RACGP flags scope concerns in prescribing review

Prescribing practices are currently under the spotlight, with the second edition of the Prescribing Competencies Framework under review by the Australian Health Practitioner Regulation Agency (AHPRA).
 
Originally developed by NPS MedicineWise and published in April 2021, the RACGP has broadly backed proposed changes in AHPRA’s consultation paper, but has raised concerns about a proposed updates to how scope of practice is defined.
 
Under the current framework, scope of practice is described as ‘the areas and extent of practice for an individual health professional, after taking into consideration the health professional’s training, experience, expertise and demonstrated competency’.
 
While the proposed definition changes to: ‘Professional activities that a health professional is educated (skill and knowledge), competent and authorised to perform, and for which they are accountable. Individual scope is time-sensitive and dynamic’.
 
‘Scope of practice for individual health professionals is influenced by the settings in which they practise, the health needs of people, the level of their individual competence and confidence and the policy requirements (authority/governance) of the service provider’, it reads.
 
In its submission, the RACGP says the revision appears to ‘conflate diagnosing and prescribing skills’, which ‘risks diminishing the essential role of diagnosis in safe prescribing’.
 
‘There is an opportunity to more clearly address the risks of prescribing by individuals who may lack the necessary qualifications or diagnostic training,’ the submission states.
 
‘Without adequate diagnostic expertise, there is a greater chance of inappropriate prescribing, such as unnecessary antibiotic use.’
 
Further to that, the college says that multiple health professionals offering overlapping services could lead to fragmented care, duplication, increased complexity, role confusion and poorer health outcomes.
 
‘Patient safety is paramount and best supported by multidisciplinary teams which include a GP, working together to provide coordinated, collaborative and continuous patient care,’ the submission says.
 
‘The framework should reinforce the importance of clearly defined roles, appropriate scope of practice, and team-based models of care to support safe and effective prescribing.’
 
These are among a number of concerns and recommendations put forward in its submission paper, which the college says it hopes will further enhance the framework’s ‘clarity and relevance’.
 
To ensure this, the RACGP says more must be done to clearly define the scope of prescribing competencies or risk negative or unintended effects for patients.
 
‘For example, it is unclear how over the counter/off the shelf medications recommended by prescribers, alternative medications such as Chinese medicines, as well as treatments recommended [by] naturopaths or homeopaths, are considered within the framework,’ the submission states.
 
‘This lack of definition could lead to confusion and inconsistency in prescribing practices.’
 
To address any potential conflicts of interest that may arise, the college recommends that clear guidance be included in the framework.
 
‘For example, practitioners who prescribe medicinal cannabis, Chinese medicine, or other non-traditional therapies may have financial interests in the products they recommend, which could influence prescribing decisions and raise concerns about patient safety,’ the submission notes.
 
The RACGP also believes that more explicit guidance is needed for decision-making in the context of multimorbidity and polypharmacy, especially regarding drug-drug interactions.
 
‘This is particularly relevant for Aboriginal and Torres Strait Islander peoples, who often experience multiple health conditions earlier in life, and for older Australians, where issues like frailty and complex care needs must also be considered,’ the submission states.
 
The college also raised that it would be useful to acknowledge the limitations of different consultation methods and models for safe prescribing.
 
‘The increasing use of telehealth and emerging online business models focused on prescribing specific substances such as medical cannabis present challenges,’ the submission reads.  
 
‘Prescribing based on a single phone or video consultation carries greater risks than with a person's regular GP or face to face consultations.’
 
Meanwhile, a new competency around ‘off-label’ prescribing has been proposed. While the RACGP has said that it supports the addition, it did note that ‘clearer guidance is needed on what is considered as “adequate information” to support off-label use’.
 
According to AHPRA, part of the revision’s aim is to empower the person receiving care to actively participate in shared decision-making, which has been defined as a consultation process in which ‘a health professional and a person jointly participate in making a health decision, having discussed the options, and their benefits and harms, and having considered the person’s values, preferences and circumstances’. 
 
However, the college says the framework fails to recognise situations where patient-centred or shared-decision making ‘may conflict with good prescribing practice’.
 
‘For example, patient requests for antibiotics, benzodiazepines, or low-value treatments, or views unsupported by evidence such as vaccine scepticism or ivermectin use for COVID-19,’ the submission states.
 
‘Prescribers must carefully balance patient preferences while ensuring that care remains safe and evidence-based.’
 
Further to that, the college also highlighted that it should be acknowledged that shared-decision making may involve a carer or guardian, and that it can present greater challenges for different populations such as people from Culturally and Linguistically Diverse communities.
 
When it comes to ensuring the revised framework does not result in any potential negative or unintended effects for Aboriginal and/or Torres Strait Islander people, the RACGP praised the revision for effectively embedding cultural safety into the prescribing process, but said that more specific examples of incorporating cultural identity in prescribing decisions could be useful, and if not already available, that a separate resource could be developed.
 
The preliminary consultation on the revised framework was completed in late 2024, and public consultation closed on 30 May. Once finalised, it will be submitted to the Department of Health, Disability and Ageing for approval in July.
 
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AHPRA National Prescribing Competencies Framework RACGP submission