Standard operating procedure for Adult Chemotherapy/SACT Prescribing Competencies - Standard operating procedure for

Publication: 09/06/2014  
Next review: 08/12/2021  
Standard Operating Procedure
ID: 3866 
Approved By: Chemotherapy Steering Group 
Copyright© Leeds Teaching Hospitals NHS Trust 2017  


This Standard Operating Procedure is intended for use by healthcare professionals within Leeds unless otherwise stated.
For healthcare professionals in other trusts, please ensure that you consult relevant local and national guidance.

Standard operating procedure for Adult Chemotherapy/SACT Prescribing Competencies

Background and indications for standard operating procedure/protocol

The SOP should be followed by all registrar and consultant level staff and non-medical prescribers (NMPs) (nurses, pharmacists and physicians assistants) who will be prescribing, reducing or changing chemotherapy/SACT for adult patients.

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Procedure method (step by step)

  • New consultants and Specialist Registrars (SpRs) should complete the level 1 competence within 2 weeks of starting their post at LTHT.
  • SpRs should aim to complete assessments for levels 1 and 2 within 3 months of starting their training as a SpR in Oncology (Clinical or Medical) or Haematology. SpRs should repeat level 1 assessment each time they move Trusts as chemotherapy prescribing systems and chemotherapy pathways may vary.
  • SpRs should aim to complete assessments for level 3 within 6 months of starting their training as a SpR in Oncology (Clinical, Medical) or Haematology.
  • SpRs should aim to complete assessments for level 4 prior to completion for each site specialist team.
  • Non-medical prescribers must complete levels 1 and 2
  • Time to complete for NMPs is dependent on clinical practice exposure/experience and should be negotiated with clinical supervisor/assessor/line manger as appropriate
  • Completed assessment forms should be handed to the Oncology/ Haematology Quality Manager whose responsibility will be to maintain a SACT prescribing competency electronic staff record (for example LTHT Quality manager). Competencies for medical staff should also be recorded on the e-Portfolio (instructions in appendix B).
  • SpRs will be responsible for informing a new placement of their current chemotherapy competencies.
  • Intrathecal chemotherapy training and competency assessment are the responsibility of the lead chemotherapy nurse and are out of the remit of this document.

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A summary of the levels of systemic anti-cancer treatment (SACT) prescribing competency with required assessments

*Intrathecal chemotherapy competencies are dealt with separately from this document*

Level 1: Able to review a patient undergoing systemic therapy and make dose modifications with documented evidence of supervision from a senior qualified clinician (site specific level 4 competent) but not prescribe SACT.

  • Departmental induction
  • DOPs/ minCEX on electronic prescribing system with lead oncology pharmacist
  • CBD for dose modifications and whether further supportive medicines required with senior qualified person (site specific level 4 or level 5).
  • DOPS/ minCEX for chemotherapy pathway (consent form, chemotherapy documentation) with lead chemotherapy nurse/ chemotherapy day unit sister

Level 2: Able to prescribe systemic therapy but not initiate a course of treatment. It is estimated that suitable training would be completed within the first 3 months of the SpR grade. During this period, a countersignature of a more senior qualified person is required on all prescriptions. NMPs to negotiate clinical training period and should not prescribe SACT until signed off at level 2.


  • DOST for chemotherapy pre-assessment to demonstrate primarily the appropriateness of continuing SACT and a further demonstration of an understanding of principles of toxicity management.

Level 3: Able to initiate systemic therapy under consultant supervision while prescribing within local guidelines. It is estimated that suitable training would be completed within the first 6 months of SpR training and during this period all prescriptions require a countersignature of a senior qualified person.


  • 2x directly observed systemic treatment assessments (DOST - see appendix A) demonstrating an understanding of the approach required for consenting and delivering SACT with palliative or potentially curative (primary or neoadjuvant or adjuvant) intent.

Level 4: Able to initiate all appropriate systemic therapies for an oncology site specific area. It is estimated that suitable training would be completed within the 6 month requirement for each mandatory clinical module of respective curriculums. Therefore a level 4 competence is a requirement to complete training in all the clinical modules required for CCST/ CST.


