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Review of PBS items for prescribing by nurse practitioners and endorsed midwives

Page last updated: 1 November 2024

Overview

The Department of Health and Aged Care (the Department) is undertaking a review of medicines listed on the Pharmaceutical Benefits Scheme (PBS) that can be prescribed by nurse practitioners and endorsed midwives (the PBS Review), for consideration by the Pharmaceutical Benefits Advisory Committee (PBAC).

Under current arrangements, the medicines listed in the PBS Schedule for prescribing by authorised nurse practitioners are identified by ‘NP’ and can be found at: Nurse practitioner PBS prescribing webpage. The medicines listed in the PBS Schedule for prescribing by endorsed midwives are identified by ‘MW’ and can be found at: Midwife PBS prescribing webpage.

In May 2023, the Assistant Minister for Health and Aged Care, the Hon Ged Kearney MP, released the Nurse Practitioner Workforce Plan. This included a recommended action to ‘review nurse practitioner prescribing of medicines on the PBS’ with the aim to ‘align the medicines authorised nurse practitioners can prescribe through the PBS and the Repatriation PBS (RPBS) with their full scope of practice’. The PBS Review of prescribing by nurse practitioners and endorsed midwives is limited to medicines listed on the PBS and to the prescribers termed ‘authorised nurse practitioner’ and ‘authorised midwife’ within the National Health Act 1953 (the Act).

Since late 2023, the Department has been working with stakeholders to understand current gaps within the PBS that may prevent nurse practitioners and endorsed midwives from prescribing subsidised medicines within their scope of practice. These gaps may result in patients paying privately (i.e. non-PBS) for their medicines and forgoing any PBS safety net benefits. It may also result in patients being referred to another prescriber solely for the purpose of obtaining a PBS prescription.

The PBS Review does not seek to add new medicines to the PBS or examine the merits of extending the list of authorised prescribers beyond those currently specified within the Act, nor does it seek to vary the scope of practice of nurse practitioners and endorsed midwives. The Nursing and Midwifery Board of Australia regulates the practice of nurses and midwives in Australia, undertaking functions as set out by the Health Practitioner Regulation National Law Act 2009 which is in force in each state and territory. Nurse practitioners and endorsed midwives can practice independently and work collaboratively in multi-professional environments.

Separate to this PBS Review, from 1 November 2024 the legislated requirement was removed which previously required endorsed midwives and nurse practitioners to have collaborative arrangements with medical practitioners in place to provide Medicare Benefits Schedule (MBS) services and prescribe PBS medications. More information on the removal of legislated collaborative arrangements can be found on MBS online at: MBS Online - Removal of legislated collaborative arrangements.

While the legislative requirement for collaborative arrangements has been removed, it is expected that consultation, referral, and transfer of care between health professionals will continue to obtain optimal outcomes for the person receiving care. With respect to pharmaceutical benefits, the PBAC may provide recommendations on the circumstances of listing which may include eligible prescribers and any conditions to consult or share care with particular health practitioners.

Consultation

In early 2024, the then PBAC Chair consulted with health professional groups (nurse practitioner, midwifery, medical and rural/remote medicine) in the development of general principles for determining prescriber types for PBS listings. Whilst the draft guidance principles were developed in the context of this PBS Review, the guidance principles were intended to be applicable to all PBS prescribers. The PBAC endorsed the guidance principles for determining PBS prescriber type eligibility at its March 2024 meeting (an abridged version is shown in Table 1).

Table 1. PBAC general principles for guiding PBS prescriber type eligibility (abridged)

Principle

Considerations may include (but are not limited to):

1

Scope of practice of the health practitioner group

Consider if the prescriber group is likely to be required to treat patients with this medicine.

2

Scope of practice of individual health practitioners

Consider whether a subset of prescribers within the health practitioner group have an extended or specialised scope of practice. Consider what education, training or experience may be required, how this is recognised, and the context of practice for these health practitioners.

3

Medicine specific considerations

Consider any medicine-specific risks for prescribing e.g. narrow therapeutic index, addiction/diversion risks, dosing error risks, severe side effects, medicine scheduling. Consider medicine cost/overall Government budget impact.

4

Health condition specific considerations

Consider the complexity of the condition the medicine is used for, risk and implications of misdiagnosis or mismanagement, and consequences of possible treatment delay.

