





How to respond

What podiatrists do










Appendix 1

Appendix 2

21

QUESTION

2. Which of the above options do you believe would safely add the most value to patient care? (if option 6, please provide details)

3. Have you any comments on the arrangements outlined above for the governance of independent prescribing by podiatrists if the proposals are taken forward? Are there other factors which should be taken into account?





How to respond

What podiatrists do










Appendix 1

Appendix 2

22

Further considerationsControlled drugsControlleddrugsareprescriptionmedicinescontainingdrugscontrolledundertheMisuseofDrugslegislation.Examplesincludebenzodiazepine,morphine,andpethidine,butalsomorecommonlyuseddrugssuchasdiazepamorcodeinepreparations,whichpodiatristsmayneedtousetohelpcontrolapatient’spain.Theyareclassifiedbylawbasedontheirbenefitwhenusedinmedicaltreatmentandtheirharmifmisused.Ifpodiatristsaretobeabletoprescribecontrolleddrugsindependentlyaspartofanyoftheaboveoptions,separateamendmentswouldneedtobemadetolegislationgoverningcontrolleddrugswithintheUKbytheHomeOfficeandtheDepartmentofHealthandPersonalSocialServicesinNorthernIreland’sMisuseofDrugsRegulations).

Podiatristsarecurrentlyabletoprescribecontrolleddrugsviasupplementaryprescribingarrangements.Atpresent,nurseindependentprescriberscanprescribefromalistof13controlleddrugs,butonlyforspecifiedconditions.Pharmacistindependentprescriberscannotasyetprescribeanycontrolleddrugindependently.Optometristindependentprescriberscannotprescribecontrolleddrugs.However,changestoUKmisuseofdrugsregulationsareanticipatedtoenablenurseandpharmacistindependentprescribingofcontrolleddrugs,thusremovingthepresentrestrictionsfornurseandpharmacistindependentprescribers.

QUESTION

4. In what circumstances would it benefit patients if appropriately trained podiatrists, were able to prescribe controlled drugs independently?





How to respond

What podiatrists do










Appendix 1

Appendix 2

23

Mixing of medicines prior to administration Clinicalpracticesometimesrequiresthemixingoftwolicensedmedicines,forexamplecorticosteroidandlocalanaestheticagents,inthemanagementofcertainmusculoskeletaldisorders,thuscreatinganunlicensedmedicine.InMay2010,newguidanceonmixingwasissued6whichclarifiedthat:

• Doctorsanddentistscanmixmedicinesthemselvesanddirectotherstomix

• Nurseandpharmacistindependentprescriberscanmixmedicinesthemselvesanddirectotherstomix

• Supplementaryprescriberscanmixmedicinesthemselvesanddirectotherstomix,butonlywherethatformspartofthewrittenClinicalManagementPlanforanindividualpatient.

QUESTION

5. In what circumstances would it benefit patient care if appropriately trained podiatrist independent prescribers were able to mix medicines themselves prior to administration or direct others to do so?

6NationalPrescribingCentre(2010).Mixingofmedicinespriortoadministrationinclinicalpractice:medicalandnon-medicalprescribing.Gatewayref:14330





How to respond

What podiatrists do










Appendix 1

Appendix 2

24

Prescribing of unlicensed medicinesUnlicensedmedicinesarethosewhichdonothaveaMarketingAuthorisation(orproductlicence)whichisvalidintheUK.Theprescribingofunlicensedmedicinesispermittedunderlegislationsubjecttocertainconditionswhicharethattherelevantmedicinalproductsaresuppliedinresponsetobonafideunsolicitedorders,formulatedinaccordancewiththespecificationsofcertainprescribersforusebyindividualpatientsontheprescriber’sdirectpersonalresponsibility,andinordertofulfil“specialneeds”.Theproductmustbemadebyapersonholdingamanufacturer’slicenceforthispurpose.

