Why is it that the authority of doctors to prescribe medicines is rarely questioned, while the safety of other healthcare providers prescribing is frequently scrutinised? As we highlight in this article, the published research evidence shows that non-medical prescribing has several benefits over ‘traditional’, that is, medico only prescribing models, either as an alternative to medico prescribing or as an adjunct.
Why is it that doctors have secured an assumed ‘ownership’ over prescribing?
The historic medical hegemony, which reinforces medical ownership of prescribing (amongst other things), can be attributed to a range of factors:
The early systems of medical registration (such as the 1858 Medical Act in Britain and similar laws in Tasmania, NSW and Victoria) did not give the medical profession an occupational monopoly, but did provide the mechanisms that the medical profession used to restrict and shape the roles of other emerging health profession craft groups (for example, see Medical Dominance by Evan Willis, and Occupational Monopoly and Modern Medicine by Gerald Larkin). Control by the medical profession over the scope of practice of other health professions extended well into the late 20th century through the inclusion of medical practitioners on the registration boards of other health professions and making access to some allied health services conditional on a referral from a medical practitioner. While the medical profession no longer has such control over the scopes of practice of other health professions, organised medicine still maintains a position of political power and influence which it uses to resist changes to legislation that extend the scope of practice of other professions. Prescribing medication is the most obvious and contentious of these at present.
2. Regulatory frameworks
In many jurisdictions, laws and regulations reinforce medical hegemony by limiting prescribing authority to medical practitioners. These legal constraints strengthen the perception that doctors are the safest and most qualified prescribers, while casting doubt on the capability of other healthcare providers. However, it is worth noting that non-medical prescribing has been supported by legislation in Australia and the UK for three decades or more.
3. Insurance and reimbursement models
Health insurance policies and reimbursement schemes tend to prioritise medical services and treatments, with limited coverage for allied health services. In many cases, access to rebates for allied health services is contingent on referral by a medical practitioner (such as Medicare funding for allied health in Australia), creating an additional step in accessing health care, and further reinforcing the role of medical practitioners as gate-keepers to allied health services. This also increases the overall cost of delivering care and reduces accessibility from the patient perspective.
4. Research funding and infrastructure
Biomedical research receives a significant amount of funding, leading to a strong bias in favour of this paradigm. This reinforces the notion that biomedical interventions are the most reliable and effective solutions to health problems and accords public health, primary care and prevention a lower priority.
5. Professional hierarchies
In many healthcare settings, doctors are considered the primary decision-makers and hold significant authority over other healthcare practitioners, including allied health practitioners. This hierarchy can sometimes devalue or marginalise the role and contribution of allied health practitioners in patient care.
6. Education and training
Despite growth in interdisciplinary education, the roles of allied health practitioners are poorly understood, including by the medical profession. This results in a lack of understanding and appreciation of their contributions among medical practitioners and other healthcare providers, as well as patients.
7. Resource allocation
Healthcare resources, including funding, workforce, equipment, and facilities, are often prioritised for biomedical interventions and medically led services. This is, in part, due to the lack of sound tools to help identify allied health service needs and plan and allocate resources accordingly.
8. Lack of awareness of the roles and expertise of AHPs
Many in the community are not aware of the training, qualifications, and capabilities of healthcare providers such as nurse practitioners and allied health practitioners. This limited awareness perpetuates the view that only doctors are competent to prescribe medications, making it more likely for individuals to be tentative about or to question the safety of non-medical prescribers.
9. Media influence
Popular media continues to portray of doctors as the ultimate medical authority. Other healthcare providers do not receive the same level of recognition or exposure – and in many cases, the public lack awareness of non-medical roles, further fuelling skepticism about their prescribing abilities.
The purpose of this article is not to question the obvious expertise and value of the medical profession, but to gently challenge the century-old tradition of medical hegemony and instead promote a model that is patient-centred, not profession-centred, and embraces input from a collaborative health workforce, recognising the expertise and input of a wide range of health practitioners.
Why we need a more collaborative approach to prescribing medication
Our society takes for granted that the medical profession are the rightful gatekeepers of restricted medicines, based largely on historic precedents and medical hegemony, largely reinforced by colonial systems of governance and regulation. The role of non-medical prescribers has expanded significantly in recent years, with nurse practitioners, pharmacists, and other healthcare practitioners being granted prescribing rights. To justify ‘non-medical’ access to and prescription of restricted medicines, a growing body of research has compared the patient outcomes of non-medical prescribers with medical prescribers.
