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AS someone who has worked both as a pharmacist and a GP, I can say without a doubt the Queensland Government’s plan to allow pharmacists to dispense medicines without a prescription is fraught with danger.
In April, the Queensland Health Minister Steven Miles announced a statewide trial allowing pharmacists to provide the contraceptive pill and antibiotics for urinary tract infections without a current prescription. The trial was recommended by a Parliamentary Committee into expanding the scope of services of pharmacists.
As a GP who has worked on both sides of the pharmacy counter, it is something I am very concerned about.
Before I became a GP, I completed a 4-year Bachelor of Pharmacy and worked as a community pharmacist. I then completed a Bachelor of Medicine and Surgery (4 years), residency (2 years) and Fellowship training (3 years).
So, when a patient presents to me with symptoms of a urinary tract infection, and to an outsider our discussions may seem relatively short and “easy”, it is those 13 years of training and experience I call on when diagnosing the problem and finding a solution.
My training and experience allow me to consider that there may be an alternative diagnosis and to ensure there is appropriate management of the condition, followed by adequate health screening and safety netting.
A pharmacist, who is not trained as a GP, may feel they can perform this same consultation easily due to the simplicity of the condition, but they don’t have the knowledge, training or background to ensure it is not something more serious which, if left untreated, could become a major health issue.
In my view, allowing pharmacists to prescribe puts convenience ahead of patient safety.
There are too many unseen risks and potentially higher costs.
Instead of allowing pharmacists to take on the role of doctors, the government should focus on injecting more funding into general practice to combat the rise of out-of-pocket expenses and increase funding for pharmacists to collaborate with GPs within their practices.
I am not dismissing the hard work that pharmacists do – I’ve been there. During my employment as a pharmacist, we trained heavily in pharmacology and became the experts of quality use of medicines. Pharmacists are the final barrier to ascertain drug interactions, dosing and counselling to ensure the doctor has prescribed the right drug, at the right dose for the correct patient.
But the differences between the prescriber and dispenser are what ensure safety for the patient.
Allowing pharmacists to prescribe could also potentially lead to conflicts of interest within their business.
During my time as a pharmacist, I had training in the workplace for “companion selling”, that is, trying to boost sales of other products while selling prescribed antibiotics.
So, for example, if I was dispensing antibiotics for a urinary tract infection, I would recommend customers also try probiotics or cranberry or an immune booster. I may have even promoted the odd fragrance or two during the festive season!
Pharmacy, like all areas of health, is underfunded because of the price-cutting of prescription medications from government and from within the pharmacy profession.
Pharmacists are not charging for their clinical expertise. For example, one commonly prescribed antibiotic PBS (Pharmaceutical Benefits Scheme) fee is $13.08; however, many pharmacies will charge $5.50 in the hope that customers will buy other items.
While this discounting saves money for the general public, it has affected the bottom line of pharmacy owners.
The way to improve the business of pharmacists is not to increase their scope of practice without also requiring they undergo the appropriate training. Health is not about convenience; it cannot be operated like a fast food chain. It is about the delivery of safe and quality health care. Increasing the scope of practice of pharmacists is a gamble that we can’t afford.
Queenslanders deserve safe, quality and accessible health care, but altering the scope of practice of pharmacists is not the way to deliver it. We need an appropriately funded health system, not shortcuts and further fragmentation of care.
Dr Nick Yim is a GP in Hervey Bay on Queensland’s Central Coast.
The statements or opinions expressed in this article reflect the views of the authors and do not represent the official policy of the AMA, the MJA or InSight+ unless so stated.
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In my opinion, the issue is not whether pharmacist should or not be allowed to prescribe medication.
The issue is have we forgotten the basic principles of medicine, diagnose first (History taking, examination, confirm with necessary investigation) and then treat appropriately?
So the question is by allowing non medical people to treat patients, are we practicing best medicine or are we just only treating symptoms with no proper diagnosis?
Pharmacists had responsibility for the appropriate “prescription” of Codeine for many years. The result was a huge problem of overuse and abuse of codeine. Recent events have proven how utterly incapable the system and individual pharmacists were in overseeing the responsible and appropriate use of codeine as an analgesic. This role has now been removed from pharmacists and given back to doctors to control. Authorities are already claiming how much the management of the codeine problem has been improved by doing this.
As 10 states “pharmacists have been unofficially prescribing for years -(Schedule 3 medications)……… “this function has not been performed well throughout the years”………. “Nearly all of these products are handed out with minimal interaction with the pharmacist”.
How will the proposed system vary from this? As far as I can see when I visit a Pharmacy the pharmacists are all very busy dispensing prescription medication! When patients present with “pharmacist appropriate condition”, where are the pharmacists going to find the time to spend 10-15mins per customer taking a detailed history, before determining what treatment is appropriate and then discussing how this is taken/ S/Es etc before dispensing the medication. Obviously they won’t be formally examining patients which already removes one of the most important aspects of patient assessment.
