There is talk by government sources of new systems whereby nurses and pharmacists, and one questions whether perhaps other paramedical professional may be included, will be able to prescribe. On the other hand there is legitimately considerable concern on the part of the medical profession regarding the meaning of all this. An email sent to GPs expresses concern that if doctors do not accept what the government is offering, this is what is going to happen – that government will try to replace the work of general practitioners by other paramedical professionals. This state of affairs can be interpreted as bribery or enticement. That nurses and pharmacists in some countries do prescribe is no secret. That they will not be necessary if doctors had to accept one or other system is not so either, especially if it is cost effective to the government. There are however concerns to be addressed.

It is true that in the UK, for example, nurses do some limited amount of prescribing. This was deemed necessary because it was in the best interest of the patient and because GPs were not unreluctant to hand over this business. It is also true however that prescribing by a community nurse or nurse practitioner may take place only after the introduction of the necessary changes to the Medicines Act in the UK. For a nurse to legally prescribe, the law must not only cater for it, but the Minister concerned must justify that action. Usually this justification is based upon the fact that the doctors cannot cope in one particular area and they themselves recommend that nurses can be trained to prescribe in certain particular areas but never as autonomous prescribers.

In fact in the UK the Medical Products Act of 1992 enabled nurses, pharmacists, midwives and other health professionals to prescribe only under certain circumstances. It would be detrimental to our system that we introduce a concept simply because that is what they do abroad. There is a long-standing history of nurse practitioners and we should learn however from experiences of other countries. Criteria for nurses to prescribe include, being registered, being employed by the Department of Health, be registered as a health visitor, be named on the professional register and marked as qualified to prescribe, and that there exists a necessity due to a gap in the health system. For example, a community nurse may be allowed to prescribe a specified list of medicine for particular conditions, and for which doctor-availability is limited and therefore is cost-effective.

Usually nurses prescribe only those parenteral (by mouth) prescriptions which they are authorised to prescribe and are allowed to issue ‘repeat prescriptions’ with a limit to the number of repeats before the patient should again be seen by the doctor. The Crown report of 1999 made several recommendations which are worth noting. The report was issued in the light of a necessity to extend current prescribers and was limited to specific therapeutic areas. There were two important points which the report laid down: first that newly authorised groups should not normally be allowed to prescribe specific categories, including controlled drugs, unlicensed drugs, or drugs over which there is professional concerns by doctors. Second, and perhaps more importantly, the report recommended the establishment of an advisory body to see which drugs can and cannot be allowed to be prescribed by nurses in the best interest of patients, and to recognise that there should be two types of prescriber: ‘independent’ and ‘dependent’.

By an independent prescriber one is referring to doctors, who are allowed to prescribe as independently; there are those then who ‘depend’, and hence ‘dependent’, on other professionals in order to prescribe. A nurse or pharmacist can only fulfil the latter criteria, as ultimately any patient has to be the responsibility of the doctor. In the report, the “Independent prescriber is defined as the person who is responsible for the assessment of patients with undiagnosed conditions and for decisions about the clinical management required, including prescribing”. This group includes doctors and dentists, and some nurses who are legally authorised. “Dependent prescriber is defined as the person who is responsible for the continuing care of patients who have been clinically assessed by an independent prescriber. The continuing care can include prescribing which will be informed by clinical guidelines and will be consistent with the individual treatment plans. They may be allowed to adjust the dose. There should be provision for regular clinical review by the assessing physician.”

What are the conditions in which nurses can usually prescribe? These are usually recognised by law as extended duties, and not duties which fall under the realm of the normal nursing duties. The extension applies to four main areas: Minor injuries and ailments such as cuts, burns, and hay fever; promotion of healthier lifestyles such as help with giving up smoking; chronic diseases including asthma and diabetes; and, palliative care. The prescribing would fall within the realm of adjusting doses of drugs which doctors feel can legitimately be adjusted by nurses who have the training and experience in the area.

There are additional criteria which the Crown report insisted upon and which subsequently were recognised by the Act. The nurse must have the ability to study at tertiary (degree) level and have at least three-years post-registration clinical nursing experience. A medical practitioner must be willing to contribute and to supervise the nurse, and finally the support of the employer and confirmation of certain conditions. The UK Department of Health gives detailed guidance on who may prescribe, the implementation strategy, education and training, action of employers in primary care, the role of pharmacists, the security and handling of prescription forms, good practice and ethics, nursing records, adverse reaction reporting, legal and clinical liability, dispensing items, and setting of budgets and monitoring.

