What Does The Research Evidence Say About Non-Medical Prescribing?
Non-medical prescribing—that is, people who are not medical doctors picking up a prescription pad and providing access to medicine for their patients—has been a hot topic for at least 30 years. The conversation rears its head every year or so as another ‘non-medical’ group (mostly allied health practitioners these days) enters into an argument with a peak medical body about whether or not they should be able to prescribe restricted medicines, effectively by-passing the patient’s medical practitioner.
For example, a proposed trial in North Queensland enabling pharmacists to administer vaccines and prescribe medicine for a range of common conditions has met with opposition from the RACGP, in part, on the basis of unpublished data of a survey of GPs that suggests that a separate trial for urinary tract infections resulted in high levels of complications for patients. This is despite (and ignores) several high quality, international, peer reviewed studies supporting the benefits of pharmacist input into the management of UTIs and respiratory tract infections (for example, this 2019 systematic review and meta analysis, and this one from 2021). The same studies also demonstrate that pharmacist input also improves antimicrobial stewardship, which is important to prevent antibiotic resistance, and that non-medical prescribing for common conditions is reasonably widespread internationally, particularly in countries that lack good access to primary care.
A quick glance at the sociology of the professions shows that access to prescribing of medication is a classic turf war between occupational groups, where one group claims a monopoly over an area of practice that is not available to other groups, thereby protecting their profession and security their means of earning an income. The successful outcome of this argument (i.e., who can do what to whom) is actually what differentiates the health professions from each other. In reality, the boundaries between professions are fairly fluid. More information on the history of non-medical prescribing in Australia and the UK can be found in this article.
In Australia, there are very few tasks that health practitioners do that are actually protected by legislation. In fact, most allied health professionals—even those that are registered with the Australian Health Practitioner Regulation Agency (AHPRA)—have no tasks that are protected by legislation. Only allied health practitioners registered with AHPRA (such as physiotherapists, podiatrists, occupational therapists, Chinese medicine practitioners, etc.) can use those protected titles, but in reality, the actual tasks those practitioners perform can be delivered by anyone.
However, the medical profession cemented its dominance in the health field initially, by determining who could be considered a ‘health practitioner’ by holding a position of authority in the health care regulation system, and simultaneously, by restricting access to the tools and technology that would give them a monopoly over certain areas of practice. The most powerful of these tools was taking ownership of prescribing medicine, but also limiting access to certain invasive techniques, such as performing surgery, and some diagnostic tools such as radiographic imaging. In the early days of the professionalisation of the health workforce (around a century ago), doctors also ran hospitals, which also further cemented their hegemony over all areas of health practice.
In the early days of the modern health professions (from the early 1900s until about 1980), only a handful of allied health professions were fully trained to degree level. Since the mid-1990s, all allied health practitioners and nurses in Australia receive at least degree level training at a higher education institution. It was about the same time that evidence based practice came into being, which has been strongly embraced by allied health practitioners. Subsequently, allied health professionals have sought access to medical prescribing, variously supported by additional training and appropriate legislation in some jurisdictions. See Graham-Clarke et al (2019), and Borthwick et al, 2010 for more detail on the history and development of non-medical prescribing in Australia and the UK.
What does the evidence tell us about non-medical prescribing and outcomes?
Non-medical prescribers normally include nurses, pharmacists, and other allied health care professionals who have undertaken additional training to prescribe medications. The research evidence on non-medical prescribing is dispersed across a range of occupational groups, interventions, study types, and different types of outcomes, however overall, some strong themes emerge. In particular, non-medical prescribing has a positive impact on patient care, accessibility, safety, and healthcare service efficiency, and has very few risks or downsides (in several cases has better outcomes than traditional prescribing). Some examples are provided below (using meta-analyses or other systematic review data where possible).
Patient outcomes and safety
Non-medical prescribing has been found to be safe and effective. Studies have shown that non-medical prescribers make appropriate prescribing decisions and demonstrate competence in managing various clinical conditions, and can reduce the rates of prescribing errors compared with ‘treatment as usual’ (ie ‘medical prescribing’). Patients did not express a preference for a particular prescriber. For example, see Latter, et al. (2010). Evaluation of nurse and pharmacist independent prescribing. University of Southampton and Keele University and Poh et al (2018) The effects of pharmacist prescribing on patient outcomes in the hospital setting: a systematic review . As mentioned above, there is also evidence in this meta analysis that antibiotic stewardship programs (to reduce rates of inappropriate antibiotic prescribing) that included pharmacists were found to be effective at decreasing antibiotic prescribing and increasing adherence to antibiotic prescribing guidelines by GPs.
Improved access to care
Non-medical prescribing has been associated with improved access to medications and reduced waiting times for patients, particularly in primary care and rural settings. An international Cochrane Systematic Review including 46 clinical trials and 37,337 participants found evidence that non-medical prescribers produced similar outcomes for management of patients with high blood-pressure, diabetes control and high cholesterol. Prescription by trained pharmacists and nurses achieved similar outcomes to medical prescribing in terms of patient adherence to therapy, adverse events, overall satisfaction, quality of life, and resource used (hospitalisations, visits to the emergency department, and consultations). The authors concluded that with access to appropriate training and support, non-medical prescription by nurses and pharmacists can be as effective as medical prescribing. See Weeks et al (2016). Non-medical prescribing versus medical prescribing for acute and chronic disease management in primary and secondary care. Cochrane Database of Systematic Reviews, 2016(11), CD011227.
Interprofessional collaboration improves medical prescribing safety
Interprofessional collaboration between doctors and pharmacists has been found to reduce prescribing error rates in a series of studies (for example, see Sheehan et al, 2021) undertaken in the UK and repeated in New Zealand.
Cost-effectiveness
A 2018 systematic review of randomised controlled trials by Noblet et al explored the effects of non-medical prescribing on one or more outcome(s) of: pain, function, disability, health, social impact, patient-safety, costs-analysis, quality adjusted life years (QALYs), patient satisfaction, clinician perception of clinical and functional outcomes. In all studies, participants who received non-medical prescribing demonstrated significant improvement in outcomes compared to treatment as usual. Interestingly in this study, ‘raw unadjusted mean costs’ were lower for non-medical prescribing, however after adjustments for variance at baseline, the costs of non-medical prescribing were higher than treatment as usual. However, the experimental groups generated increased QALYs compared to TAU.
Patient satisfaction
A number of studies exploring patient preferences demonstrate that patients generally do not have a preference for the type of practitioner prescribing medications and are generally satisfied with the care provided by non-medical prescribers, and trust in their ability to prescribe medications (For example, see Latter et al, 2010, Courtenay et al, 2012, Stenner et al, 2011).
Conclusion
The debate around non-medical prescribing is not new, and many countries have had models of non-medical prescribing for decades. For instance, the 2000 NHS Plan introduced non-medical prescribing by nurses and allied health professionals as a way to address health workforce shortages. Australia has also had levels of non-medical prescribing for some professions and in different jurisdictions for more than a decade. At a time of critical workforce shortages across most health care professions, the time has never been better to review any systems or processes that will increase access to healthcare.
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