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17 Aug 2018

By A/Prof Andrew C Miller, Chair, AMA Medical Practice Committee

When the AMA cautions against independent prescribing of schedule 4 and 8 medicines by nurses, optometrists, pharmacists, and other non-medical health practitioners, we are usually accused of trying to ‘protect our turf’.

In fact, the AMA supports many models of non-medical practitioner prescribing.

The critical factors for the AMA in considering non-medical practitioner prescribing are that it: is within the scope of practice, training and expertise of the health practitioner; occurs within a medically-led and collaborative health care team; and, above all, does not compromise patient safety. It is for these reasons that we fully support dentists independently prescribing. Dentists are trained to prescribe medicines for dental conditions and prescribe within their scope of practice.

The Pharmacy Board of Australia recently hosted a stakeholder forum to discuss pharmacist prescribing, which was attended by the AMA. The Board is keen to explore the potential for pharmacists to prescribe, initially within a hospital or general practice setting.

Pharmacist prescribing is an excellent example to illustrate the AMA’s position on non-medical prescribing and why we urge a conservative and sceptical approach to expansions of scope of practice into prescribing.

Firstly, the Pharmacy Board argues that pharmacist prescribing is necessary to meet an unmet demand. This argument is nearly always used by non-medical practitioner organisations when seeking to prescribe medicines. However, the AMA is yet to see good quality, consistent evidence that demonstrates superior effectiveness - and cost-effectiveness - of non-medical health practitioner prescribing compared to medical practitioner prescribing.

Without evidence of improved outcomes for patients and the health care system as a whole, the AMA does not support expanding prescribing for the sake of a health practitioner’s career satisfaction. Indeed, Health Ministers have agreed that expansion of non-medical prescribing should not occur without this evidence.

Secondly, the AMA strongly believes in a strict separation between prescribing and dispensing. We have applied this long-standing policy to our own profession. In fact, at the AMA’s annual National Conference in May this year, we reaffirmed this strong position. Medical practitioners should only ever dispense medicines in situations where pharmaceutical services are unavailable. For example, in remote areas of Australia. This removes any potential conflict of interest in deciding the most appropriate treatment for patients, which medicine to prescribe, or not to prescribe at all.

There is an inherent conflict of interest with any pharmacist associated with a community pharmacy being involved in prescribing that should not be overlooked. Even if a community pharmacist were simply ‘continuing’ an existing prescription initiated by a medical practitioner, the commercial benefit of recommending additional ‘complementary’ medicines is undeniable.

Thirdly, the AMA opposes independent prescribing of Schedule 4 and 8 medicines by non-medical practitioners because of the risks to patient safety.

Only medical practitioners are trained to take a comprehensive history, examine, and put together the whole person when making a diagnosis, initiating investigation, management, and treatment. Only medical practitioners are trained to know the full range of clinically appropriate treatments for a given condition, including when not to prescribe; and to understand the potential impact of treatments on other unrelated conditions that may co-exist.

We do support, and value, non-medical health practitioners prescribing under the following medically-led and/or supervised models:

  • prescribing by protocol or limited formulary;
  • initiating therapy according to protocol and symptoms; and
  • continuing, discontinuing, and maintaining therapy according to a pre-approved protocol.

Most non-medical prescribing occurs in public hospital or primary health care settings where these collaborative care models work well. For example, in a public hospital, care by a nurse practitioner, which includes prescribing, occurs under a protocol that covers the care provided by a clinical unit. The protocols clearly set out: the medications a nurse practitioner can prescribe; in what circumstances they can prescribe; and when the nurse practitioner will refer the patient to a medical practitioner.

If pharmacists wish to prescribe, they will need to provide compelling evidence and detailed examples of models and settings where an ability to prescribe medicines, rather than provide advice about medication management as they do now, will improve outcomes for patients compared to the care provided by currently endorsed prescribers.

Dr Andrew C Miller

Chair, Medical Practice Committee

Published: 17 Aug 2018