BMJ  2006;332:2 (7 January), doi:10.1136/bmj.332.7532.2

Editorial

Epilepsy and supplementary nurse prescribing

The NHS needs advanced nurse prescribers

The scarcity of health professionals for managing epilepsy results in uncontrolled seizures, drug side effects, and psychosocial and physical morbidity.^{1 2} Of the more than 1000 deaths related to epilepsy in the United Kingdom each year, up to half might have been prevented by optimal treatment.³ Recently, NICE (the National Institute for Health and Clinical Excellence) recommended that specialists should diagnose and manage refractory epilepsy and that patients should have access to epilepsy nurse specialists. Moreover, the government has offered general practitioners incentive payments to conduct annual reviews for epilepsy.

In the UK there are more than 350 000 people with epilepsy, and the NHS employs around 350 neurologists and 100 epilepsy nurse specialists. Access to nurse specialists improves patients' management and reduces the need for appointments at hospital clinics, with specialists, and with general practitioners,⁴ but variations in the quality of services throughout the country make these outcomes unreliable. Less than half of all epilepsy nurse specialists have postgraduate qualifications relevant to managing epilepsy, provide nurse-led clinics, or take responsibility for managing the condition. This throws doubt on the use of titles such as specialist nurse and may have implications for patients' safety. In response the Nursing and Midwifery Council has proposed that nurses with advanced level skills are recognised by a protected title and registered as such.⁵

The proposed education and competencies of an advanced nurse practitioner include a masters degree and the ability to undertake case management, make differential diagnoses, and prescribe medicines. The masters degree, however, may be generic rather than clinically focused, which would allow nurses with qualifications unrelated to epilepsy to register as advanced nurse practitioners in epilepsy care and—after completing a course on supplementary prescribing—to prescribe antiepileptic drugs. To manage epilepsy and prescribe antiepileptic drugs requires knowledge of the semiology (presentation) of seizures and classification of syndromes, and of differential diagnosis, medical and surgical treatment, pharmacology, neurophysiology, neuroimaging, neuropsychology, and psychosocial aspects of epilepsy. These subjects are usually taught only in specialist training with the main focus on epilepsy.

Around 28 000 nurses are currently registered in the UK as independent prescribers and 4000 as supplementary nurse prescribers. The aims of nurse prescribing include improving access to drugs and better use of nurses' skills. Supplementary prescribing enables nurses to prescribe most of the appropriate drugs in the British National Formulary for a chronic illness, following a clinical management plan.⁶ From spring 2006, qualified nurse prescribers will be able to prescribe any licensed medicine for any medical condition (with the exception of controlled drugs).⁷

To ensure that the NICE recommendations and incentives for general practitioners on managing epilepsy are effective, suitably qualified epilepsy nurse specialists should register as advanced nurse practitioners. They would practise in consultation with specialists, accept direct referrals from general practitioners, and provide unrestricted advice on treatment to general practitioners and patients. To provide advanced level care for 350 000 patients, a minimum of 350 advanced nurse practitioners are needed; they would have caseloads of 1000 patients, roughly the same number as are managed by consultants who specialise in epilepsy. In the NHS there are now, however, only around 25 nurse specialists who would qualify as advanced nurse practitioners in epilepsy.

University College London Hospitals Trust, National Hospital for Neurology and Neurosurgery, London WC1N 3BG
(phosk{at}hotmail.com)

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Competing interests: None declared.

References

1. Clinical Standards Advisory Group. Services for people with epilepsy. London: HMSO, 1999.
2. Hanna NJ, Black M, Sander JW, Smithson WH, Appleton R, Brown S, et al. National sentinel clinical audit of epilepsy-related death: epilepsy—death in the shadows. London: HMSO, 2002.
3. Cockerell OC, Johnson A, Sander JW, Hart YM, Goodridge DM, Shorvon SD. Mortality from epilepsy: results from a perspective population-based study. Lancet 1994;344: 918-21.[CrossRef][ISI][Medline]
4. Hosking P. The specialist nurse role in the treatment of refractory epilepsy. Seizure 2004;13: 303-7.[Medline]
5. Nursing and Midwifery Council. Consultation on a framework for the standard for post-registration nursing. 2005. www.nmc-uk.org/(spzpnh55bbetagu5rgrh0c55)/aArticle.aspx?ArticleID=82 (accessed 1 Dec 2005).
6. Department of Health. Nurse prescribing training and preparation: extended formulary nurse prescribing. 4 Jun 2004. www.dh.gov.uk/PolicyAndGuidance/MedicinesPharmacyAndIndustry/Prescriptions/NonmedicalPrescribing/NursePrescribing/NursePrescribingArticle/fs/en?CONTENT_ID=4123001&chk=2KTZRP (accessed 8 Jun 2005).
7. Department of Health. Nurse and pharmacist prescribing powers extended. 10 Nov 2005. www.dh.gov.uk/PublicationsAndStatistics/PressReleases/PressReleasesNotices/fs/en?CONTENT_ID=4122999&chk=Mjc1MS (accessed 15 Dec 2005).

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