October 5, 2008

Eczema and Prescribing

By Davies, Jill Hillman, Elizabeth

Two local branch board members report on developing and running a study day on prescribing and the management of childhood eczema With the recently published National Institute for Health and Clinical Excellence (NICE) guidance on the management of atopic eczema in children1 and NMC Standards of proficiency for nurse and midwife prescribe(TM),2 this is an ideal time to update colleagues on prescribing for children with atopic eczema. As two health visitors and board members of the local Unite/CPHVA branch, we developed and evaluated an educational study day, which attendees reported as enhancing both their confidence and health visiting skills.

Prescribing and atopic eczema

Health visitors and district nurses were identified by the Department of Health to become one of the first groups of healthcare professionals to take on the added role of prescribing within their job descriptions.3 In the 1999 Crown Report,4 prescribing powers were extended to include other healthcare professionals, and the range of products that could be prescribed was widened. In November 2002, Lord Hunt announced supplementary prescribing, in which the main emphasis was on interprofessional working and partnerships. More recently, prescribing has continued to evolve to include pharmacists and allied health professionals, and the Opening up' of the British national formulary (BNF) to allow a wide range of healthcare professionals to prescribe from the whole of the BNF subject to certain guidelines.5

However, the majority of health visitors are only able to prescribe from what used to be referred to as the Nurse preservers' formulary for district nurses and health visitors, recently renamed the Nurse prescribes' formulary for community practitioners6 (the NPF). The NMC's standards for prescribing give clear indications and professional recommendations for all nurses who prescribe, whether they are able to prescribe from the NPF or from the whole BNF.

Having the skills and qualifications to prescribe from the NPF is an integral part of the role of many community practitioners. However, research has suggested that health visitors are not using this skill,7 and a lack of confidence is one reason behind this. According to Davies,8 health visitors also identify a number of logistical reasons, revolving mainly around time factors - health visitors found it difficult to import prescribing into an already busy day. In addition, the time required to travel back to the GP surgery to document prescribing was also problematic. Otway9 suggests that educational needs also play a role, arguing that continual professional development and clinical support is required to enable practitioners to take on this expanded role.

In a limited review of the clinical areas in which health visitors are prescribing, Groat10 identified the management of skin conditions as being particularly relevant, especially regarding atopic eczema in children. Slater11 recognises this as an important arena for health visitors and describes the setting up of an 'infant eczema clinic', and it has become more interesting and evidence based in light of the NICE guidance1 and NMC standards.2

It could be argued that health visitors working in primary health care may be ideally placed to offer support and education and to prescribe for children with atopic eczema (see Box 1),1,12 as well as to refer on to other agencies when the patient requires treatment from other healthcare professionals.

The study day

Given this background, we agreed that it would be timely and appropriate to review the NICE and NMC documents1,2 in an educational event, in order to promote best practice and prescribing regarding the management of atopic eczema in children. This is an area of practice that has caused debate among health visitors, and one of great potential professional development.8

A study day was organised that included the clinical nurse specialist in dermatology from the local hospital Lesley Lyons, who reviewed the diagnosis of eczema and presented on the management of atopic eczema and the use of emollients. One of the authors of this article, Jill Davies, discussed the NMC standards and issues related to legal prescribing. The learning outcomes for the study day were to raise:

* Awareness of the NICE guidelines1

* Knowledge of atopic eczema

* Knowledge of the use of emollients

* Knowledge of prescribing concepts and appropriate prescription writing

* Awareness of appropriate health promotion advice when managing atopic eczema.


The study day was only open to members of Unite/CPHVA, as it was organised by the local branch. A total of 15 health visitors attended - more than three quarters of those practising within the local trust.

The evaluations were anonymous, and all health visitors were informed that the authors were planning to present the work for publication, and asked whether they had any objections to the work being published (there were none). Attendees were assured that no names would be identified and of confidentiality. The importance of evidence-based practice was discussed, as was the need to share good practice with other community practitioners who may wish to deliver similar events.

There were 14 completed anonymous evaluations, all of which stated that they had gained knowledge through the event. Attendees were asked three questions:

* Has this educational event met your needs?

* Do you feel more confident in the management of eczema?

* Do you feel more confident about prescribing for eczema?

All 14 respondents gave positive answers to these questions, with additional comments such as 'much more confident'. They were also asked for further feedback or recommendations (see Box 2).

