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Rapid Responses: Rapid Responses published:
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Prescribing rights for Non-medical prescribers
- Mohammed Mujtaba Ahmed (18 November 2005)
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Pick 'N Mix
- nicola brooker (18 November 2005)
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If
- Kerry Thornbury (21 November 2005)
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Unnecessary worrying
- Kuldeep S Paik (21 November 2005)
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Soap Boxes
- Miriam A. Atkins (21 November 2005)
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Independent Pharmacist Prescribers
- Patrick J Lynch (21 November 2005)
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Prescribing also means being accountable
- Erik T Walbeehm (22 November 2005)
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Team work
- Ayesha F. Husain (23 November 2005)
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Who should prescribe?
- Alexander SD Spiers, none (24 November 2005)
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Mohammed Mujtaba Ahmed, Pharmacist Prescribing Doncaster West PCT DN4 8QN
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I am saddened to read the news that BMA does not approve the extension of prescribing to non-medical prescribers.
I am a pharmacist and for past 2 years have been working with my other healthcare professionals (GP's and nurses) collaboratively as a prescriber(1,2). I have been prescribing evidence based cost effective medicine for past 2 years. We all work as a team. I diagnose and prescribe, however I do know my limitations and I have never compromised patientcare in preference to my ignorance or my incompetency. I would not hesitate to ask my colleagues for their advice when needed. Similarly the colleagues (GP's) I have worked with, would not hesitate to ask my advice about drug management for a condition (if it is needed) or about a drug (could be a new drug, drug discontinued, drug withdrawn, side effects, drug interactions etc).
In reply to Dr Hamish Meldrum's quote (3) "While we support the ability of suitably trained nurses and pharmacists to prescribe from a limited range of medicines for specific conditions, we believe only doctors have the necessary diagnostic and prescribing training that justifies access to the full range of medicines for all conditions. This announcement raises patient safety issues and we are extremely concerned that the training provided is not remotely equivalent to the five or six years training every doctor has undertaken." As far as I am aware the five to six years of doctor training only includes 6 months of training on prescribing. Junior doctors in hospital rely on their colleagues (pharmacists and nurses) for prescribing advice and procedures respectively. and in response to Dr Paul Millers quote (3) "This is an irresponsible and dangerous move. Patients will suffer. I would not have me or my family subject to anything other than the highest level of care and prescribing, which is that provided by a fully trained doctor." I am assuming that Dr Miller things patients did not suffer under doctors. I believe Shipman(4) was a doctor. There is plenty of published evidence of patient harm due to doctors negligence. I also believe by extending prescribing rights to non medical prescribers without any proper training would definitely be harmful. I would be naive to think that there will be no non-medical prescriber who may go beyond his competencies but non medical prescribers should also be aware that they have a legal duty to deliver a standard of care that was expected of the post. Inexperience in diagnosis or incompetency in prescribing would be no defence(5). I am fully aware of that any actions I take would be judged against the standards of a GP(6). Thus I would consult my other healthcare professionals where appropriate. In summary I would plea the British Medical Association, BMJ and others to embrace this new development and work with organisations(7) to train non-medical practitioners to the standards where patientcare or patient safety is not at risk. I have a trustworthy relationship with my medical healthcare professionals and we all are aware of our limitations. 1.http://www.pjonline.com/pdf/news/pj_20040828_accessinthenhs.pdf 2. http://www.pjonline.com/editorial/20050716/news/p73firstcontactcare.html 3. BMA. BMA calls for urgent meeting with Patricia Hewitt on plans to extend prescribing powers [press release 10 Nov 2005]. 4. BMJ, Mar 2005; 330: 544 ; doi:10.1136/bmj.330.7490.544-a 5. Nettleship v Weston (1971) 2: QB: 691 6. Bolam v Friern Hospital Management Committee (1957) 2: AII ER: 118(1957): 1 WLR: 582 7. National Prescribing Centre (2001) Maintaining Competency in Prescribing. First Edition, Liverpool. Competing interests: None declared |
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nicola brooker, gp OX10
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Sir, I have read Ms Hewitt's latest plans for us with interest; namely extended GP surgery opening hours and unlimited prescribing powers for 'extended formulary nurse prescribers & independent pharmacist prescribers'. Perhaps she might consider a 24 hour medical supermarket with a Pick and Mix Medication counter open to the public? On a more serious note - (not withstanding the glaringly obvious lack of diagnostic training/years of experience) has she considered what the medical indemnity cover might be for these powerful 'new' prescribers or will be it the doctors that have to bear the responsibility for their mistakes? Competing interests: None declared |
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Kerry Thornbury, GP Wellington , NZ
