Independent Prescribing Commission Application 24/25

1. Personal information: *

Name	*
Email	*
Phone number	*
Profession	*
Regulatory body	*
Pin / Registration Number	*
Date of qualification	*
Start date in primary care	*

2. Do you hold a substantive contract with a Primary Care organisation - please state how many hours a week *

Comment:

3. Surrey Training Hub can offer commissioned places at The University of Surrey, The University of Brighton and The University Nottingham (Distance learning), University of Portsmouth.

The University of Surrey
The University of Brighton
The University of Nottingham
The University of Portsmouth

4. Employment information *

Name of practice	*
Practice address	*
PCN	*
Contract start date	*

5. Employer contacts:
When submitting these contact details please note they will be contacted for supporting information and declarations for the application.
Please make sure your Practice Manager and Supervisors are aware.
Applications can not progress without their support. *

Practice manager's name	*
Practice manager's email	*
Practice mangers contact number	*
Supervisors name	*
Supervisors email	*
Supervisors, If not a GP - Please confirm your DPP (Designated Prescribing Professional) meets supervision requirements	*

6. Do you have a current professional registration? (NMC, HCPC) *

7. Do you have an up to date DBS check (within last 3 years) *

8. Is there an identified need for an independent prescriber within your practice / PCN. *

Please explain why.

9. Have you read the KSS document for Multi-Professional Independent Prescribing in General Practice?

This can be found on the Surrey Training Hub Independent Prescribing page. *

10. Have you already started a Non-Medical Prescribing Programme either funded by Health Education England or self-funded that you did not complete? *

If YES please state: when and when you were on the programme and the reason for non-completion of the programme.

11. Are you currently undertaking any other programme of study? *

Please state what other study you are currently undertaking, where and how long the programme lasts.

12. At which University would you like to undertake the programme? *

13. Do you meet the recommended prerequisites set out by your professional body and the Training Hub? Nurses *

Have successfully completed a module/relevant study of health assessment that includes diagnostic examination and consultation skills or equivalent. Or you can evidence this skill?
Have at least 1 years post registration experience.
Worked in primary care for at least 1 year.
N/A

14. Do you meet the recommended prerequisites set out by your professional body and the Training Hub? AHP's *

Have successfully completed a module/relevant study of health assessment that includes diagnostic examination and consultation skills or equivalent. Or you can evidence this skill?
Have at least 3 years post registration experience.
Have you completed stage 1 & stage 2 of your road map.
N/A

15. Why are you planning to undertake the independent prescribing course? *

16. What will be your initial scope of prescribing and why?

Please provide evidence of courses undertaken to support scope of prescribing identified *

17. Please state how by undertaking the NMP Programme your local patient population will benefit?

How will you plan to deliver person centered care?
How will you address equality, diversity and inclusion? *

18. Please state how you plan to provide safe practice and ensure a culture that promotes learning from both incidents and best practice within your team? *

19. Please state how you plan to maintain competence? *

20. How do you plan to audit your prescribing practice? *

21. Please explain what Multi-professional lifelong learning is and how it can improve patient care?

How do you plan to contribute to establishing an effective workplace learning culture through relationships, teamwork and leadership? *

22. Trainee Declarations: *

I agree to work with the PCN towards developing a multi-professional learning environment and continues to work to develop others around them
I agree to notify the training hub immediately if I defer, extend or cease my studies. The training hub will consider the impact of the changes, and may ask the learner to provide further information in writing to support the request.
I agree to remain working within the Organisation identified on this application form for the duration of the programme.
I agree to work with the practice and PCN to develop others across the system
I agree to attend regular Peer Support / Action Learning Sets to support my learning (where available)
I consent to Surrey Training Hub storing and processing my data in order to facilitate and deliver the Fellowship scheme. Data will be processed in accordance with Surrey Training Hub's Privacy Notice found here: https://www.surreytraininghub.co.uk/Privacy
I understand that I may occasionally be asked to provide feedback on this process, to support programme evaluation.