QUESTION

6. In what circumstances would it benefit patient care if appropriately trained podiatrist independent prescribers were able to prescribe unlicensed medicines for their patients?





How to respond

What podiatrists do










Appendix 1

Appendix 2

25

“Off-label” prescribing or supply of medicinesThesearemedicineswhichhaveaproductlicenceandaUKmarketingauthorisation,butareprescribedorsuppliedforadifferentusetothosedetailedinthesummaryofproductcharacteristics.Anexampleistheuseoflowdoseamitriptyline(anantidepressant)whichisalsoused“off-label”atalowdoseforthetreatmentofneuropathicpain.Presentlydoctors,dentists,nurseandpharmacistindependentprescribers,andalliedhealthprofessionsupplementaryprescribersareabletoprescribemedicinesinthisway.

QUESTION

7. In what circumstances would it benefit patient care if appropriately trained podiatrists, acting within their level of competence, were able to prescribe medicines ‘off label’ independently?





How to respond

What podiatrists do










Appendix 1

Appendix 2

26

Simultaneous prescribing and administrationForsafetyreasons,itisalongstandingprinciplethatprescribersprescribemedicinesandapharmacistthensuppliesthemedicinesinaccordancewiththatprescription.However,incertaincircumstancesitmaybeinapatient’sbestinterestsforaprescribertobeabletosupplyoradministeramedicinetothatpatientimmediately,withoutwaitingforapharmacisttodispenseit.Forexample,apatientmaybenefitfromthedeliveryofacorticosteroidinjectionforarthritispain,duringthecourseofanoutpatientappointment,ratherthanhavingtowaitforanotherappointmenttohavetheinjectiondelivered.PodiatristsarealreadyabletosupplyalimitedrangeofmedicinesdirecttotheirpatientsunderExemptionsandsimilararrangementsexistunderPatientGroupDirections.Insuchsettings,thesuppliesofmedicinesmustbestoredsafelyandinaccordancewithanyspecialconditionsrelatingtospecificmedicines.

Itisnothowevertheintentionthatpodiatristindependentprescribersshould,asanormalroutine,supplymedicinesdirecttotheirpatients.Thedispensingofprescriptionsproperlylieswithpharmacists.Thesale,supplyandadministrationarrangementsexistingunderExemptionsandPatientGroupDirectionswouldremainunchanged.

QUESTION

8. How would it benefit patients and in what settings, if appropriately trained podiatrists were able to supply and/or administer medicines that they had prescribed independently?





How to respond

What podiatrists do










Appendix 1

Appendix 2

27

Additional questions:9. Can you offer any information about potential costs and benefits of podiatrist independent prescribing for the impact assessment, eg. Benefits in terms of time savings to GPs, costs relating to the numbers of podiatrists likely to go forward for training, or any other factors?

10. Can you offer any information on how these proposals would impact on equality in your area, particularly concerning disability, ethnicity, gender, sexual orientation, ages, religion or belief, and human rights? Could any group be excluded, or better included because of the proposal, and will there be any problems or barriers for any minority group?





How to respond

What podiatrists do










Appendix 1

Appendix 2

28

11. Are there any other implications for implementing independent prescribing for podiatrists?

Name

Patient/Public AHP Doctor Nurse Pharmacist

Organisation(ifapplicable)

Areyourespondingonbehalfoftheorganisation

Email:

TelNo:

Nowclickon‘Saveform’tocreateapdfwhichyoucanemailtousatahpprofessionalleadershipteam@dh.gsi.gov.uk(pleaserefertopage5ifyouneedmoredetailedinstructionsonhowtodothis).

Save form






How to respond

What podiatrists do










Appendix 1

Appendix 2

29

APPENDIX 1Non-medical prescribing and medicines supply mechanisms7

Mechanism summary

Patient Specific Directionisaprescriber’s(normallywritten)instruction,whichenablesapersontosupplyoradministeramedicinetoanamedpatient.

