RACGP, AMA put nurse prescribing out of play

The groups raised concerns for patient safety and fragmented care if nurses were to extend their scope to prescribing.

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Both the RACGP and the AMA have opposed giving registered nurses prescribing rights for a selection of scheduled drugs, even under supervision.

They were responding to a proposal from the Nursing and Midwifery Board of Australia, which presented four prescribing options:

• Option 1 – Retain the status quo prescribing practice.
• Option 2 – RNs expand their scope of practice to prescribe Schedule 2, 3, 4 and 8 medicines under supervision, in accordance with governance frameworks and prescribing agreements.
• Option 2(a) – enable RNs to expand their scope of practice to prescribe only Schedule 2, 3, and 4 medicines under designation/supervision.
• Option 2(b) – enable RNs to expand their scope of practice to prescribe Schedule 2, 3, 4 and 8 medicines only under designation/supervision, except for RNs working in private practice or as a sole practitioner.

While both the AMA and the RACGP hailed the NMBA’s thoroughly researched proposal, the colleges were wary.

In its response, the RACGP supported the first option outlined by the NMBA proposal – “retain the status quo prescribing practice”. The college suggested reform at this time was unnecessary but said that it might consider the proposal to allow registered nurses to prescribe schedule 2, 3 and 4 medicines “in identified areas of need and under GP-supervised care”.

The college suggested that remote and rural areas may benefit from registered nurse prescribing but that this should only be under a strict, GP-guided protocol, meaning additional funding would be needed for general practice to provide suitable supervision.

The college said the prescribing models outlined in the proposal could lead to fragmentation of care.

“Fragmenting healthcare has been shown to be less safe and more expensive than models that facilitate continuity of care,” the college said.

The RACGP also said the inherent role of diagnosis in prescribing had been forgotten.

“Prescribing requires in-depth experience and training in diagnosis, treatment and drug interactions,” it said.

“The proposal also does not consider non-drug interventions and quality deprescribing strategies. Deprescribing (reducing the number of medications) is an active process for GPs in the context of the patient’s medical history and the broader Quality Use of Medicines perspective.”

In concurrence, the AMA quoted the 10-14 years of training GPs undertake to facilitate patient care.

“Only medical practitioners are trained to make a complete diagnosis, monitor the ongoing use of medicines and to understand the risks and benefits inherent in prescribing.”

The AMA also raised concerns over the effects increasing prescribers may have on the sustainability of the PBS and the potential for indemnity insurance risks for new prescribers.

The AMA said that while it would be on board with prescribing reform, it must be evidence-based and medically led to ensure patient safety. It said it would like to see pilot studies trialling models of registered nurse prescribing to assess safety and effectiveness in practice.

Both the AMA and the RACGP opposed registered nurse prescribing of schedule 8 medicine, due to safety risks, and agreed ultimately that increasing the number of prescribers was not the answer to workforce woes.

“Local and international evidence shows that better support for, and use of, general practice is associated with lower emergency department presentations and hospital use decreased hospital re-admission rates, and significant savings for the healthcare system,” the RACGP said in its response.

“We agree there is potential for [registered nurse prescribers], but we need to ensure that the expansion of scope is done safely and with the right goals in mind noting, in particular, that this will not be a solution to medical workforce shortages, which need to be comprehensively addressed as an issue in their own right,” said the AMA.