Yohann White | Should non-doctors prescribe medication?

The shifting of tasks from medical doctors to other members of the healthcare team has been one strategy aimed at improving access to health services. The idea is that medical doctors will have more time for tasks that really only they can do. One task that is sometimes shifted from doctors to non-doctors is prescribing medicines. One concern that would be foremost in the minds of many is whether non-doctor prescribing is likely to negatively impact patient safety.

“First, do no harm,” is the most important ethical principle for the practice of medicine. Yet, according to the World Health Organization Global Patient Safety Action Plan 2021-2030, the number of persons who die in low- and middle-income countries (LMICs) each year because of unsafe healthcare is about the size of Jamaica’s entire population. The action plan also states that medical errors lead to US$42 billion dollars in costs in LMICs. Medical errors may affect as many as one in four patients in LMICs, compared to one in 10 patients in wealthy countries. Mistakes related to prescribed medications contribute to unintended patient harm, even with experienced medical doctors. In a May 2016 issue of the British Medical Journal, researchers at Johns Hopkins University identified medical errors as the third leading cause of deaths in the US, more than deaths from diabetes or chronic lung disease. We have a dilemma that requires careful balancing between expanding access to care and ensuring patient safety.

NOT NEW

In a busy clinic with many patients to be seen, it would not be unusual if a nurse wrote a prescription and asked the physician to sign. Usually, the physician would already have some familiarity with the case. Even more importantly, there is a certain level of trust within the team. If a team member makes an error in prescribing, someone can communicate same, giving the opportunity for corrective action without alarmist accusations – a non-blaming culture. Often, bewildered patients leave the doctor’s office, chasing the nurse for an explanation of “what is on the prescription” and “what the doctor just say”. Advanced nurse practitioners have been essential to the delivery of health services in Jamaica, including providing thoughtful patient counselling, physical examination, and diagnostics they competently perform daily. Back in 2017, there was the discussion of experienced nurse practitioners in Jamaica being considered for prescribing powers. Variations of non-doctor prescribing have been in practice in the USA since the 1970s, and in the United Kingdom (UK) since 1994.

IS IT EVIDENCE-BASED?

If we believe, or are experimenting with, the idea that low-risk patients can be seen by experienced competent non-doctors for uncomplicated medical issues, in order to decrease patient waiting time and improve clinic workflow, then this strategy could be useful. But, what evidence is there that supports this approach? There is not much to refer to in the extant literature in terms of evidence on whether non-doctor prescribing improves healthcare based on important indicators. Indicators relevant to the assessment of healthcare quality include whether health services exist and are ready for use, within reach when desired without barriers, pleasing for patients, safe, and clinically effective. Encouragingly, a 2016 review by the independent Cochrane group, discussed some evidence supporting good patient outcomes for non-doctor prescribing comparable with doctor prescribing resulting in control of blood pressure, and blood cholesterol and sugar, indicators relevant to clinical effectiveness. On this and other relevant outcomes, however, the reviewers concluded that there remain “substantial gaps in the knowledge base to help evidence-based policymaking.” Rather than as an after-thought, evaluating the impact of changes in healthcare policy and practice should be considered at the outset before implementation. The task of evaluating should be deliberate and conducted by dedicated personnel, not overworked clinicians, and may include incident reporting, audits, and research. We may seek to change the structure of healthcare or its processes, but, ultimately, it will be the outcomes, intended and unintended, on the health of individuals and populations that matter.

While non-doctor prescribing appears to be aimed at improving access to health services, if we are committed to evidence-based health policy and practice, we have to acknowledge that there are gaps in our knowledge of its impact. Alongside a systems approach to medical error prevention and mitigation, periodic evaluation of this initiative should be carried out to determine the impact on patient safety.

Dr Yohann White is a medical doctor and a certified infection prevention and control professional. Send feedback to yohann.white@caribewellness.com