Borthwick, Alan M.

Boyce, Rosalie

Short, Tony

English

Southampton (e-Prints Soton)

Allied Health Professionalism in a Changing World: AHP Prescribing in Australia and the UKDr Alan M Borthwick, University of Southampton, UKDr Rosalie Boyce, University of Queensland, AustraliaMr Tony Short, Queensland University of Technology, Australia‘Prescribing’ and the medical profession• “legally and otherwise, the physician’s right to diagnose, cut and prescribe is the center around which the work of many other occupations swings, and the physician’s authority and responsibility in that constellation of work are primary” (Freidson 1970)• “prescribing is one of the core activities that demarcate the medical profession from other groups… “ “…in British general practice, prescribing is the battleground on which the cause of clinical autonomy is defended” (Britten 2001)• “Prescribing is now the most common form of treatment in the NHS….80% of all NHS prescriptions are written in primary care” (Bradley, Hynam and Nolan 2007) ‘Prescribing’ in a changing world: challenges to medical     power• neo-liberalism, NPM and economic rationalism (Boyce 2006; Willis 2006)• workforce flexibility & changing roles of ‘allied health’ professions (Nancarrow and Borthwick 2005; Titcomb and Lawrenson 2006; Willis 2006)• state-sponsored regulatory change & health policy reform: – “new ways of working”  “breaking down traditional barriers” and “working across traditional professional boundaries” (Allsop 2006; DoH 2000a, 2000b, 2001)AHPs in the UK and AustraliaAustralia:• 19 allied health professions (Boyce 1998)• 30,000UK: • 13 allied health professions (HPC 2008)• 50,000Active AHP ‘prescribers’ in the UK and AustraliaUK:• podiatry• optometry• pharmacy• radiography• physiotherapyAustralia:• podiatry• optometry• pharmacyActive AHP ‘prescribers’ in the UK and AustraliaUK:• podiatry• optometry• pharmacy• radiography• physiotherapyAustralia:• podiatry• optometry• pharmacyNon-medical ‘Prescribing’ in the UK and AustraliaUK• independent prescribing (2006, Nursing & Pharmacy; 2007 Optometry)• supplementary prescribing (2005, CMP only)• patient group directions (2000, physician authorisation)• profession-specific statutory exemptions (post-1968, CHM authorisation)Australia• formulary (independent but limited eg. SA 1989)• protocol prescribing (by written physician ‘delegation’) • patient group directions (as UK eg. immunisation clinics)• repeat prescribing (pharmacy‘medication refill’)• collaborative prescribing (medical-AHP joint prescribing)The UK Medicines Act (1968)‘The White paper [1967] reviews the action taken by the government in 1962 as a result of the disquiet caused by the teratogenic actions of thalidomide…’(Cmnd. 3395, cited in BMJ, 16th September 1967, p.743). • general sales list• pharmacy only (P)• prescription only medicines (POM)POMs for ‘approved prescriber’ groups only:– doctors of medicine–d e n t i s t s– veterinary surgeons and veterinary practitioners– Medicines Commission & CSM for submissionsAHP early ‘prescribing’: podiatrists & optometristso Podiatrists allowed ‘administration’ rights to 4 local anaesthetic agents (The Medicines (Prescription Only) Order 1980 (SI 1980/1921)o “Training should invariably be in the hands of anaesthetists…” (Medicines Division, DHSS, 1980)o Optometrists: Opticians Act (1958) denied a pharmaco-therapeutic role to opticians (medicines for diagnostic purposes only, limited in range) (Larkin 1981; Lawrenson 2007)Neo-liberalism, economic rationalism and ‘prescribing’: 1980s• Deregulation of medicines (POM to P to GSL)• ‘indicative’ prescribing for physicians (Bradlow and Coulter 1993)• Specialist nurse and midwife ‘limited’ prescribing (McCartney et al 1999; Taylor 1999)AHPs ‘limited’ extensions (1998) *• Optometry:Access for sale and supply of antibiotics limited to sulphacetamide and chloramphenicol - prophylaxis only (Lawrenson 2007; Larkin 1981, 1983)• Framycetin sulphate limited to ‘administration only’ limiting its use therapeutically  (Titcomb and Lawrenson 2006)• Podiatry:“…seemingly worthless extension which omits antibiotics and adrenalin for resuscitation…a bitter blow to those who had fought for so long to bring about sensible change” (BJP 1998)* POM (Human Use) Amendment Orders 1998 & Medicines (Pharmacy and General Sale-Exemption) Amendment Orders‘prescribing’ and the ‘New NHS’• ‘Crown Report’ on non-medical prescribing (DoH 1999)• Podiatrists as possible ‘independent prescribers’ (extended scope physiotherapists, podiatrists & optometrists)• ‘supplementary’ prescribing 2005 (inc radiographers)• Podiatrists SI 2006/2807 (antibiotics and adrenalin)• Optometrists: Opticians Act amended 2005 to enable ‘therapeutic role’• ‘Additional supply’ optometrists access fusidic acid (antibiotic) for sale and supply as well as administration (Needle et al 2007)• Independent prescribing: consultation proposal for ‘option 3’ limited formulary (MLX 334) AHP Prescribing in Australia• “workforce flexibility” as a response to ageing population, increased costs of technology, recruitment & retention problems (especially in rural areas) & ‘empowered consumers’  (Sibbald et al 2004; Duckett 2005a)• Australian Health Ministers’ Conference (2004) “to make optimal use of workforce skills…a realignment of existing workforce roles or the creation of new roles”• MBS and PBS “could also apply to podiatrists, optometrists, physiotherapists and other[s]” (Duckett 2005b) AHP prescribing in Australia• Access governed by a ‘Drugs and Poisons Authority’ in each State or Territory (Short 2006)• ‘Scheduling’ of medicines undertaken by Commonwealth (Federal) via – Australia New Zealand Therapeutic Products Authority – Department of Health & Ageing (until recently via National Drugs and Poisons Schedule Committee NDPSC) (ACT 2007)Podiatric Prescribing in Australia• Limited ‘local anaesthesia’ * & ‘Schedule 4’ rights: South Australia (1989 & 1996), Western Australia (1995) and Victoria (2005) • Victoria (2005) Health Professions Registration Act gives authority to decide on prescribing needs to the Podiatrists Registration Board– AMA “the suggestion that there have been no adverse side effects to medications prescribed by podiatrists reflects the hubris of many non-medical professions who seek prescribing rights…” (AMA Victoria 2003)* ranging from no restrictions (SA) to 1% lignocaine only (Qlnd)   Optometric Prescribing in AustraliaFirst ‘therapeutically qualified’ optometrists (2006)• NSW:– glaucoma medicines only in ‘co-management role’ with ophthalmologists (2007) • Victoria:– Prescribing for 7 years– Glaucoma medicines prescribed ‘after an initial diagnosis and management plan by ophthalmologist’ • Queensland:– Prescribing rights gazetted, but amended after “ophthalmologists threatened a walk-out of the public system” (list still in debate) (ACT 2007)Discussion• Medical opposition to AHP prescribing evident in both UK and Australasia• Health policy reform continues to legitimise AHP prescribing as part of wider workforce modernization agenda (Australian Productivity Commission, Council of Australian Governments, UK Department of Health)• AHP prescribing currently remains ‘limited’ and largely under medical control (eg. ‘supplementary’, PGDs)Thank you for your attentionab12@soton.ac.uk

Confronting exclusivity with flexibility: AHP prescribing in the UK and Australasia

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