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We need a common-sense approach to policy when it comes to medication prescribing and dispensing without pitting doctors and pharmacists against each other, writes Dr Alisha Dorrigan.
Given recent headlines, one could be forgiven for thinking that GPs like myself are spending their days bickering on the phone with pharmacists and refusing to collaborate in patient care. The reality couldn’t be further from the truth; most GPs and pharmacists work together seamlessly most of the time. We ensure scripts are renewed and medication lists updated, Webster packs adjusted, and home medication reviews attended for patients with chronic diseases and complex medication regimens. Collegiate phone calls are had, letters are exchanged, and every working day we provide care to our shared patients within an imperfect and under-resourced health system. Together we navigate medication shortages, ever changing Pharmaceutical Benefits Scheme requirements and the logistics of getting antiviral medications to patients with coronavirus disease 2019 (COVID-19).
Our roles are inextricably linked and we rely heavily on one another to deliver health services, but who exactly should be delivering what services has become such a heated topic that tensions are reported to be at boiling point and the rhetoric escalates with every breaking story.
It must look terribly unprofessional from the outside, after all, aren’t we all meant to share the common goal of patient care? And if so, how can the view of doctors and pharmacists be so polarised?
A vocal pharmacy lobby
One reason is that that the loudest voices are the most extreme. The Pharmacy Guild of Australia has become a roaring force in this debate. Just last week, Pharmacy Guild president Trent Twomey was visibly distressed on national television at the prospect of a 60-day script-renewal plan that will allow millions of Australians with chronic illnesses to halve their medication costs and reduce the required visits to pharmacies. This change is undisputedly good for patients, less out-of-pocket costs and less time spent travelling and waiting in line at the pharmacy. However, as this threatens to reduce income for pharmacies, it was slammed by pharmacy lobbyists – although it should be noted that the Health Minister did commit to reinvesting all cost savings back into community pharmacies.
Just a few months earlier, Twomey was also quoted as saying he needed to be able to prescribe and administer “all medicines for all people”. There is no doctor in the country with the authority to prescribe all medicines for all people, but despite this, one of the highest profile pharmacists appears to believe this should be within his scope of practice. The weight of responsibility of such a job would be overwhelming to anyone who understands what responsible prescribing entails, but as the old saying goes, you don’t know what you don’t know.
The pitfalls of prescribing
Nevertheless, community pharmacists are eager to participate in prescribing schemes as it presents an opportunity for professional development and role diversification. However, the conflict of interest when both prescribing and dispensing medications remains deeply problematic, as recommending a certain treatment could financially benefit the prescriber in this setting. Beyond this, we are dealing with proposals that involve medical conditions that are not straightforward to diagnose or treat. For example, the Queensland pharmacy prescribing pilot includes infections such as otitis media and otitis externa — differentiating the two is impossible when you have never used an otoscope before.
The current Therapeutic guidelines also recommend that the mainstay of treatment for acute otitis media is adequate and regular analgesia, with most patients not needing treatment with antibiotics. As such, pharmacists ironically can already treat the majority of cases, and those who need antibiotics are at higher risk of complications and should be reviewed by a doctor regardless. This is just one of many examples where pharmacy prescribing simply doesn’t make medical sense.
In addition, these pilots and trials are effectively paving the way for antibiotics to become over-the-counter medicines, which will be a disaster for antimicrobial resistance, one of the world’s most urgent public health concerns.
The Australian Medical Association has launched a refreshingly measured “You deserve more” campaign that puts forward the very real threats to patient safety and our health system if pharmacy prescribing expands. It is interesting to hear pharmacist turned GP Dr Nicholas Yim present a relatively common case in general practice that would have likely resulted in a critical missed diagnosis and useless script for trimethoprim if dealt with in a pharmacy.
What is best for patients?
One voice that is seemingly quiet from the discourse is that of patients. We can assume from the uptake of the Queensland pharmacy prescribing pilot, where almost 10 000 women with possible urinary tract infections (UTIs) used the service, that there is demand. What we don’t know is whether these women preferred to see a GP but were unable, and whether these patients even had UTIs.
Despite many unknowns, doctors must be wary of falling into the trap of thinking in black and white terms when it comes to pharmacy services. Medications already available without prescription, such as salbutamol inhalers and adrenaline auto-injectors, are life-saving. Others, such as chloramphenicol eye drops and ointment, do not seem to cause any significant harm — although the ointment is frequently recommended and dispensed for skin infections, which is another reason we need to tread carefully in broadening the range of medications available from pharmacies.
Being able to get immunised against influenza and COVID-19 at the pharmacy makes complete sense, extending this to include certain travel vaccinations seems logical. Furthermore, while a consultation for a prescriptions for the oral contraceptive pill is a great opportunity to ensure preventive health checks are attended to, it does not necessarily justify restricting access to contraceptive options for women. It is interesting to note that, globally, over 100 countries now offer oral contraceptive pills over the counter, and there are safety checks and balances that can be effectively implemented to ensure harm minimisation such as self-screening tools.
