Revised National Prescribing Competencies Framework (3rd Edition)

Personal Reflection on the Revised National Prescribing Competencies Framework (3rd Edition)
Submitted May 2025

Introduction

This letter accompanies our formal submission and internal review and serves as a personal reflection on the deeper ethical, social, and systemic concerns raised by the Revised National Prescribing Competencies Framework (NPCF). While many of the document's aims are commendable in principle, I remain unconvinced that the expenditure of resources, the scope of regulation, or the language of inclusion in this policy process leads to tangible improvements in patient outcomes or protection for diverse practitioners.

1. Regulatory ROI and Opportunity Cost

Healthcare is a finite system. Every regulatory review diverts attention, funds, and human capital from other activities. Despite numerous assertions about safety and quality, the NPCF offers no quantifiable evidence that prior iterations of this framework have meaningfully improved health outcomes. Nor does it offer an analysis of whether adjustments proposed in this version will yield a measurable return on investment in lives improved, lives saved, or burdens reduced.

Meanwhile, Australia faces a chronic disease crisis, growing mental health burdens, rising practitioner burnout, and persistent inequality. In this context, it is not unreasonable to ask: Does this framework, in its current form, represent the best possible use of our collective resources?

Evidence Gap: No reference in the NPCF explicitly links prescribing competency refinement to reductions in hospitalisations, morbidity, or mortality. Evaluation is procedural, not outcome-based.

2. Symbolic Inclusion vs. Structural Exclusion

The NPCF contains many affirmations of diversity and health equity—especially concerning Aboriginal and Torres Strait Islander peoples. Yet, I find a disturbing disconnect between these statements and the underlying centralisation of clinical authority that characterises modern regulation.

Minority health beliefs—whether cultural, spiritual, or philosophical—are routinely marginalised by public health institutions. This includes:

• Regulatory action against practitioners offering alternative therapies

• Vilification of vaccine choice, functional medicine, and nutritional models

• The banning of unvaccinated children from public spaces

These may or may not be justified by public health ethics. But the regulatory process makes no space for patients or clinicians who challenge mainstream biomedical orthodoxy. Inclusion is expressed in words, but oppression is enacted in process.

Evidence Note: The NPCF references cultural safety (p. 4) and individualised care (p. 5), but offers no enforcement mechanism or accountability framework to ensure these are honoured in cases of system conflict.

3. The Highway Cop Phenomenon: Discretion and Coercion

Perhaps the most pernicious injustice embedded in overregulation is what I call the “highway cop phenomenon.” The more rules a system creates, the more selective discretion it grants to those who enforce them. In theory, rules ensure fairness. In practice, they can become tools of coercion against those who vary from the norm.

A highway patrol officer can’t legally stop you because of your race—but if your tail light is out, they now have cause. Likewise, regulators may claim neutrality, but in reality:

• Prescribers outside the mainstream are scrutinised more intensely

• Guidelines are used as retroactive justification for punishment

• Diversity of thought is penalised under the guise of safety

The more rules a regulator creates, the more arbitrary leeway they have to persecute those who do not conform. Regulators insist that they do not discriminate, but within their domain of control, discrimination based on diversity of clinical practice and thought is real, explicit, and routinely exercised.

Contradiction within the NPCF: It states that patient outcomes must take precedence over all else (Competency 7.6), yet in the same framework insists that guidelines and protocols must be followed (Competency 4.3). When these two are in conflict—as they often are—the regulator may exercise its prerogative arbitrarily with little meaningful oversight. Such contradictory rules do not protect patients or practitioners. They protect regulators and guideline authors, while placing frontline clinicians in ethical and legal dilemmas.

Evidence Analogy: Research into systemic bias in policing (e.g., Epp et al., 2014) shows that rule enforcement often disproportionately affects minorities. The same risk exists in health regulation when oversupply of rules leads to discretionary enforcement.

4. Liability Without Authority

Another systemic imbalance is the outsourcing of risk. Clinicians must adhere to regulators’ guidance but are solely liable for adverse outcomes. This creates a moral hazard:

• Practitioners are denied discretion yet blamed for failure

• Guidelines become de facto laws with no shared accountability

This structure not only deters innovation—it corrodes trust, morale, and professional identity.

Evidence Note: The NPCF does not address clinical liability or the ethical implications of guideline-driven decision-making. No support is offered to those who comply with guidance yet face litigation or complaints.

5. Systemic Inertia and Commercial Influence

The NPCF assumes that guidelines and medicine registrations are based on neutral, objective science. Yet literature in medical sociology, public health, and critical EBM increasingly documents the infiltration of industry bias:

• Publication bias

• Ghostwritten guidelines

• Sponsorship of advisory boards

• Suppression of negative trial results

This is not a theoretical risk. It implies that Clinical Practice Guidelines are often directly influenced by profit motives over patient care. This influence represents a real threat to patient outcomes, and may help explain why we continue to fail to address the chronic disease epidemic. Despite the severity of this concern, it is systematically—some would say suspiciously—ignored by the very regulators charged with protecting public health.

Key Sources: Ioannidis (2016); Moynihan & Cassels (2005); Gøtzsche (2013)

Regulators have not meaningfully addressed this structural risk. Nor have they created frameworks to protect practitioners who seek to act ethically outside compromised consensus mechanisms.

In Conclusion

I submit this reflection not in opposition to safe, coordinated, and rational prescribing—but in defence of diversity, integrity, and humility in medicine. We must recognise when systems drift from protection to oppression; when inclusion becomes symbolic; when safety becomes a cover for stasis; and when regulation becomes a barrier to care.

Let this consultation not be another performative ritual but a moment of genuine reflection on the ethics, outcomes, and power structures embedded in how we govern clinical practice.

Submitted respectfully,
Dr Christopher Maclay