Patient Group DirectionwithintheNHSisawritteninstructionforthesupplyand/oradministrationofalicensedmedicinetoapatientorgroupofpatients,wherethepatientmaynotbeindividuallyidentifiedbeforepresentingfortreatment.TheDirectionmustbeagreed/signedbyadoctorandaseniorpharmacist,andapprovedbytheemployer–typicallyaPCTorNHSTrust.Itauthorisescertainnamedregisteredhealthprofessional(s)tosupply/administeralicensedmedicine.

Patient Group DirectionsoutsidetheNHSarerestrictedtoindependenthospitals,clinicsandagenciesregisteredwiththeCareQualityCommissioninEnglandandequivalentsinthedevolvedadministrations.Theycanalsobeimplemented,subjecttoconditions,bytheDefenceMedicalServices,theUKPoliceForcesandtheUKPrisonServices.TheDirectionenablesthesale,supplyand/oradministrationofalicensedmedicinetoapatientorgroupofpatients,wherethepatientmaynotbeindividuallyidentifiedbeforepresentingfortreatment.TheDirectionmustbeagreed/signedbyadoctorandaseniorpharmacist,andapprovedbythebodyorrepresentativespecifiedinmedicineslegislation.Itauthorisescertainnamedregisteredhealthprofessional(s)tosupply/administeralicensedmedicine.

Exemptions(tomedicineslegislation)allowsale,supplyandadministrationofspecificdrugsinspecificcircumstances.

7FurtherdetailscanbefoundinDHandNationalPrescribingCentreguidance,andanoverviewwithdefinitionsinMedicinesMatters(DH,2006).





How to respond

What podiatrists do










Appendix 1

Appendix 2

30

Mechanism summary

Supplementary Prescribingisavoluntaryprescribingpartnershipbetweenindividualmembersofcertainregisteredhealthcareprofessionalsandanindependentprescriber(doctor)toprovidetreatmentforanindividualpatient,withthatpatient’sagreement,throughawrittenclinicalmanagementplan.TheSupplementaryPrescribercanalterdose,removeorwriteprescriptionsaccordingtothatplan.

Independent Prescribinginvolvestakingfullresponsibilityforprescribingdecisionsandautonomouslywritingprescriptions.





How to respond

What podiatrists do










Appendix 1

Appendix 2

31

APPENDIX 2Main conditions and medicines – podiatry

System Medicine category Indicative conditions Evidence/guidance

Gastro- Mucosalprotectants Chronicpainconditions NICECG017(dyspepsia)Intestinal requiringopioid System analgesiause

MSKconditions requiringNSAID/anti-

plateletuse

Anti-motility Conditionscausing Antimicrobialsareacuteuncomplicated reportedtobediarrhoea–during responsiblefor25%ofmedicalmanagement acutediarrhoea.Earlyofinfection(inpost- managementcanreduceoperativesituationsor thechanceoflongertermseverediabeticinfection) complications

DrugSaf.2000Jan;22(1):53-72.Drug-induceddiarrhoea.ChassanyO,MichauxA,BergmannJF





How to respond

What podiatrists do










Appendix 1

Appendix 2

32


Gastro- Oralrehydration Duringacutediarrhoea ProgressionofsuchIntestinal therapy (earlymanagement) clinicalpresentationSystem wouldindicatereferralon(continued) formedicalmanagement

insecondarycare

Laxatives NSAIDusehasawell NHSClinicalKnowledgereportedincidence Summaries(CKS)forofdyspepsia–Upper ConstipationBowel.(TheNSAIDsincludeaspirin(33%),ibuprofen(17%),naproxen(11%),piroxicam(9%),indomethacin(8%),anddiclofenac(7%))

BrJClinPract.1995Mar-Apr;49(2):67-70.Gastrointestinalside-effectsofNSAIDsinthecommunity.JonesRH,TaitCL

Additionallylowerbowelproblemssuchasconstipationisseen.Thereforemanagementofthisisrequired