The common thread in such examples is that these services utilise the expertise and skill set of our pharmacist colleagues, and do not go beyond them by requiring diagnostic skills that are honed over many years of education, intensive training and rigorous assessments that are currently unique to medical schools and specialist training pathways.
It is time to dull the noise and go back to basics, we need a common-sense approach to policy when it comes to medication prescribing and dispensing. Pharmacists play a valuable and critical role in our health care system. For GPs, it is a familiar feeling to work in a role that is often disrespected and underappreciated, and it is not a feeling we wish on our colleagues. However, after completing specialist training and developing a skill set that allows for accurate diagnosis and, therefore, appropriate treatment, we are acutely aware of what is at stake if prescribing is coupled with dispensing rather than diagnostic ability. We need the rhetoric to slow down, for patients to be heard and for politicians and health leaders to be reminded of what it is we should all be striving for: a world-class health system with positive health outcomes. This requires a strong primary care network that is underscored by the basic tenets of universal health care by putting patients before profits and safety first. Doctors and pharmacists have worked together to get us this far, let’s continue to do so.
Dr Alisha Dorrigan is a Sydney-based GP.
The statements or opinions expressed in this article reflect the views of the authors and do not necessarily represent the official policy of the AMA, the MJA or InSight+ unless so stated.
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Great article. Quite difficult to swallow the claim that GP’s are ‘often disrespected and underappreciated’. Underappreciated compared to what exactly, other specialties? Doctors are well known to receive just about the most respect and gratitude of any profession, such is the case when you constitute the last and most visible mile of a complicated treatment delivery journey. Patients thank the doctor who gave them a simple shot, not the scientists who developed it or the warehouse workers that loaded it onto the truck. You’d struggle to find many professions void of those who feel disrespected and underappreciated, but GP’s certainly get far more chances to take a bow than most.
Great article. It might be time to revise the Australian retail pharmacy model and return the pharmacist to the middle of the health care team instead of at the back of the “supermarket” selling supplements and cosmetics.
As another commenter points out, the physical task of “dispensing” is largely automated these days. The skills of the pharmacist would be better used (and more appropriately remunerated) for providing education and counselling, drug audits, general pharmaceutical advice etc, perhaps within a health care hub.
Superb, balanced and articulate article – thanks Alisha.
I’m a consultant physician, and I too work alongside fabulous pharmacists every working day.
That said, I’ve never understood why anyone would vociferously push to become a prescriber WITHOUT being able to (a) make the diagnosis in question in the first place through crafted history, examination and investigation, and (b) then juggle and reason through the other comorbidities to assess if prescribing is even warranted or safe.
To me, I’ve always thought: “I can’t do their job” when I watch other clinicians work their magic. I certainly don’t know how to dispense and pack medicines safely- an absolutely vital task. In the same spirit though, I don’t understand how anyone has the courage (or perhaps occasionally the hubris) to prescribe medications without the preceding diagnostic skills of a doctor. Although we are imperfect at times, the reality is that Medicine is the only discipline where these skills are deliberately and painstakingly acquired (and by design). There is a reason it takes 6 years of university and then 10+ years of specialising — diagnosing diseases and weighing-up complex mixtures of morbidity are often far harder and more nuanced than meets the eye.
I love pharmacists, and want to keep working with them, not against them. Common sense is key… fully agreed!
Ps – fascinating to hear that the Pharmacy Guild doesn’t represent anything like all pharmacists – I suspect many docs don’t know this.
Just to address the commenter who cited examples of pharmacists incorrectly giving the wrong med etc.. I too can cite numerous examples of GPs making serious errors.. there are good and bad in every profession.
As a former pharmacist, I found our current practice forces us into being a “dispensing machine”.. if we are to practice to our full scope then we need pharmacist technicians to also do that.. we should only intervene in dispensing when there is a potential issue.. not be sticking labels on repeats half the day.
I found the AMA campaign quite disingenuous.. their examples of issues with the pilot were things like “a 67 yr old women could have this complication” and such.. whereas pharmacists won’t be prescribing for the young or elderly..
I really don’t think all pharmacies are going to start prescribing.. there isn’t a consultation room in some for one.. owners wouldn’t want to loose a pharmacist for 10 mins for only $20 odd when they could have dispensed and earned more in that time (esp in discount pharmacies).. who knows if the training costs will be covered (we pharmacists are paid pennies and can’t afford such things).. this will be for very few pharmacies I think
Thank you for your article. The comments attached to this article reflect a much broader set of opinions than is generally reported in the media. As a GP, part of my role is to facilitate various specialities working together for the benefit of the patient. The current conflict, whether real or perceived makes this part of my job more difficult. Until I read the comments attached to this article I was unaware of how few pharmacists the Pharmacy Guild represents.
