This was a comment made in response to my post ‘What is a paramedic’s ‘authority to practice’? (19 August 2014)

This is a very informative post. I would be appreciative if you could confirm a doctor’s ability to legally delegate permission to carry and dispense S4 – S8 drugs to Registered Nurses outside of a hospital environment or government sanctioned medical centre for the purposes of providing first aid.

Responding to this comment was so important that I’ve made it a separate post so it is not ‘lost’ in the comments.

A doctor has NO ‘ability to legally delegate permission to carry and dispense S4 – S8 drugs to Registered Nurses outside of a hospital environment or government sanctioned medical centre for the purposes of providing first aid’.

I’m not sure what state the comment came from, so I’ll stick to NSW.  Section 17A of the Poisons and Therapeutic Goods Act 1966 (NSW) says:

A nurse is authorised to possess, use, supply or prescribe a poison, restricted substance or drug of addiction for the purposes of the practice of nursing, if:

(a) the nurse’s registration is endorsed under section 94 of the Health Practitioner Regulation National Law as being qualified to possess, use, supply or prescribe that poison, restricted substance or drug of addiction, or

(b) the nurse is a nurse practitioner who is authorised in writing by the Director-General to possess, use, supply or prescribe that poison, restricted substance or drug of addiction.

It says nothing about being ‘delegated’ permission by a doctor.  A medical or nurse practitioner must not prescribe or supply drugs of addiction (s 28) without a proper authority.  A proper authority is issued by the Director General of Health, not any doctor who chooses to.

A person must not possess a prescribed restricted substance unless they are, inter alia, a nurse practitioner authorised under s 17A (see above); or is getting the substance in accordance with a prescription, or is caring for the person for whom the drugs have been prescribed or otherwise approved by the Director General (s 16; see also s 23 ‘Possession and supply of drugs of addiction by carers’); not who is authorised by ‘a doctor’.

It is an offence to supply schedule 1, 2 or 3 drugs unless the person is a nurse practitioner authorised by the Director General (s 10); not who is authorised by ‘a doctor’.

A prescription for a restricted (Schedule 4) substance or drug of addiction (Schedule 8) must contain, inter alia, the patient’s name and address (Poisons and Therapeutic Goods Regulation 2008 (NSW) clauses 35 and 80).   Clearly one cannot write some general prescription to issue drugs to someone the nurse thinks should get the drugs.

Both nursing and medical practitioners are registered under the Health Practitioner National Law.  Unprofessional conduct, of a registered health practitioner includes ‘the conviction of the practitioner for an offence under another Act, the nature of which may affect the practitioner’s suitability to continue to practise the profession’ (Health Practitioner National Law s 5).  A nurse who is carrying schedule 4 or schedule 8 drugs because ‘a doctor told them they could’, would be acting in contravention of the Poisons and Therapeutic Goods Act 1966 (NSW) (or its equivalent in other jurisdictions) and could expect to  be prosecuted and subject to professional discipline.

A relevant health registration board can establish codes of conduct that are relevant in determining whether or not a practitioner’s conduct ‘constitutes appropriate professional conduct or practice for the health profession’ (Health Practitioner National Law ss 39 and 41).  The Medical Board of Australia’s ‘Good medical practice: a code of conduct for doctors in Australia’ says that good medical practice requires

2.1.1 Assessing the patient, taking into account the history, the patient’s views, and an appropriate physical examination. The history includes relevant psychological, social and cultural aspects.

Somehow ‘authorising’ others to carry and use drugs does not involve making that assessment.    A doctor who purports to authorise people who are not authorised under the relevant drugs legislation to carry drugs and in effect treat people as the doctors’ agent is not engaged in good medical practice.  They can expect to be liable in the event of a poor outcome and to be subject to disciplinary action.

Nurses are, and paramedics want to be, health professionals.  They have their own skills and their own professional standards.  They do not, and should not consider that they practice their professions because doctors authorise them to do so.  Doctors are not the authority that determines who can carry and use drugs, the Parliament is and the parliament determines who can give other authority, in NSW it’s the Director General of Health.

To reiterate: A doctor has NO ‘ability to legally delegate permission to carry and dispense S4 – S8 drugs to Registered Nurses outside of a hospital environment or government sanctioned medical centre for the purposes of providing first aid’.