Before we can fulfil these conditions, especially the keeping of records and adverse reactions, the taking on of responsibility and clinical liability on the part of the nurse and setting clear boundaries and limits on to what can be prescribed, we should not even contemplate introducing such a system. Not to mention the fact that prescribing by non-doctors should be done on official forms and not simply prescription pads which carry a professional rubber stamp. Clearly all prescriptions should be monitored.

The three key principles are patient safety, maximising benefit to patients in terms of quicker and more efficient access to medicines for patients, and of course better use of nursing skills. What concerns most doctors are the first two. Is it safe? And do we actually need a more efficient and faster system? In certain areas the answer is clearly ‘yes’. For example, in hospital the administration of Warfarin is often based on simply algorithms which can be worked out on a computer and which the pharmacist should be authorised to dispense without any official doctor’s signature, providing that there are clear guidelines on the periodic review by the latter. It is clear that there is no case for more efficiency in primary care. In fact private practice is overflowing with doctors who are not even primary care physicians in the true sense of the word. In health centres it may be a different matter, and relieving doctors from certain burdens may be a good thing. Therefore nurses can be employed to issue repeat prescriptions for those chronic conditions which require a prescription every three months. A yearly review by a doctor would be enough. In hospital, an ophthalmic surgeon told me that some patients are on life-long treatment and come to out-patients every year simply for approval of the permit for special drugs. Unless there is a specific cause for a specialist’s time to be used for reviewing the patient, nurses can probably handle such repeat requests easily.

The whole idea should be to make the system more efficient thus benefiting the patient. What it should not be is merely allowing an outlet whereby a paramedical professional is allowed to prescribe privately and independently. This is unfortunately the state of affairs we have today and allowing this to happen would be simply ‘rubber-stamping’ the bad that is occurring. I have patients who tell me that their podologist prescribes drugs such as antifungals and non-steroidals. If you do not know what this means, consider that the podologist has not studied them either and is prescribing them only because he sees the doctor do likewise for the condition he is seeing. There is no background tertiary level of education and no background study of pharmacology, pharmacokinetics and pharmacodynamics. These people probably do not even ask you whether you suffer from kidney or liver problems and what to do in the eventuality. They simply prescribe because this is how they may be contributing for the premises they are allowed to use.

Introducing a system because these people are prescribing ‘anyway’ is perpetuating something which is inherently wrong. What one should be asking is whether we need the podologist to prescribe these drugs and whether the patient would be served better. If the patient cannot be efficiently seen by a doctor, then one would have to contemplate whether giving the appropriate training and making the appropriate legislation is useful. I doubt how much in our system this is the case. This is not about individual egos. It is about having the people who have the proper knowledge and background give appropriate care. I would have no problem with a pharmacist giving emergency treatment to a tourist whose bag did not arrive. Giving a two-day prescription of an anticholesterol agent and/or an antihypertensive should be feasible.

The real question is whether the pharmacist would open a box just to give one or two tablets. But just because we are not able to sell the rest of the box is no excuse for allowing one to sell the whole box. The next thing would be having patients change their own antihypertensive drugs because a friend is on a different kind of medication. We face these questions in general practice. It is not the first time that a doctor prescribes a drug to a patient who the following week returns asking whether he can have or should be on the other brand which a friend has shown him or her. The doctor who has prescribed the medication is in a position to explain why he or she had chosen that drug in the first place.

Before pharmacists take histories and examine patients the way doctors do (and this would make doctors out of them), the choice of drugs they can prescribe will remain legitimate. This is not to undermine the work of any professional. Pharmacists have key roles to place in asserting that some drugs are safe for patients, even if they have been seen by the doctor. Perhaps the pharmacist knew something about the patient which he wants to assert that the patient has discussed with the doctor. The pharmacist in my area is a safety net which I would not like to lose.

Prescribing by non-doctors has come of age and we have to accept it. But it is a political responsibility which, like other things, cannot be introduced without the proper mechanisms and boundaries which guarantee patient safety and necessities which justice demands, and not simply that since-they-do-it-in-the-UK-we-should-do-it-here.

Pierre Mallia is Associate Professor in Family Medicine, Patients’ Rights and Bioethics at the University of Malta; he is also Ethics Advisor to the Medical Council of Malta. He is also former president of the Malta College of Family Doctors.