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Prescribing rights

Adequate training required

From Professor H. McGavock

Over the past 40 years, prescribing has become ever more effective and ever more risky, with more potent drugs and a limited scientific knowledge of their effects in many tissues other than the “target” organ. General practitioners have to use around 90 per cent of therapeutic groups, yet they receive grossly inadequate training in the fundamental science of pharmacology. The result is that 5 per cent of all acute hospital admissions are due to prescribed medicines, rising to over 10 per cent in the elderly. The truth is that no one should be allowed to prescribe who does not have a thorough understanding of those pharmacological principles which are directly relevant to medical treatment.

Pharmacists have this requisite knowledge. They receive about 500 per cent more training in pharmacology at the undergraduate level than doctors. Pharmacists are in a position to understand the implications of drug intervention and the underlying reasons for the myriad side effects, adverse drug reactions and drug interactions. Safe and effective prescribing depends on two things: accurate diagnosis and a pharmacologically logical prescribing response to that diagnosis.

Just as GPs lack adequate pharmacological knowledge, so pharmacists receive only a small fraction of the training in diagnosis and differential diagnosis that doctors do. In addition, pharmacists are at present entirely dependent on questioning clients and are not taught to elicit physical signs, upon which most medical diagnoses depend.

What does this mean for the extended prescribing role of the pharmacist? Clearly, the pharmacist who wishes to prescribe widely should undertake a university level certificate or diploma in the diagnosis and management of the common illnesses in primary care, including a thorough understanding of the importance of differential diagnosis, which is so essential in the community setting. Armed with this, their existing expertise and knowledge, and the experience that regular practice brings, I believe that pharmacists can become far safer and more effective prescribers than nurses.

This brings me to the question of why the present Government seems to have opted for extended nurse prescribing without specifying the necessary training. There appear to be two reasons: first, nurses cost much less than doctors or pharmacists and, second, the Department of Health seems desperate to fulfil the Government’s pledge of extending availability of primary care, even at the cost of reducing the quality of medical care and increasing the risk of widespread serious harm to patients — patients who are also electors and tax-payers. The Government appears to be planning a further scandalous reduction in quality, with its proposal for minimally training health care assistants (HCAs) — to do work which previously only a qualified nurse was allowed to do. Are we regressing to the Soviet concept of the feldsher? The problem here is, as the health planners in the UK should be aware, that patients have no way of knowing that they are being treated by inadequately trained staff. Doctors and pharmacists are, in their complementary roles, the gold standard, and their professional skills are worth paying for. At present, pharmacists' knowledge and skills are grossly underused in the National Health Service and the public is losing out as a result.

Few of us believe in the demarcation of 20 years ago. There has to be far more co-operation among health care professionals — doctors, pharmacists and nurses — to meet the ever-increasing demands of the public for health care, including a rapidly ageing population. So, yes, there should now be considerable overlap of roles in primary care, but that must be preceded by adequate training — pharmacists as above, and nurses must achieve university level accreditation in both basic pharmacology and basic therapeutics. Perhaps, in the near future, medical, pharmaceutical and nursing students may be required to train jointly in those parts of their functions which overlap. In the meantime, we professionals must warn and continue to warn the public that everyone in a white coat is not equivalently trained or equally safe to prescribe modern medicines.

Hugh McGavock
Visiting Professor in Prescribing Science, University of Ulster

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