Application for Non-Medical Prescribing

APPLICATION FOR NON-MEDICAL PRESCRIBING

Sections 1, 2 & 3 – All Applicants to complete

Section 4 – Only Independent/Supplementary Prescribing Applicants & their DMP to complete

Section 5 – Only Community Practitioner Prescribing Applicants & their Mentors to complete

Section 6 – Trust Manager or Line Manager to complete for all

Section 7 – Non-Medical Prescribing Lead to complete

Section 8 – Budget Holder to complete

Section 9 – Applicant to complete

SECTION 1

Course Details
University / Start Date
Level of Study / 6
 / 7 (Independent/Supplementary only)

Type of Prescriber / Supplementary (Radiographer)
 / Independent/
Supplementary Nurse (V300)
 / Community Practitioner (V150)
 / Independent/Supplementary
(Pharmacist/Allied Health Professional)

Applicant Details
Name
Profession / Nurse/Midwife  / Pharmacist/Allied Health Professional 
Please state profession: ………………………………………………
Job Title
Contact Details / Work / Home
Address
Post Code
Telephone Number
Mobile Number
Email Address
Tick preferred correspondence details /  / 
Disclosure and Barring Service Check (previously CRB checks)
Do you have a current enhanced DBS (current employer and issued within 3 years of the start date of the module for nurses,and within 3 months for AHPs)?
*If you answer no, you must apply for one. / Yes  *No 
Date applied for

SECTION 2

Professional Eligibility (Please complete section relevant to your professional background)
Nursing and Midwifery
Are you a 1st level registered nurse/midwife/specialist community public health nurse currently on the NMC register / Yes  No 
Please state area of practice
Community Practitioner prescribing (V150) only
Do you have at least 2 years or equivalent relevant post registration experience? / Yes  No 
Independent/Supplementary prescribers (V300) only
Do you have at least 3 years or equivalent relevant post registration experience? / Yes  No 
NMC PIN / Expiry Date
Allied Health Professionals
Professional Group
Please state area of practice
Do you have at least 3 years or equivalent post qualification experience? / Yes  No 
HCPC registration number / Expiry Date
Optometrist
Please state area of practice
Do you have at least 2 years or equivalent post qualification experience? / Yes  No 
GOC registration number / Expiry Date
Pharmacist
Please state area of practice
Do you have at least 2 years or equivalent post qualification experience? / Yes  No 
GPhC registration number / Expiry Date

SECTION 3

Requirements for Prescribing
Professional Qualifications Attained
Awarding Body / Level / Year / Subject / Result / Place of study
Supporting Information (additional qualifications, professional experience likely to facilitate prescribing)
Have you registered or commenced and partially completed a non-medical prescribing course previously? / *Yes  No 
*If yes please give reasons for NOT completing the course
NURSES ONLY
Please provide evidence of your ability to study at degree level

SECTION 4

Independent/Supplementary Prescribers (with the exception of Pharmacists). Complete the following section
Have you completed a health/clinical assessment course (or specialist equivalent) / Yes  *No 
*If no have you been deemed competent by an appropriate Professional Colleague, in clinical assessment and diagnosis prior to being put forward for this course (see professional regulations for guidance re competence)
Please give details and ensure section below is completed and signed
I confirm that the applicant is competent in clinical assessment and diagnosis and is a suitable candidate for non medical prescribing
(NB this may be achieved by internal assessment of competence or completion of an appropriate health/clinical assessment course)
Name (print) / Title/position
Signature / Qualification
ALL Independent /Supplementary Prescribers
Please provide reasons for your application for a prescribing course
a)How will your ability to prescribe maximise benefit to the patient? (Role/service delivery benefit, expected changes to clinical pathway, timeliness of provision, effectiveness, impact on patient journey/experience, improve access to medicines)
b)How will your ability to prescribe benefit your organisation? (Service improvements, financial improvements, skills utilisation, capacity improvements)
c)Please provide details of the service you intend to prescribe in
Designated Medical Practitioner Arrangements
Eligibility criteria for becoming a Designated Medical Practitioner (DMP)
Further information for supervisors is available on the Department of Health website
Are you a registered medical practitioner who:
1)has normally had at least 3 years recent clinical experience for a group of patients/clients in the relevant field of practice
and are you:
2)i) within a GP practice and either vocationally trained or in possession of
a certificate of equivalent experience from the Joint Committee for Post-Graduate Training in General Practice Certificate (JCPTGP)
OR
ii) a specialist registrar, clinical assistant or Consultant within a NHS Trust or other employer
and have you:
3)support of the employing organisation or GP practice to act as DMP who will provide supervision, support and opportunities to develop competence in prescribing practice
and have you:
4) some experience or training in teaching and or supervising in practice
If not an Approved Training Practice/Institution, then please outline your experience of teaching, supervision and assessment of students: / Yes  No 
Yes  No 
Yes  No 
Yes  No 
Yes  No 
Agreement by Designated Medical Practitioner for Supervision of Applicant
Please tick / GP
 / Consultant
 / Specialist Registrar
 / Clinical Assistant
 / Other