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you as a pharmacist wanted also to diagnose and prescribe, why did you not become a doctor? Being a doctor is hard. It is complete rubbish to say only 6 months of medical training is pharmacology. During the entire medical train pharmacology and prescribing is involved. Indeed through the whole medical career one must continue to learn and evolve one's prescribing. I've been doing this 10 years now, and I wouldn't dream of pretending that I have nothing to learn as a prescriber, I learn something every day. How can one learn diagnosis and prescribing in depth with a few short courses? I think as doctors we undervalue our own profession if we think prescribing is so insignificant a skill, or art if you prefer, that it can be an add on to a nursing degree. If you want to be a doctor, become one. But I think all these sideways entry to prescribing rights are dangerous. Is more accessibility for patients preferable to more safety? Competing interests: GP |
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Kuldeep S Paik, Pharmacist PAH Hospital, Harlow, CM20 1QX
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I have read with interest the opinions of senior figures within the medical profession on the subject of non-medical prescribing. It appears that the main concern would appear to be over the nurses'/pharmacist's ability to diagnose a condition. I cannot speak for nurses, but from a pharmacist point of view, most of the pharmacists I know who have an interest in prescribing plan to do so following an initial diagnosis from a qualified physician. For example, a patient presents to A+E with acute chest pain and is seen by the admitting doctor and diagnosed with ACS. The plan would be then for the pharmacist to prescribe appropriately from the initial diagnosis (i.e. aspirin/clopidogrel, beta blockers etc). Furthermore, the likelihood is pharmacists would pick an area of specialist interest i.e. emergency medicine, cardiology and would only be interested in prescribing drugs relevant to their specialist area and not 'willy nilly' as some of these senior figures appear to think. I have to admit that I am a bit miffed about the term 'suitably trained' with regards to prescribing. Pharmacists spend 5 years of their training purely on drugs and their handling, side effect profiles etc. So under what pretense do pharmacists know less than newly qualified pre-registration house officers about medication issues? I am disappointed that the powers-that-be within the medical profession feel so negatively about non medical prescribing and I can only hope as time goes by and a better understanding of non-medical prescribing is attained that attitudes will improve. Here's hoping anyway Competing interests: None declared |
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Miriam A. Atkins, Nurse Kiryat Malachi 70700
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My dear coworkers, please descend from your Olympic pedestals! We are not trying to take work away from you or entering through a back door! Nurses are professional health workers who have specialised in a certain field and so' are able, very competently, to carry the treatment regime the next step forward and decide which medications their patient - whom they know much better than many of the doctors treating him, needs.We are not about to dish out pills left, right and centre! If our asteemed colleagues would listen a moment, they would realise this. As the pharamist says, most young doctors are consulting with us anyway! Competing interests: None declared |
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Patrick J Lynch, Resident Pharmacist, Addenbrookes Hospital, Cambridge
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The worry that patients are going to suffer at the hands of prescribing pharmacists is understandable but not an inevitability. If applied correctly independent prescribing pharmacists will free up doctors time and allow pharmacists to utilise their skills and training to make agreed and shared, evidence based decisions about the pharmaceutical care of the patient. The 'diagnostician' / 'prescriber' model makes sense for a number of other reasons. It will help reduce drug related morbidity for patients. Interactions and side-effects could be minimised and monitored more closely. The 10.1% of hospital admissions that are drug related could be reduced. Our decisions will be evidence based and reflect current best practice. Our training gives us implicit knowledge of the action of drugs from a molecular level to how they will impact on the daily lives of patients. In practice we will probably see prescribing by pharmacists limited to clinical areas that they a proven competence in. Dentists are allowed by law to prescribe all medicines yet in practice their prescribing habits are directed to their speciality and pharmacists will probably follow suit. Notwithstanding this, I firmly believe prescribing is not for every pharmacist and see many hurdles which must be overcome. I hope that the medical profession will eventually embrace this and will come to recognise it as the ubiquitously benefical step forward that we hope it will be. Competing interests: None declared |
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Erik T Walbeehm, SpR Plastic Surgery Rotterdam, 3022 BC, The Netherlands