Between 1 March – 1 April 2024, the Department published a consultation survey to inform the PBS Review, to collect data on which medicines are frequently being prescribed privately by nurse practitioners and endorsed midwives that are subsidised through the PBS when prescribed by another prescriber type, and the settings in which this is occurring. The survey received feedback from consumers, carers, health professionals, consumer groups and peak representative organisations.

PBAC considerations relating to the PBS Review

December 2023 intracycle meeting

At its December 2023 intracycle meeting the PBAC noted that a review is being undertaken by the Department on PBS-listed medicines that may be appropriate for nurse practitioner or endorsed midwife prescribing. The PBAC noted the Department’s intent to undertake an open consultation in early 2024, and that consultation findings and a consolidated list of PBS medicines identified as priorities for nurse practitioner and endorsed midwife prescribing are to be considered by the PBAC at a subsequent meeting.

May 2024 intracycle meeting

At its May 2024 intracycle meeting the PBAC noted an update on the PBS Review and acknowledged the Department is working through a high volume of survey responses received. The PBAC agreed to review and provide its advice on relevant PBS listings in tranches at its subsequent meetings.

July 2024 meeting

At its July 2024 meeting the PBAC reviewed a subset of PBS listings for nurse practitioner prescribing that are subject to a Shared Care Model (SCM) administrative note requiring a ‘formalised arrangement’ to be in place between a nurse practitioner and medical practitioner.

The PBAC recommended that the SCM note be removed for most listings to which it applied, noting that professional practice standards for nurse practitioners, together with a nurse practitioner’s individual scope of practice and setting of care, would largely determine the degree of consultation or collaboration that occurs with medical practitioners.

For some medicines the PBAC recommended that the SCM administrative note be replaced by a restriction criterion for PBS prescribing by a nurse practitioner requiring the patient’s care to be shared with a medical practitioner as follows: Must be treated by a health practitioner who is any of: (i) a medical practitioner, (ii) an authorised PBS prescriber who is not a medical practitioner, but who is: (a) sharing care of the patient with at least one medical practitioner; (b) intending to share care of the patient with a medical practitioner.

The PBS changes were implemented on 1 November 2024 as part of a routine monthly update to the PBS schedule. Importantly, these changes only relate to eligibility for prescriptions authorised by a nurse practitioner to attract a PBS subsidy. Prescribing by nurse practitioners continues to be limited by an individual’s scope of practice, adherence to professional practice standards as set by the Nursing and Midwifery Board of Australia, and state and territory prescribing rights.

The PBAC recommendations and rationale with reference to the general principles are summarised in the document below (provided in word and PDF format).

September 2024 intracycle meeting

At its September 2024 intracycle meeting, the PBAC considered approximately 50 PBS medicines identified through consultation that were requested for prescribing by endorsed midwives.

The PBAC recommended that PBS listings for over 30 medicines be amended to allow PBS prescribing by endorsed midwives without any further conditions beyond those that may already be specified in PBS restrictions. For an additional 11 medicines, the PBAC recommended that endorsed midwives be added as authorised prescribers under certain circumstances (e.g. for continuing therapy only, where care of the patient is shared with a medical practitioner).

The PBAC did not recommend the addition of endorsed midwives as authorised prescribers for some medicines due to the following reasons: where the proposed use is not Therapeutic Goods Administration (TGA) registered; the medicine is currently withdrawn from the market; or clinical guidelines do not support use of the medicine during pregnancy in favour of alternative medicines. Some requested medicines were excluded from PBAC consideration if they were not already listed on the PBS, or the intended form, presentation or indication were not PBS-listed.

The PBAC’s recommendations are expected to be implemented in the first half of 2025 as part of upcoming routine monthly changes to the PBS schedule.

The PBAC recommendations and rationale with reference to the general principles are summarised in the document below (provided in word and PDF format).

Next steps

At its November 2024 meeting, the PBAC is expected to review the subset of PBS listings for nurse practitioner prescribing that have a Continuing Therapy Only (CTO) administrative note and provide advice on whether the CTO note remains appropriate for each of the listings to which it currently applies.

In 2025, the PBAC will be asked to provide advice on other PBS-listed medicines identified through consultation that may be suitable for PBS prescribing by nurse practitioners. The PBAC Meeting Agenda provides information on upcoming considerations by the PBAC.

PBAC recommendations arising from the PBS Review will be implemented as part of routine monthly changes to the PBS schedule.

For further information, please visit the PBAC outcomes which are published six weeks following each meeting.

All authorised PBS prescribers are encouraged to check the Summary of Changes to the PBS that is published at the beginning of each new calendar month for changes to individual medicine listings.