The attendees clearly acknowledged a benefit from the study day, which they expected would in turn enhance their prescribing practice and subsequent patient experience.

It is envisaged that the local branch will aim to manage and deliver a similar event next year, in an attempt to continually update and educate health visitors.

This is an ideal time to update colleagues on prescribing for children with atopic eczema

Box 1: Atopic eczema in children

Atopic eczema is a chronic inflammatory skin disease characterised by red, itchy dry skin that usually follows a relapsing and remitting course.1 It predominantly affects the flexor surfaces of the elbows and knees, as well as the face and neck.12 It usually occurs in early childhood, when a child presents with itching and scratching. There may also be some genetic predisposing factors - a first-line relative with atopic disease such as asthma, eczema or hay fever - but this is not always the case. The skin's barrier function breaks down, leading to greater susceptibility to 'trigger factors' that exacerbate the eczematous disease process. NICE identifies several of these, including irritants, skin infections, contact allergens, food allergens and inhaled allergens. Eczema is not usually life threatening, but there Is significant impact on quality of life for each member of the sufferer's immediate family.

Treatment of atopic eczema includes the use of emollients and topical corticosteroids (mild to potent), moving onto more complex treatments such as tacrolimus and phototherapy.1 Health visitors, district nurses and other community practitioners may legally prescribe from the NFP, which includes only a wide range of emollients. They must complete the independent prescribing course successfully in order to prescribe more comprehensive treatment.

It is envisaged that the local branch will aim to manage and deliver a similar event next year

Box 2: Further feedback

'As a student health visitor, this has been extremely useful - both in terms of information about eczema and also prescribing experience.'

'Excellent for confidence building.'

'I would like more sessions on prescribing in the future.'

'I really enjoyed the session, and it will enhance my health visiting skills.'

'Please can we have some more?'

'Useful update.'

'NICE guidelines useful, and useful update on prescribing practice.'

'More updates please.'


1. National Institute for Health and Clinical Excellence. Atopic eczema in children: management of atopic eczema in children from birth up to the age of 12 years. London: National Institute for Health and Clinical Excellence, 2007. Available at: www.nice.org.uk/ nicemedia/pdf/CG057FullGuideline.pdf (accessed 25 July 2008).

2 NMC. Standards of proficiency for nurse and midwife prescribers. London: NMC, 2006. Available at: www.nmc-uk.org/ aFrameDisplay.aspx? DocumentID=1645 (accessed 25 July 2008).

3 Department of Health. Report of the Advisory Group on Nurse Prescribing. London: Stationery Office, 1989.

4 Department of Health. Review of prescribing, supply and administration of medicines: final report. London: Stationery Office, 1999. Available at: www.dh.gov.uk/en/ Publicationsandstatistics/Publica tions/ PublicationsPolicyAndGuidance/DH_4077151 (accessed 29 July 2008).

5 Department of Health. Supplementary prescribing by nurses, pharmacists, chiropodists/podiatrists, physiotherapists and radiographers within the NHS in England: a guide for implementation. London: Department of Health, 2005. Available at: www.dh.gov.uk/en/ Publicationsandstatistics/ Publications/ PublicationsPolicyAndGuidance/ DH_4110032 (accessed 25 July 2008).

6 Mehta DK (Ed.). Nurse preservers'formulary for community practitioners (edition 2007 to 2009). London: British Medical Journal Group, Royal Pharmaceutical Society Publishing, 2007. Available at: www.bnf.org/bnf/extra/current/popup/ NPF2007-2009.pdf (accessed 25 July 2008). 7 Harrison S. Community nurses slow to use prescribing power. Nursing Standard, 2004; 18(27):5.

8 Davies J. Health visitors' perceptions of nurse prescribing: a qualitative field work study. Nurse Prescribing, 2005; 3(4): 168- 72.

9 Otway C. The development needs of nurse prescribers. Nursing Standard, 2002; 16(18): 33-8.

10 Groat D. Eczema care for children: the health visitor's role expanded. Community Practitioner, 2002; 75(2): 54-6.

11 Slater H. Addressing the skin care burden: developing primary care eczema clinics. Community Practitioner, 2002; 75(5): 186-7.

12 Buxton P. ABC of dermatology. London: British Medical Journal Group, 1998.

Jill Davies

Health visitor, university lecturer and local branch secretary

Elizabeth Hlllman

Health visitor and local branch vice chair

Copyright TG Scott & Son Ltd. Oct 2008

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