How to respond

What podiatrists do










Appendix 1

Appendix 2

33


Cardiovascular System

CPRadrenaline Cardiaccollapse

Stroke

NICECG8(MS);NICECG68(Stroke);NICECG35(PD)NICECG92–VTEpreventionNICECG5,chronicheartfailure

Anticoagulants

Post-operativeconditionswithprolongedreducedmobility

NHSClinicalKnowledgeSummaries(CKS)forStrokeandTI

Thromboprophylaxis(surgeryorinanyclinicalsituationwereapatientisimmobilised)

NICE:CG92Venousthromboembolism–reducingtherisk:fullguideline

AssessmentusingtheVTEproformaisrequired–toidentifyriskfactors

(Low-MolecularweightHeparin/Enoxaparin)

Skeletalmusclerelaxants

Nocturnalcramp BNF

DrugSafetyUpdateJune2010(cautioususe)





How to respond

What podiatrists do










Appendix 1

Appendix 2

34


Cardiovascular Calciumchannel Raynaud’sphenomenon BNFsystem (continued)

blockers

PeripheralvasodilatorsIntermittentclaudication

BNF

TASC

SIGN2006

Respiratory Oxygen Useinday-casetheatre Anaphylaxis(adrenaline/System settings chlorphenamine/atropine)

Asthma(Acute)–inStimulants Life-savingsituations clinicalsetting/during

responsetoprocedure(Salbutamol)

Generallyincommunityclinical(surgery)settingabilitytostockandadministerinlifesavingevents.TheIPstatuswouldaffordaccess





How to respond

What podiatrists do










Appendix 1

Appendix 2

35


Central Nervous Neuropathicpain Chronicpain NICECG96(neuropathicSystem medicines management pain)

e.g.Tricyclicantidepressants Diabeticneuropathy

MSK/rheumatoidpain

BritishPainSocietyGuidelinesforopioiduseinpainmanagement

Post-operativecare WHOanalgesicladder

Opioidanalgesia CRPS NHSClinicalKnowledge

ChronicpainservicesSummaries(CKS)forNSAIDprescribing

Torsiondystonia Adultandpaediatric RoyalCollegeofspasticityequinusfoot Physicians–Spasticityin

Adults–ManagementUsingBotulinumToxin

Musculoskeletal Localcorticosteroid LocalInflammatory NHSClinicalKnowledgeand Joint injections disordersofjointsand/or Summaries(CKS)forDisease softtissuese.g.OA SprainsandStrains

Rheumaticdiseases RA/OA

NSAIDs Localinflammatory

Rubefacientsdisordersandinjuriesofjointsand/orsofttissues

Nutirceuticals e.g.strains,sprains,muscleandligamenttears,swelling,bruising





How to respond

What podiatrists do










Appendix 1

Appendix 2

36


Musculoskeletal and Joint Disease (continued)

Systemiccorticosteroids

Skeletalmusclerelaxants

Degenerativejointdisorder/softtissueinjuries

Systemicinflammatorydisorders/connectivetissuedisorders

NICETA160/TA161–Osteoporosis

http://www.nice.org.uk/nicemedia/live/12131/43326/43326.pdf

Bisphosphonates Osteoporosis

Anaesthesia Sedatives Pre-operativeanxiety

Chronicmusclespasm

Localanaesthesia

Inhalational

Procedure&operativemanagement

anaesthesia Acuteseverepain

Other injectable medicines

Sodiumchloride0.9%forinjection

Associatedwithinjectiontherapy

Waterforinjection

Antimicrobial Antibiotics–topical,oralandIV

Woundinfection

Post-injectioninfection(rare)


Post-operativeinfection

Skininfections

Cellulitis



To seek views on possibilities for introducing independent … · 2013-07-16 · This engagement...

Documents

Transcript of To seek views on possibilities for introducing independent … · 2013-07-16 · This engagement...