  • 1 or 2 DOPS/ minCEX of presentation of cases/ acceptance of referrals at MDT
  • CBDs for management of palliative and non-palliative settings
  • Ensuring trainees are cognisant of clinical trials regulatory framework will be the responsibility of the clinical trials team

Level 5: A level 5 person is able to introduce a new therapy into a clinical department. This may be following a critical review of published evidence or as a clinical trial to evaluate new therapy. This person can also devise a new treatment for a condition and propose appropriate methods for critical evaluation and determination of the cost effectiveness. This professional is likely to be a Consultant. The demonstration of this level of competence will be by the award of Certificate of Completion of Training (CCT) in Medical Oncology. Suitable training will take 48 months in an approved training programme within the SpR grade.

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Appendix A

DOST Guidance (directly Observed assessment of Systemic Therapy Skills)
This form can be used for non-medical prescribers as well as medical trainees. Registration details with relevant professional organisation post title and grade should be entered onto the form.
The DOST focuses on the core skills that trainees require when managing the initiation of or continuation of systemic therapy. Where possible all elements of the process should be assessed on one occasion. You should explore a trainee’s related knowledge as appropriate.
The process should be trainee led. It is the responsibility of the trainee to choose a suitable clinical case and assessor. The assessor should agree that the clinical case is appropriate.


  1. The assessor must have expertise in prescribing the systemic therapy being assessed
  2. On completion of the assessment, the assessor should complete the assessment form (see Appendix B) and give feedback to the trainee immediately, especially where deficiencies have been identified. The form can be completed on paper or electronically. The trainee and assessor should agree areas that were done well and areas for development.
  3. Please score the trainee on the scale below. Please note that your scoring should reflect the performance of the trainee against that which you would reasonably expect at their stage / year of training and level of experience.
  4. After fully completing a form, give it to the trainee. It is their responsibility to photocopy it, keeping the original for their records and giving the copy to their clinical supervisor.

Descriptors of competencies demonstrated during DOST:

Rationale for treatment

Understands the indications for and can define the aims of treatment
Understands the potential risks and benefits of treatment
Evaluates available test results and identifies any omissions or findings which impact on treatment strategy

Obtains informed consent

Confirms patients disease status and discusses rationale for treatment plan
Discusses potential risks and benefits of treatment
Ensures that the patient has the relevant written information
Completes consent form accurately
Interacts professionally with the patient and companions

Pre-treatment procedures / tests

Identifies tests or procedures which are required prior to therapy
Ensures that all pre-treatment requirements are fulfilled

Clinical assessment of patient

Ensures patients fitness to proceed with therapy
Assesses toxicity of previous systemic therapy
Carries out appropriate clinical examination

Awareness and management of complications

Demonstrates awareness of side effects of treatment
Ensures patient knows about likely side effects
Explains actions required if side effects are experienced


Generates an appropriate prescription (including supportive drugs) which is accurate, safe and meets local and national standards.
Gives clear instructions for management before, during and after treatment.

Documentation of consultation

Documents key aspects of the process clearly, including:

  • rationale for treatment and potential side effects discussed with patient
  • assessment of patient and results of relevant investigations
  • treatment prescribed and any modification, plans for future management

Interaction with staff

Communicates effectively with all members of the team.
Seeks advice where appropriate e.g. from consultant, pharmacist, nurse

Communication with patient

Explores patient’s perspective, ensures all patient’s concerns are addressed, and agrees management plan with patient.

Overall ability to prescribe this therapy

An overall judgement based on above. Even If the trainee is considered ”Able to prescribe without supervision” this assessment does not automatically entitle him/her to do so.

DOST form

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Appendix B

Uploading the DOST Form

  • If the DOST form was completed in paper format, this should be uploaded to your eportfolio.
  • Scan the document, inserting the date of the assessment and disease site in the file name.
  • Log in to and select physician trainee.
  • Hover the mouse cursor over ‘Profile’ and click ‘Personal Library’ from the drop-down menu that appears.
  • On the right hand side of the screen, there is a box marked with ‘Upload File’ – click the ‘Select’ button.
  • Choose the appropriate document that you would like to upload.
  • Click ‘Shared’ to allow your supervisors to view the document.
  • You can add a description of the document in the ‘Description’ box.
  • Click ‘Upload File’ to add the document to your personal library.