How many times do the govt have to make the same mistake before they realise that the system as it stands works well and should remain unchanged.
I agree that ultimately this is not about doctor Vs pharmacist. The Govt’s aims are at ending patient generated, fee for service primary care in Australia and moving to a capitated system such as that in the UK (and isn’t that “doing really well” by all reports) to save money! Never mind about the availability and the quality of patient care. Patients need to understand the govt’s plan and decide whether this what they want.
I would offer an example of the quality of UK health services of a woman who is noted to have a likely BCC on her forehead. She attends her GP in London and is referred to a dermatologist. After waiting 3 months to see them she is told the lesion is likely to be a BCC. This will require a biopsy for confirmation but to have this done she will need to be referred to a Pathologist. After a further 3 months the biopsy is performed. She then waits 2 more months to find out the results (it was a BCC) and is then told she will go on a waiting list to see a plastic surgeon! In summary she waited 8 months to obtain a diagnosis without being treated. Most GPs in Australia would have performed the biopsy themselves and had the diagnosis within a week. Incidentally she decided that whilst she was in Australia on holiday she would have her surgery rather than waiting any longer. This was arranged and completed within a week.
Why would you want to change what most people consider to be one of the best health systems in the world.
Re Anonymous 13, can you suggest a better solution to “doctor-centric models of care” when people are genuinely sick? Who would you suggest people see if having a heart attack, or diabetic ketoacidosis, or sepsis?
To say doctors have “no interest in providing person-centred care” is astonishing. Do other clinicians know how to diagnose encephalitis, or bladder cancer, or endocarditis? And to then prescribe for the same states? It reminds of when alternative practitioners say they are “holistic”, yet when people are really ill, suddenly doctors become the go-to option.
You could make the same argument about pharmacists dispensing cold and flu medication or Panadol – the presenting symptoms may be indicators of a more serious underlying illness. This is just another example of the classic turf war the medical profession has engaged in to generate more business and promote their own doctor centric models of care that have no interest in providing person centred care, just furthering their own self interest.
Is the pathogenesis of UTI no longer of cosequence? How much investigation will the pharmacist be advised to undertake before dipensing substances resistance to which is now at world crisis level?
Should we now be considering the re-establihment of the old English qulification of Apothecary?
Other nations permit pharmacist prescribing. It is a service that can be safely supplied and well regulated. These extended services are supplied by qualified subset of pharmacists to patients with symptoms of uncomplicated UTI. Take a look across the Tasman: this is the practice in New Zealand.
This article perpetuates fear, interprofessional warfare and resistance to change. Shouldn’t GPs be more concerned by the population of imminently ageing patients that they need to support? You’ve got the years of training to effectively manage that complexity.
Perhaps this is an effort to improve access for patients with uncomplicated health issues. Risk management practices will ensure it is done in a way that supports safety and wellbeing.
As a registered pharmacist and medical practitioner, I too believe am well placed to provide a balanced overview of the current proposal to allow for pharmacist prescribing.
Firstly, pharmacists have been unofficially prescribing for years. Schedule 3 medications are technically a pharmacist prescription for a restricted medication to treat specific conditions. I believe that this function has not been performed well throughout the years. Nearly all of theses products are handed out with minimal interaction with the pharmacist. The patient also has been given a false lowered expectation and an inaccurate sense that these medications are safe. The above partly explains the issues surrounding over the counter codeine.
Secondly pharmacists have also been unofficially prescribing via a medication continuance model that skirts the edges of PBS legality, but essentially has been needed and used by many patients throughout the year. Under DPCS regulations, a pharmacist can give a 3 day supply to a patient for the continuation of medical therapy in the instance that they have run out of a medication for their chronic disease (exceptions to this rule include drugs of dependence). The reality is that while some will provide 3 days supply (or more), the remainder of the prescription is kept and given out with a valid PBS prescription – which means technically the entire PBS supply has not been made on the of prescription dispensing.
Thirdly, the role of a pharmacist has been as the gate keeper to the PBS and last safety net prior to the dispensing of a medication to ensure that such medications are safe, doses are appropriate, indications are correct and so forth. If the prescriber and dispenser are the same person, this last check is lost.
Fourthly, there is an inherent conflict of interest in prescribing and dispensing a medication where there is a fee involved in the dispensing and supply. Many pharmacies are large business owned by a conglomerate of hidden unofficial owners protected by dubious secretive service trust arrangements; they are run as businesses only purely for profit and I fear the lure of the dollar and meeting of potential key performance indicators may sometimes override the professional standards. This is by no means meant to attack the professionalism of my colleagues just highlighting a human trait that has been proven time and time again.