Non-medical prescribing has been shown to improve access to healthcare, reduce waiting times, and promote more efficient use of healthcare resources. In some cases, non-medical prescribers may have more specialised knowledge in a particular area, leading to better care and outcomes for patients. Given this growing body of evidence, should we be asking questions about the safety and efficacy of doctors as the primary prescribers of medications, and instead embracing more collaborative approaches?
The following arguments support a more collaborative approach to health care delivery – including non-medical prescribing:
1. The changing landscape of healthcare
The healthcare system has experienced significant changes in recent years, with an increased emphasis on integrated care models and a growing recognition of the value of interdisciplinary collaboration. In this context, maintaining the dominance of the medical profession in prescribing may hinder the development of a more collaborative and holistic approach to patient care. By embracing the expertise of non-medical prescribers, healthcare systems can benefit from a more comprehensive and well-rounded approach to medication management.
2. Addressing the shortage of primary care providers
Many countries face a shortage of primary care providers, which can limit patient access to healthcare services. Medical workforce shortages are particularly acute in rural and remote areas and for hard to serve populations. By empowering non-medical prescribers to take on a more significant role in prescribing medications, healthcare systems can address this shortage and improve access to care. Non-medical prescribers such as nurse practitioners, optometrists and pharmacists can provide high-quality care to patients, helping to alleviate the burden on the medical workforce and ensuring that patients receive timely and appropriate treatment.
3. Workload and time constraints of doctors
Doctors often face high workloads and limited time with patients, which may affect their ability to prescribe medications safely. In contrast, non-medical prescribers, such as nurse practitioners, generally have more time to review patient history, discuss treatment options, and monitor medication adherence. This additional time could result in more informed prescribing decisions and reduced risk of medication errors.
4. Harnessing the unique expertise of non-medical prescribers
Non-medical prescribers possess unique expertise that can be invaluable in the prescribing process. For example, pharmacists have specialised knowledge of drug interactions, side effects, and dosing, while nurse practitioners often have a strong understanding of patient needs and preferences. Optometrists are the generalist practitioners of eye care. By challenging the dominance of the medical profession in prescribing and incorporating the skills and knowledge of non-medical prescribers, healthcare systems can optimise treatment plans and reduce the risk of medication errors.
5. Promoting patient-centred care
A patient-centred approach to care is increasingly recognised as essential for improving patient outcomes and satisfaction. By diversifying the prescribing process and involving non-medical prescribers, healthcare systems can better address the individual needs and preferences of patients. This may include providing more personalised treatment plans, better patient education, and improved monitoring of medication adherence, ultimately resulting in a more patient-centred and preventative approach to care.
6. The need for interdisciplinary collaboration
Given the complexity of patient care, interdisciplinary collaboration is essential for ensuring safe and effective treatment. An argument that the medical profession uses to maintain authority over prescribing is that they have a unique, holistic, and systemic perspective of the patient. By allowing non-medical prescribers to contribute to the prescribing process, a more holistic approach to patient care can be achieved. This collaboration enables different perspectives and expertise to be incorporated into treatment plans, potentially reducing the risk of medication errors, and improving patient outcomes.
7. Continuing education and training
While doctors receive extensive training in medical school, non-medical prescribers are also required to complete rigorous education and training programs. These programs are specifically designed to ensure that non-medical prescribers possess the necessary skills and knowledge to safely prescribe medications. As a result, their qualifications should not be discounted in evaluating the safety of prescribing practices.
While doctors have traditionally been the primary prescribers of medications, it is essential to consider the potential benefits of expanding the role of non-medical prescribers. This includes the specialised knowledge that non-medical prescribers possess, the potential for reduced workload and time constraints for doctors, and the importance of interdisciplinary collaboration in patient care.
Of course we don’t question the importance of medical prescribing, but it is important to challenge the socially accepted norms that put treatments solely in the hands of one occupational group, based on history, when there is strong evidence to support a more effective way of delivering services that will increase accessibility for more patients.
If you are interested in more information about the history and sociology of the health professions – and particularly the role of the allied health professions in prescribing, see The Allied Health Professions – A Sociological Perspective that I co-authored with Professor Alan Borthwick OBE.