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In a world where patient safety is the primary goal, where, as a doctor one is under constant scrutiny of one's performance. Where the slightest mishap might cause one to be struck of the register and be condemned , I do not understand that people who are less trained in "being" a doctor, with all respect for pharmacist's and nursing training, would want to take over those tasks that carry the most important risks. "Being" a doctor also involves being at risk. Does this also mean that non-medical prescribers get the power to change medication?? It might be of interest for the professionals involved to investigate the judicial standpoint on these matters, before embarking on extending their tasks. "Being" a doctor means knowing your patient, keeping a record of what has worked and being creative in what might work for this patient. It also means knowledge of other specialities, because mistakes do not arise in areas that one has knowledge of, but in matters that are NOT recognised, because one has never come across it before. As a doctor you spent time in most specialities, which gives you, however modest sometimes, the possibility of having seen something before, and therefore taking appropriate actions. Doctors are defenitely NOT perfect, and make mistakes, but we are also accountable for it. I hope the non-medical prescribers are willing to take the same responsabilities, including telling the patient or the family what has gone wrong, and how that mistake was made. I already know, that when something has gone wrong, doctors will be the ones sitting there, trying to explain. In the end, all health care professionals are there to help patients, but I feel this will only confuse matters, and create more problems. And freeing up doctors time is not by diminishing the number of prescription we have to write, but by reducing the ever increasing amount of administration and paperwork inflicted on us by non-medical managers. Competing interests: None declared |
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Ayesha F. Husain, Pre Registration House Officer Milton Keynes General Hospital, MK6 5LD
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I started my PRHO training three months back and one of the various facts that I have so far learnt about medicine is that good patient care involves teamwork. What works best in patient's interest is that each member of the team recognises their limitations to practice and is willing to involve more appropriate and experienced member of the team as and when required. I believe that as long as all of us, doctors, nurses, pharmacists, physiotherapists, dieticians and other team members understand this principal of individual limitations to practice within our own fields, the UK government's decision of giving unlimited prescribing power to nurses and pharmacist will be beneficial for the patients, particularly with regards to simple drug prescribing i.e. painkillers, antiemetics etc. and repeat prescriptions. As far as prescribing new medications is concerned, we are all responsible individuals and the power to prescribe brings with it the accountability for action, therefore wherever there is a doubt, a second opinion should be sought from another member of the team that could be a doctor or a pharmacist. At the end of the day it’s all about good teamwork and sense of responsibility. Competing interests: None declared |
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Alexander SD Spiers, Professor of Medicine - Retired. , none
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The British Medical Association's opposition to extended prescribing by nurses and pharmacists deserves strong support by every member of the profession. Extended prescribing by inadequately qualified personnel is an idea spawned by politicians who basically have no understanding of medicine, and think that medical care might be provided more rapidly by fostering a huge increase in the number of individuals with the power to prescribe. This measure might meet the approval of administrators and accountants, who are also devoid of medical knowledge and experience but are keen to cut down on expenditure. (Which might in fact increase very sharply.) Pharmacists have an extensive knowledge of drugs but mostly are lacking in clinical experience of anything but minor ills and have very limited diagnostic abilities. Nurses, on the other hand, have extensive first-hand knowledge of sick people but limited knowledge of pharmacology and therapeutics. Some nursing oaths contain prohibitions against diagnosing disease or prescribing medicines. By contrast, doctors train for six years before becoming house officers and continuing to train. They learn physiology, pharmacology, pathology, clinical diagnosis and therapeutics. They are the only people qualified to prescribe the whole range of drugs. Even then, doctors are adjured to prescribe within their own area of competence: the anaesthetist does not prescribe cytotoxic drugs and the medical oncologist does not prescribe anaesthetic agents. Extended Formulary Nurse Prescribers are well trained in the prescribing of a restricted number of drugs and limited evaluations suggest that they do this well. This does not mean that they should be able to prescribe "every licensed drug except narcotics". The "independent pharmacist prescriber" is a new breed that has not been evaluated at all. The Chief Nursing Officer and a spokeswoman for the Department of Health have stated that nurses would be "expected" to prescribe within their area of expertise. An expectation is not an adequate safeguard. Regulation and supervision is a better, but not perfect, protection for the patient. If nurses and pharmacists prescribe inappropriately and patients are harmed, who will underwrite the inevitable financial claims? Who would provide malpractice insurance for these prescribers? Who will compensate patients who have been harmed? I contend that the content of Mrs. Hewitt's address to the Chief Nursing Officers' annual conference was premature, ill-advised, under- researched, and a downright dangerous proposal. Competing interests: None declared |
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