Speciality
Name of DMP
(Please print)
GMC registration
number
Work address
Telephone number
Email address
I confirm that I have agreed to supervise, support and assess the applicant for a minimum of 12 days (78hours) (for Pharmacists and AHPs this is 90 hours) in their prescribing role during clinical placement
Signature

SECTION 5

Community Practitioner Prescribers (V150) ONLY Complete this section
Have you been deemed competent by an appropriate Professional Colleague, in clinical assessment and diagnosis prior to being put forward for this course? (See professional regulations for guidance re competence)
Please give details:
Please provide reasons for your application for a prescribing course
a)How will your ability to prescribe maximise benefit to the patient? (Role/service delivery benefit, expected changes to clinical pathway, timeliness of provision, effectiveness, impact on patient journey/experience, improve access to medicines)
b)How will your ability to prescribe benefit your organisation? (Service improvements, financial improvements, skills utilisation, capacity improvements)
c)Please provide details of the service you intend to prescribe in (Candidates are usually required to have worked for a minimum of 2 years in the area they will be prescribing in. Please indicate range of medication that you anticipate will be prescribed)
Agreement by Mentor for Supervision of Applicant
Name
Job title
Work address
Telephone number
Email address
Qualifications. Please include Mentorship with module code(s) / Date of last Mentor Update or date booked to attend
NB If your Trust/employer uses Electronic Staff Record (ESR) the date of your last Update will be available to view there.
I confirm that:

• the applicant is competent in clinical assessment and diagnosis and is a suitable candidate for non-medical prescribing
• I have agreed to supervise, support and assess the applicant for a minimum of 10 days in the development of their prescribing role
• I am a Sign-off Mentor and will be on the live Trust Register of Mentors during the supervision period

Signature / NMC PIN
Print name / Date

SECTION 6

Trust Approval – Line Manager Confirmation
Please confirm the following:
1)Agreement for the applicant to be released, as part of the non-medical prescribing course for a minimum of:
a)Independent/Supplementary Prescriber: 26 study days with additional 78 (nurses) or 90 hours (AHPs) learning in practice
OR
b)V150 Community Practitioner Prescriber 10 study days, with an additional 10 days of supervised learning in practice
2)The applicant has appropriate mentorship
3)The area of non-medical prescribing activity is linked to core service provision.
NB If the service is time limited or a pilot service please give details below:
4)On qualification the applicant will have access to a prescribing budget and other practical requirements for prescribing
5)On qualification the ongoing CPD requirements of the prescriber will be supported
6)I confirm that non-medical prescribing is included in the applicant’s Job Description (JD) or a letter of empowerment to prescribe within the Trust will be appended to the JD / Yes No N/A
Yes No N/A
Yes  No 
Yes  No 
Yes  No 
Yes  No 
Yes  No 
Name (Please print)
Job title
Work address
Telephone number
Email address
Signature / Date

SECTION 7

Trust Approval – Agreement by the Non-medical Prescribing Lead
Non-medical Prescribing Lead agreement that there will be access to a prescribing budget and a benefit to patient services by training this nominee
Name (Please print)
Organisation
Job title
Work address
Telephone number
Email address
Signature

SECTION 8

Funding
Please give details of funding source for this course – tick appropriate box
Funding will be allocated by means of Learning Beyond registration process within the Trust/organisation
OR
Other (please specify) / 

Budget Holder signature
Budget Holder code

SECTION 9

Applicant (Student) Agreement

• I agree to communication between my employer, NMP lead for my Trust/Organisation and the University I am attending to discuss any aspect of my attendance and progress on the prescribing course
• I agree to undertake Continuing Professional Development on completion of this course
• I have read and understood ‘Appendix 1’

Additionally (please delete the statement that is not applicable):

• I confirm that I have appropriate numeracy skills to undertake this course

or

• I recognise that my numeracy skills require updating and will undertake appropriate study to ensure that they meet the required standards prior to undertaking the prescribing course

Signature / Date
Print Name

Appendix 1

Please see relevant section for conditions on signing Non-medical Prescribing applications

