Concerns have been expressed about the expansion of prescribing rights. These include the quality and safety of prescribing by non-medical practitioners and the potential to fragment care as patients interact with multiple prescribers across professional groups.1 However, perhaps what matters most to patient care is not which health professionals prescribe, but their competency to prescribe and the model within which they prescribe.
Prescribing rights for medical practitioners are automatic through registration with the Medical Board of Australia. Non-medical prescribing rights are evolving in the context of professional scopes of practice and within collaborative and shared care arrangements with other healthcare professionals.
Prescribing rights for non-medical prescribers, including nurse practitioners, are determined by endorsement from national professional boards (www.ahpra.gov.au) and are subject to individual state and territory legislation.1 These endorsements define the additional requirements that must be met to gain prescribing rights. Midwives, podiatrists and optometrists currently have limited prescribing rights defined by their national boards. For example, for podiatrists and optometrists prescribing is limited to a specified list of medicines.
A number of authors have emphasised the need for core prescribing competencies.2,3 Organisations such as the National Prescribing Centre in the UK have produced competency frameworks for a number of non-medical prescribing groups.4
In Australia, current prescribing is not of a uniformly high quality. The problem of poor prescribing by junior doctors is not new and the causes of errors are multifactorial.5 The medical profession has recognised that prescribing is a core skill for every graduating medical student and their competence should be assessed before they are allowed to prescribe.2
Competency has been defined by the Australian Medical Council as an observable ability of a health professional to integrate multiple components such as knowledge, skills, values and attitudes.6 Statements about competence require descriptive qualifiers to define the relevant abilities, context and stage of training. Competence is dynamic and changes over time with experience, and depending on the setting or scope of practice.1 The critical link between demonstrating specific prescribing competencies and being a competent prescriber develops with experience, quality feedback and reflection. There is a minimum accepted level of competence which should be required before any practitioner is allowed to prescribe for patients, but this will vary depending on their scope of practice and level of supervision.
A determination of the core competencies requires a detailed understanding of the prescribing process. But what are the core knowledge, skills, values and attitudes required for safe prescribing? Should they be based solely on an understanding of pharmacology and therapeutics, or does the evidence suggest a broader requirement?2
A study identifying why junior doctors made serious prescribing mistakes5 led to a concept of four domains of prescribing competence.7 The first domain involves the skill of gathering information such as relevant patient diagnoses and medication history (including previous allergies and adverse drug reactions) or recent changes to medicines. The second domain requires a cognitive step that involves using pharmacological knowledge to select not only the right drug for the disease, but also the right drug and dose for the patient with the disease. The third is the ability to safely and effectively communicate these decisions to other health professionals and the patient or carer. This may involve completing either paper-based or computer-generated orders which, in a community setting, constitute clear instructions to pharmacists to dispense or nurses to administer. A critical component of the communication involves discussion with the patient or carer so that they clearly understand the reasons why certain drugs were prescribed and are therefore more likely to adhere to therapy. The fourth domain is the ability to review both therapeutic and adverse impacts of the therapy. This information will inform decisions to continue or modify therapy.
Most medical practitioners have a potentially broad scope of practice when it comes to prescribing, far broader than most non-medical prescribers. While some medical schools have prescribing education programs,8 many of the postgraduate vocational training programs lack specific curricula based on frameworks such as the prescribing competency framework.4 It could be argued that such a curriculum, with its specific learning outcomes and methods of assessment to ensure safe and effective prescribers, should exist for all clinicians.
Health Workforce Australia is currently working with NPS to develop a framework for prescribing competency. Adopting national prescribing competencies for all prescribers would inform the training, development and credentialing of all clinicians. This would enable the national professional boards to undertake their key role of ensuring optimal safe and quality healthcare.
The authors wish to acknowledge Associate Professor Charles Mitchell, Clinical Director, Centre for Safe and Effective Prescribing, University of Queensland for his contribution to the manuscript.
Conflict of interest: none declared
