Medicines and prescribing are highly risky areas of health care. It is estimated that more than 200 million medication errors occur in NHS every year, and that avoidable adverse drug reactions (ADRs) cause 712 deaths per year, at a financial cost of at least £98.5 million every year.
Many medicines and prescribing issues have been highlighted in reports and investigations into patient deaths over the years, yet the issues around prescribing competency are yet to be fully addressed. It is time this omission was rectified.
This blog explains why I believe patients, the public and healthcare practitioners, need to be aware of the Prescribing Competency Framework. It outlines why the framework must be applied in practice, used in clinical supervision and CPD, and why we must all speak out of it is not being followed. The benefits of this will include prevention of unnecessary medicines being prescribed, avoidance of drug related harm, and lives saved.
The Prescribing Competency Framework covers 10 areas, all of which are essential to medication safety (the version in this blog was updated in May 2022). In plain language they are:
- Assessment of the patient’s presenting complaint and medical history and other areas such as medicines history, adherence and Safeguarding.
- Prescribing options (including stopping / reducing medicines).
- Always Involving the patient, including reaching a ‘shared decision’ on the treatment, or respecting the patient’s right to refuse.
- Writing legible / legal prescriptions, with full & unambiguous directions.
- Providing information on medicines & following this up with the patient.
- Monitoring and reviewing the effect of medicines and acting on this.
- Safe prescribing, including ensuring that allergies, sensitivities, adverse reactions, and interactions are acted on appropriately.
- Prescribing professionally, including record keeping, staying up to date on guidance and following all related laws (e.g. the Mental Capacity Act).
- Improving prescribing practice through audit, clinical supervision, clinical governance, meaningful patient involvement and continuing professional development.
- Prescribing as part of a multi-disciplinary team, and as part of wider inter-disciplinary care plan(s), in all settings
Since the advent of ‘non-medical prescribing’ (i.e. prescribing by healthcare professionals other than doctors) over 15 years ago, prescribing has been a subject that is taught and assessed at Universities. Only experienced and specifically qualified registered healthcare professionals can prescribe medicines. Becoming a non-medical prescriber involves an in-depth course of both written and oral (scenario based) assessment, and not all who undertake it pass. The bedrock of this course is the Prescribing Competency Framework.
Embedding the framework
In view of the obvious benefits of following a competency framework for prescribing, here are some questions for reflection:
1. Do the prescribers in your team use the competency framework?
2. Is the competency framework part of the prescribing CPD in your organisation?
3. Is the competency framework used as part of prescribers’ annual appraisals?
4. How is prescribing competency monitored in your organisation, and is the competency framework included in clinical supervision?
5. Does your organisation use the prescribing competency framework in clinical governance sessions?
6. Is the prescribing competency framework referred to in incident investigation reports?
The framework is missing from the narrative of major investigations
I can find great examples of the implementation and the resulting patient safety benefits of points 1 to 5 above. Although I am saddened to see references to the prescribing competency framework missing in major investigations, inquests, and related commentaries.
Major examples of failings where prescribing competency was a contributory factor include the death of Elizabeth Dixon. It appears that a failure to review opiate prescribing, and failings in inter-disciplinary communication and monitoring of medicines may have contributed to her death.
‘…the daily dose of morphine was increased over fivefold. While this may be an appropriate pattern in a child with progressive and painful malignant disease nearing the end of life, there was no evidence that this was the case for Elizabeth. The repeated increases in morphine administration are likely to have contributed further to the tendency for secretions to accumulate in the tracheostomy tube and require frequent suctioning.’
Another case where the competency in prescribing is relevant is that of Oliver McGowan, a teenager with autism and mild learning disability. He died in 2016 following experiencing neuroleptic malignant syndrome after administration of an antipsychotic medicine that he had previously reacted adversely to. Oliver did not have a mental illness, psychosis or a history of challenging behaviour. He was prescribed an antipsychotic medicine despite a number of prescribing 'red flags' being present.
