Plans are underway to introduce prescribing rights for dietitians in South Africa – something eagerly awaited by clinical dietitians, especially those in hospital-based practice. Currently, dietitians are at liberty to prescribe products which are unscheduled (schedule 0), which includes macronutrient modules, oral nutrition supplements, enteral feeds and most vitamin preparations. In fact, all medicines scheduled as 1 or 2 can also be recommended under professional guidance by dietitians, since they are freely available to purchase over the counter without a prescription. However, by law, a pharmacist has to dispense schedule 2 drugs and keep a record of the person to whom they are dispensed.
Medications of schedule 3 and above require prescriptions because they are more toxic or have higher potential for abuse, are less safe unless used in controlled doses, treat serious illnesses that require medical management, are linked to specified diagnostic categories or are controlled under global medical or legal frameworks. Parenteral nutrition, for example, is a schedule 3 substance. The current legal framework does not recognise dietitians as legal prescribers and exposes pharmacists to liability if they dispense scheduled drugs prescribed by dietitians on hospital drug charts.
The move to establish prescribing rights for dietitians arose from this specific fact. Dietitians have frequently expressed practical and professional complaints about the limitation on daily clinical practice created by their inability to legally prescribe parenteral nutrition, while simultaneously having to provide expert advice on its use to medical doctors who formally write the prescription without adequate clinical expertise. This highlights a problem inherent to training of various health professionals in traditional health sciences faculties i.e. lack of cross-disciplinary integration of knowledge and expertise in nutrition. Medical doctors may have as little as a few hours of training in medical nutrition during their whole degree, and generally lack the depth of knowledge required to make rational medical nutrition therapy prescriptions, yet are highly trained in prescription processes. By contrast, dietitians are highly skilled in nutrition therapy and have complementary insight into underlying medical management of nutrition-impacting diseases, yet lack the rights to prescribe. There is therefore a disconnect between the nutrition care process and the prescriptions that drive and support it. There is also little data on the potential clinical harms resulting from inappropriate or wasteful prescriptions of medical nutrition therapy at the hands of registered prescribers.
It is possible that prescribing rights for dietitians may extend to other classes of scheduled drugs that impact upon and integrate with medical nutritional therapy of patients. This which would bring South Africa in line with some other countries (see Table 1). In fact, there is global support for this so-called “task shifting” approach advocated by the WHO. The intention is to create more efficiency in medication prescribing for a number of diseases by expanding the range of healthcare professionals able to prescribe scheduled medications – as a response to sub-optimal numbers of healthcare professionals. The idea is that expansion of legal capabilities of suitbaly trained and advanced non-medic health professionals and a reduction in dependence on medical doctors for prescriptions will have the following positive impacts upon clinical care:
- Better medical support of patients
- More timely care of patients, with reduced delays in delivery of medical nutrition in clinical settings
- Improved patient safety and reduced risks
- Reduced pressure on other health professionals and on health care facilities
- Increased efficiency and modernisation of clinical systems
- Maximised ability to comprehensively respond to clinical needs of patients
- Improved cost-efficiency and economic benefits
- Improved use of diverse professional skills and expertise
- More integrated multi-disciplinary team approach
Table 1. Examples of possible medications under dietitian’s prescribing rights
Policy support exists, but the legal framework and scope of practice in South Africa needs to be brought in line with the sentiment of support for such steps. There is general view that prescribing rights will elevate the capacity of dietitians to practice to the extent of their expertise and provide overall better clinical service. It should be understood that in terms of legal status, de-prescribing of medications is the same as prescribing. Both rely on clinical expertise and skill to review medication and recommend use, dose adjustment or discontinuation. This will mean that dietitians will require assessment and certification of their knowledge of the requirements and regulatory framework to be able to prescribe. Prescribers remain accountable for prescriptions even when the dispensing or adminstration is a delegated task. Certification would include demonstration of competency in the following aspects:
- Legal, accountability and ethical aspects of prescribing medications
- Pharmacological properties of applicable drugs, including drug safety, dosage guidelines, drug interactions, pharmacodynamics and pharmacokinetics
- Prescribing processes and managementIndications for and uses of applicable drugs within clinical management algorithms
- Prescribing within public health context limitations and rationalised formulary
- Responsibilities and duties of prescribing within a multi-disciplinary team context
- Requirement for continuing professional development