Furthermore, I believe one of the proposed models involves the use of GP practice pharmacists to be able to independently prescribe as part of the team. This was to reduce the work load of the doctors who apparently often do not have any free appointments especially in rural and remote areas. This model while noble is not likely to work. In metropolitan Melbourne where there are plenty of doctors and appointments there are also plenty of pharmacists.
In the end, we need a strong medical and pharmacy sector to look after the health of the patients and ensure that timely, effective medical care is achieved. For the last 15 years the earnings of the pharmacies and pharmacists has been decimated as the expanded PBS reforms leading to reduced profitability and career prospects for pharmacists with poor remuneration. A better use of such reviews is to ensure pharmacists are being remunerated appropriately for their skills.
Ultimately only one thing needs to be said about this issue: you can only newly prescribe (or deprescribe) medication with confidence if you yourself make the diagnosis for which it is indicated, AND if you can discern potential harms possibly stemming from your proposed therapy in the face of the comorbid diseases – esoecially in elderly patients. You can’t take a (single) diagnosis from one doctor and just “treat” whatever they said; diagnostic error rates are high enough already. It is nonsensical to suggest pharmacists and nurses can prescribe without specific (full) medical training. Doctors wouldn’t dream of saying they know how to nurse patients or dispense medicine – and I honestly cannot understand why people so badly want to step out of their scope and enter territory which is so hugely dangerous to both themselves and others. I’m a consultant physician and patient cases tax my brain everyday – the web of diagnostic and therapeutic conundrums is huge in most people seen these days, and massive amounts of thought, experience and compromise go into proposed management plans. I’d be very nervous prescribing if I didn’t have years and years of intensive practice under the belt…
Well written. Concerns me re the breakdown of providing wholeistic care – getting a script by a GP takes time and contact,giving opportunity to seek advice and follow up. Could this open a Pandora box with easy access to contraceptives for our young girls that assists in making unhealthy sexual choices.
My Mother had recurrent UTI’s turns out it was Leukaemia. Can Pharmacist’s also order blood tests and referals to Specialists? I can see danger in this one.
They are doing immunisations to over 18’s and want to do children… what’s next?
If they want to be Dr’s then do a post grad and become one.
Do they have professional medical insurance even?
This is not about pharmacist versus GP.
There is a developing tide of energy aimed at ending patient generated, fee for service primary care in Australia. The Labor Party has talked about salaried general practice for decades, so Qld may have a head start in that regard, but it is across party politics.
Care planning, health assessments, cycle of care item numbers etc on the MBS are not just there to boost bulk billing rates. They are there to sway primary care away from hands-on clinical medicine toward more financially manageable models aimed at population health and chronic disease management.
Politicians (of all kinds RACGP, AMA etc included) think they know what the public needs more than doctors. GPs are being squeezed out of basic primary care in preference of unsubstantiated, alternate models of health care. And, yes we are really bad at defending our profession andris b.
If the NDSS presentation I attended at the Sydney GPCE last week is representative of the logic coming from advisors leveraging public health expenditure, then we are in trouble. Apparently fat Australians eat healthier than you think compared to other Australians according to the Australian Healthy Eating Guidelines (1+1 = bad eating guidelines!). Overweight and obesity are not causes of diabetes: age and family history are the only risk factors. Advising patients to lose weight increases their mortality. The appropriate management of overweight diabetics is NDSS referral (of course) and psychologist referral for weight acceptance counselling. Potentially, relaying this sort of “health care” to the public is one possible future of general practice.
This is about a lot more than doctors versus pharmacists.
Would the same concerns apply to Pharmacists providing the contraceptive pill?
I see a lot of harm by treating issues in isolation.
I agree with what Nick says. Much more can be behind symptoms that get people seeking healthcare. His example of UTI symptoms is a good one as my experience is while infection often presents with more urgent symptoms, those same symptoms can have a variety of ethology. An over the counter discussion won’t be conducive to determining these issues. In this case antibiotic therapy will be abused. Just one good example of the GP role as versus pharmacist prescribing.
I agree with what Nick Yim says in the main. However, the GP world seems very poor at getting its message across to the wider community, government and the bureaucracies that tie this stuff together. In other words I’m suggesting you are poor systemic advocates with an underdeveloped spectrum of messages that seem to have a ‘sad seam’ of poor us running through it.
Is your sector very passionate about this issue? Ernest Hemingway said “Don’t confuse movement with action.” So far i’m only seeing movement.
Cheers and good luck.
Andris Banders – a user and admirer of what GP do for us to maintain and improve our quality of life.
If pharmacists are allowed to diagnose and treat, GP’s must be allowed to dispense. What is good for the goose, must be good for the gander. Period.