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Appendix C - Overview of Chemotherapy/SACT Prescribers Competency

Medical Staff and Non-Medical Prescribers prescribing chemotherapy/SACT must have the required competency to do so. This will be documented in the Chemotherapy/SACT Prescribers Register available on the intranet (http://lthweb/sites/chemotherapy/chemotherapy-competency-registers/chemotherapy-competencies-register).

  1. Consultants

    Medical and Clinical Oncology Consultants and Haematology Consultants are deemed to be fully competent (Level 4) to prescribe chemotherapy as completion of training is a requirement for appointment.
    On-going competency will be self-certified annually following appraisal. The forms for registration and annual renewal are available on the intranet
    Consultants starting at LTHT will undergo Level 1 training to familiarise themselves with the e-prescribing system (Chemocare) and local protocols/pathways.
    If involved in assessing and signing off medical trainees and non-medical practitioners consultants must be included on a register of chemo competency assessors. An annual self-certified declaration of competence as an assessor (available on the intranet) should be submitted to the Oncology/Haematology quality manager.
  1. Specialty Registrars training in Clinical Oncology, Medical Oncology or Haematology at LTHT are required to undergo assessment in order to achieve progressive levels of chemotherapy competency. The necessary assessments for different competency levels are detailed in the SOP “Adult Chemotherapy/SACT Prescribing Competencies, St James’s Hospital”, which is available on the intranet (click here).

  2. Non-medical Prescribers (Nurses, Pharmacist and Physician Assistants) will follow the assessment schedule outlined in “Adult Chemotherapy/SACT Prescribing Competencies, St. James’s Hospital” to obtain progressive levels of competency. Level 1 and 2 should be completed and documented on the “Levels of Adult Chemotherapy/SACT prescribing competency” form on initial attainment of competence and on an annual basis for competency renewal.

    It is the responsibility of the non-medical prescriber to arrange an annual assessment with an assessor of competence (who is on the assessors register having submitted a self-certified declaration of competence as an assessor). This assessor must be working within the same tumour specific group as the NMP.

    The assessment should consist of case presentations and reflexive discussion of prescribing practices or Direct Observation of Systemic Therapy (DOST) (see Appendix A) to ensure competence in continued prescribing of cytotoxic chemotherapy. The completed Levels of prescribing competency form must be sent to the Oncology/Haematology Quality manager for inclusion on the LTHT chemotherapy/SACT prescribers register.

    This procedure is additional to the requirements set out in the “Procedure for the registration of Non-Medical Prescribers within LTHT” and “The Procedure for Prescribing and Record Keeping of Non-Medical Prescribers within LTHT” policies which must be complied with for inclusion on the Trust’s central register for NMPs. It is recommended that annual renewal of competency for Chemotherapy/SACT prescribing is completed at the same time as the submission of annual declaration of competence to remain on the Trust register and continue prescribing to the Lead Clinician Workforce Development Pharmacist. The NMP cannot remain on the Adult chemotherapy/SACT prescribers register if have failed to submit the required documentation to be on the Trust NMP central register.

  3. Assessors of competency must be included in the Register of Chemotherapy Prescribers and must meet the following additional criteria:
    1. Assessors must be of Consultant grade and work in Clinical Oncology, Medical Oncology or Haematology at LTHT.
    2. Assessors must have been awarded a Certificate of Completion of Specialist Training (CCST) in Clinical Oncology, Medical Oncology or Haematology.
    3. Assessors must have undergone formal training in assessment methods, e.g. the online training modules for Educational Supervisors or attendance at a “Supervising Trainees” Workshop.

      Designation as an assessor is renewed annually and requires confirmation that the Consultant is familiar with the current Chemotherapy Competency Levels and suggested assessments.

  4. Inclusion in the Chemotherapy/SACT Prescribers and Assessors Registers must be authorised by the LTHT Adult Oncology/Haematology Chemotherapy Lead or Deputy Lead.


Record: 3866

To define the process and share the correct documentation for acquiring adult patient chemotherapy/Systemic Anti-Cancer Treatment (SACT) prescribing competencies.

Clinical condition:


Target patient group: Chemotherapy patients
Target professional group(s): Pharmacists
Secondary Care Doctors
Secondary Care Nurses
Adapted from:

Evidence base

Not supplied

Approved By

Chemotherapy Steering Group

Document history

LHP version 1.0

Related information

Not supplied

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