Applicant
Will attend all course dates at University as required
Prior to starting course has met with supervisor and discussed learning objectives and methods for supervision
Attend all supervisory sessions with medical supervisor as required
Where possible an experienced non-medical prescriber should work alongside the student and the designated medical practitioner to provide support and guidance as appropriate. For midwives this should include the lead midwife for education
Completes requirements of course within allocated time period
If the candidate interrupts their studies for independent prescribing, the programme must be completed within the requirements of your registering body and the regulations of the University
For nurses, if assessments are not completed within 2 years from the start, the candidate must undertake the entire programme again including all the assessments to maintain currency
Once qualified informs line manager and lead for non-medical prescribing immediately
Intends to prescribe within area of work and competence once qualified
All registrants must record their prescribing qualification with their regulatory body on successful completion of the course
Participates in regular in-house and/or external CPD support mechanisms once qualified
Provides feedback on the course to manager and lead person
Mentors and supports colleagues undertaking the course at a later date
Participates in local steering group and work to develop supporting policies
Candidates should be aware of national and local policies in relation to prescribing
Line Manager
Agrees the appropriateness and suitability of candidate application and ensures the candidate is able to apply the prescribing principles to their area of practice
Understands the candidates must have 3 years’ experience as an appropriately registered health professional (2 years in the case of Optometrist), and the year preceding the application has been working in the clinical area in which they intend to prescribe (for part-timers, it is the equivalent of 3 years’ experience and 1 year in relevant clinical area)
Nurse applicant must have completed a module in diagnosis and physical assessment before accessing the prescribing programme or provided evidence of competence in history taking, physical assessment and diagnosis relevant to clinical area in which they are working
Applicants should not be put forward until they first demonstrate ability to diagnose in their area of speciality (should be identified through CPD reviews within the work setting). See Professional Regulations Guidance
Understands and accepts the requirements for candidate attendance at University and with medical supervisor
Agrees with choice of medical supervisor. The designated medical practitioner must be sufficiently impartial to the outcome for the student and should not be the same individual as the person sponsoring the student to undertake the programme
(continued…..)
Line Manager (continued)
Where possible an experienced non-medical prescriber should work alongside the student and the designated medical practitioner to provide support and guidance as appropriate. For midwives this should include the lead midwife for education
Confirms Trust policies/procedures and clinical governance infrastructure and professional indemnification processes are in place to support non-medical prescribing
Effective policies for record keeping must be in place to ensure records are accurate, comprehensive, contemporaneous and accessible by all members of a prescribing team.
Evaluates experiences of candidates and provides feedback to lead person
Provides opportunity for CPD
All registrants must record their prescribing qualification. Individuals have a duty to comply with their registering bodies regulations
Designated Medical Practitioner
Meets Department of Health requirements for supervision
Provides the required supervision in terms of time and content
Agrees learning contract and objectives with each student
Attends the induction session at University at least once or seeks further guidance from the University
Provides appropriate learning experiences
Takes responsibility for signing off competencies
Is responsible for ensuring he/she has time to supervise effectively
The designated medical practitioner must be sufficiently impartial to the outcome for the student and should not be the same individual as the person sponsoring the student to undertake the programme
The medical supervisor would be expected to work in collaboration with other support systems for students including the personal tutor
Where possible an experienced non-medical prescriber should work alongside the student and the designated medical practitioner to provide support and guidance as appropriate. For midwives this should include the lead midwife for education
The assessment of clinical practice should occur where possible with an experienced non-medical prescriber who can ensure application to specific areas of professional practice
Non-medical Prescribing Lead
Confirms Trust policies/procedures and clinical governance infrastructure and/or professional indemnification processes are in place to support non-medical prescribing
Agrees appropriateness of candidate selection and is involved in selection process. Agrees that the medical supervisor is appropriate
Maintains database of all prescribers
Represents Trust at meetings such as NHS West Midlands Non-Medical Prescribing Stakeholder Steering Groups
Know the content of curriculum and attends University curriculum group meetings to feedback evaluation, concerns, etc
Is available for candidate one-to-one support

APPLICATION FORM CHECKLIST

HAVE YOU:

Read and understood the information in the Appendix?

Ensured all relevant sections are signed by your line manager and non-medical prescribing lead?

Signed and dated the applicant agreement?

Included a completed practice educational audit form?

Failure to include correctly completed documentation may result in delays in the application procedure.

For office use only (Trust/Employer)
Approved for attendance on the courseYes / No
Signature Date

V7 – Apr 2016 Page1