Medicines, Patients and the Care Process—Tackling the Non‐Adherence Agenda

Medication Prescribing—not a Task for NonMedical Health Practitioners Fundamental to the process of prescribing is the diagnosis and determination of the indication or contraindication for medication. Advocates for nonmedical health practitioners to have authority to prescribe are generally uninformed about medical aspects of the issue, and on the basis of safety, cost and ethical considerations, such a move cannot be supported. A flight manual can be a guide to how to fly a Boeing 747, but translating the information into practical application is another matter. The engineer knows a lot about an aircraft but does not fly it. Similarly, comprehensive medical training and experience is required to apply information obtained from pharmacopoeias. Some pharmacists are urging legislators to extend their scope beyond the traditional role of preparing, compounding and dispensing medicines. This would sever a well proven and respected safety measure, which sees pharmacists auditing the prescribing of doctors, and adding an educational dimension for patients about the safe use of medicines – who will audit the pharmacists? It is paradoxical that while there is government concern about the cost of the Pharmaceutical Benefits Scheme, some are proposing liberalisation of prescriber access to those without medical qualification. This coincides with emphasis on preventive health care, which some would suggest creates a conflict of interest for chemists whose incomes rely on sales. This is an issue raised by pharmacists in the context of the quest by supermarket chains to sell medication. For a doctor to prescribe the contraceptive pill in the privacy of a consulting room, having heard the patient’s circumstances, may seem simple. However, the history may reveal the patient has risk factors, such as paralytic migraine, family history of stroke, clotting disorder or hypertension, and there is opportunity to discuss contraceptive options and sexual issues. These matters may change over time and require periodical medical review. If there is a proposal to enhance convenience for patients, then the Pharmaceutical Benefits Scheme could change the limits on the quantity of dispensed medications and repeat prescriptions, at the discretion of the doctor, thus generating a saving for patients by reducing the frequency and costs of dispensing. Similarly, hypertension is not without complications, such as cardiac valvular problems and heart failure, or rhythm disturbance. Often these complications are asymptomatic, but detected by doctors during routine review. Thirty per cent of octogenarians have atrial fibrillation, and the consequence of delay or failure in diagnosis may result in avoidable stroke and fatality. In this context, will patients reveal to a pharmacist that they have suffered a transient ischaemic attack, and will a pharmacist be capable of recognising it, particularly as the symptoms may be so varied? Such problems are routine for doctors, who are trained to diagnose and detect through periodical medical review. Misadventure with medications is well documented in the hospital and community settings. Extending prescribing to the less qualified will see this problem increase. It is also a problem with over-the-counter and herbal products, most of the latter having no scientific substantiation. It is desirable that pharmacists review their practice and enhance their role in these areas. Recently, one of my patients with prostatic hypertrophy and incomplete bladder emptying was persuaded by a pharmacist not to fill a prescription for prazosin because of the potential for hypotension, about which I had carefully counselled and titrated the dose, and instead sold a herbal product that proved entirely ineffective. I fail to see how such a pharmacist can be authorised to prescribe. It has been claimed that inexperienced medical interns have inappropriately wide prescribing powers and rely at times on guidance by hospital pharmacists. This is an example of a valuable role of pharmacists. Junior doctors invariably prescribe in collaboration with senior doctors in the clinic, in the apprenticeship model. To claim that pharmacists would not be exposed to the vagaries of learning if they were to prescribe, is fanciful. The community does not want the ignominious experience of interrogation at the pharmacy counter. If pharmacists are to prescribe in private, then appointments will be required and a fee incurred – so where is the saving? While doctors should inform patients about pharmacological issues and demonstrate the use of devices, having pharmacists add to the important educative component is integral to our system. This should be a function of pharmacists rather than delegated to their junior staff. Clearly, we should ensure integrity and protection for patients by separating prescribing from supply. It is essential to provide a setting in which to take a medical history, examine the patient, attend to their questions, provide education and review at safe periods. This is what doctors as diagnosticians do in collaboration with their patients.