This medicine was listed in the ‘allergies’ column of his drug chart and in his ‘Hospital Passport’, his parents and Oliver himself had asked not to be given the medicine, an alternative non-drug related option had been recommended, and an email had been sent by A&E doctors warning of Oliver’s sensitivity to antipsychotics. I recommend prescribers study this case and look the available information, which I attempted to summarise in a presentation in 2019.
At the inquest into Oliver’s death the coroner concluded that his care was ‘appropriate’ and was reported as saying that Oliver’s medicines were ‘properly prescribed’. There followed a Learning from Deaths Review [LeDeR] into Oliver’s death. This made no recommendations. This review was met with incredulity by Oliver’s parents, and by some clinicians. As a result, there was a review into the LeDeR process for Oliver McGowan. This review, which covered the process of the first review only, was highly critical. It found that the author of the first LeDeR review felt bullied into toning down the initial report, and subsequently left her job:
‘The interviewer asked what would have happened if she had not done this. Ms A replied: I would have been sacked, no doubt about it, they never said this, but I knew’
‘…I could never work there again’
As far as I am aware there have been no specific recommendations in relation to prescribing because of Oliver McGowan’s death, and the prescribing competency framework has not been mentioned in any related NHS report or commentary.
Other cases where prescribing competency is a factor include that of Richard Handley, who died from complications because of constipation. Richard was a 33-year-old adult with Down’s syndrome and a moderate learning disability who was also diagnosed with a mental illness and hypothyroidism and had lifelong problems with constipation. I also understand, for reading about this tragic case that Richard was prescribed medicines which had a side-effect of constipation. A serious case review in 2015 identified multiple failings, however prescribing is not specifically listed. I believe this is a missed opportunity for learning and include discussion of Richard’s case in my teaching on medicines and prescribing.
In writing this piece I was surprised to discover that the prescribing competency framework does not appear to have been referenced in any of the reports mentioned above.
Given the annual expenditure on medicines with the benefits and risks involved in their use, it seems surprising to me that the art and science of prescribing medicines receives so little attention in investigation reports, and from public bodies.
I believe patients, the public and healthcare practitioners need to be aware of the Prescribing Competency Framework and why the framework must be applied in practice, used in clinical supervision and CPD, and why we must all speak out if we believe it is not being followed.
At present it appears that, since the demise of the National Prescribing Centre, no national body is picking up on this need for more awareness, training and education specifically related to prescribing. I believe that patients are being harmed and lives may be being lost as a direct result of this gap in learning.
May 2022 update: The Oliver McGowan Mandatory Training in Learning Disability and Autism has now been launched after passing into law as part of the Health and Care Act 2022. The training aims to ensure that staff working in health and social care receive learning disability and autism training, at the right level for their role. In an interview for Woman's Hour, Oliver's mum Paula talks about Oliver and the events that led to his death, as well as discussing the new mandatory training.
- University of Sheffield, More than 200 million medication errors occur in NHS per year, say researchers, 23 February 2018.
- Royal Pharmaceutical Society, Prescribing Competency Framework for all Prescribers, September 2021.
- National Institute for Health and Care Excellence, Medicines adherence: involving patients in decisions about prescribed medicines and supporting adherence. NICE Clinical Guideline CG76, 28 January 2009.
- UK Government, How to make decisions under the Mental Capacity Act 2005, 30 September 2014.
- Dr Bill Kirkup CBE, The life and death of Elizabeth Dixon: a catalyst for change, November 2020.
- INQUEST, Coroner concludes care of Oliver McGowan was ‘appropriate’ despite parents’ pleas not to use medication which led to the teenager’s death, 20 April 2018.
- Fiona Ritchie OBE, Independent Review into Thomas Oliver McGowan’s LeDeR Process Phase two, (8, 7, 12. & 7.19), October 2020.
- Flynn Margaret and Eley Ruth, A serious case review: James’ Suffolk Safeguarding Adults Board (restricted access), Social Care Institute for Excellence, 2015.
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