One aspect that seems to have been overlooked in the media is; The Pharmacy trials target some of the easier parts of the diagnostic landscape. As a GP I deal with a very broad range of issues that my patients have. Some pathologies are easier to recognise, investigate, diagnose and treat while others can be quite perplexing. The current Medicare system does little to differentiate between a relatively straightforward problem and one that takes up more time and mental work. As such the remuneration for dealing with both ends of the spectrum is very similar if not exactly the same. My normal working day relies on a balance between easier problems and the more difficult ones. If pharmacists cherrypick the easier problems to fix, I am left with the more difficult ones. If the balance does change, we then need to address the model of care in general practice and the subsequent Medicare remuneration. This is a much more complex situation than just allowing pharmacists to prescribe antibiotics for common infections. Both patient safety and air remuneration for professional services needs to be addressed
Insightful piece. Perhaps the original 30 day scripts may protect those who seek to stockpile, poly pharmacy or intentionally/unintentionally misuse medications. Whereby a duty of care is kept as a protective factor for those who are not in their best judgment. And for those patients patients who have sound judgement and insight, including protective factors and history of normative use, something else may be arranged on a patient to patient basis.
A wonderful balanced perspective on the current saga. Well written Dr Dorrigan! I must say I was rather confused by his crying on television.
Pharmacists want increasingly to be able to prescribe and treat, but look around the average pharmacy and what do you see ? Shelf after shelf of unproven supplements, “cures’ and remedies, largely evidence- free zones, usually overpriced and of little or no benefit apart from placebo. There is also an inherent conflict of interest in that pharmacists also sell the treatments they recommend. However, patients are going to turn increasingly to pharmacists for advice if they can’t see their GP in timely fashion, which is the most common complaint we now hear from the public. Medically, this is partly self-inflicted.
I, as a customer queing in pharmacies, have witnessed several pharmacists making diagnoses on customers in a public setting over many years. The diagnosis was certanly incorrect twice and medications were sold to the “customer/patient”. One of these may have lead to serious consequences. I have also heard a qualified pharmacist advise a customer NOT to take medication prescribed by their treating doctor.
I have retired from medical practise, but I am very concerned about pharmacists diagnosing and prescribing medications, particularly when they will benefit financially from their conclusion.
A good article worth reading
Well written.
There are many Pharmacists who are not interested in having to do extra modules and take on the responsibility of diagnosing and prescribing. Their voices are not being heard.
GP’s and Pharmacists for a long time have worked well together, and continue to do so. The media are portraying something very different.
I too am a believer in a self assessment tool for OCP. The onus is then on the patient/person, not on the Pharmacist or GP. Although it gives a GP an opportunity for preventative medicine etc. If the patient does not want or value that, let them have the OCP over the counter.
As a pharmacist I want to stress that most of us, like many GPs, do not own a practice, or pharmacy. Out of 35,000 pharmacists in Australia, less than 5000 own the shop. The Pharmacy GUILD does not represent pharmacists – ONLY OWNERS. Other pharmacists are not allowed to be members of the Guild so their views are not representative of the Pharmacy profession as a whole.
This archaic organisation sets our wages (lowest for all health professionals), holds far too much political clout and manages to con the public and the AMA and RANZCP into thinking they are the voice of pharmacy. Many pharmacists think rational 60 day dispensing of certain medications is a good idea. For decades we have been saying we don’t want to just be recognized for sticking labels on boxes but to use our knowledge and skills and work alongside prescribers not in competition with them. I don’t want to prescribe – I want to advise prescribers and patients and ensure medicines are taken to their best effect.
I don’t know why we would emulate other countries health systems fragmentation.
Australia had one of the best health systems. Now it seems we are going to follow the lead of other countries simply because they do it. I wouldn’t.
We do need good policy that doesn’t offer women in particular a lesser standard of care. Health care that is whole person. Medicare has been broken by auditors and accounting principles. The wrong design for whole person care.
We need to make GP more accessible.
We need Gp to be the specialty of choice.
We need investment in expert broad diagnostics =GP
We need investment in expert skilled health care coordination.
None of that diminishes a team based approach nor pharmacy or nursing skills. Or any other allied health.
But GPs are the only health professional trained in broad diagnostics in preventive care (to that end) and in skilled confidential consultation and physical examination with investigative knowledge Pathology & radiology tools to assist. We know that responsibility and pay for it with legal insurance costs.
These proposals are still band aids. They do not address the underlying systemic issues. Other than health system design and economics failures we should ask WHY do women not have time for their own healthcare. These are structural issues.
Why is a pharmacist shop more “convenient”. (Convenience = a commercial term) than a Telehealth ethical and accredited medical service.
Many questions more than answers.
I don’t think that Doctors are fighting pharmacists. As this article indicates, there is much mutual respect for each others (different ) skill sets.
This is about health system re-design. Not fixing the degradation of that with more degrading fragmenting ideas.
Fix General practice and you fix the system. GP is not a series of tasks.
The pipeline is leaking not only at the beginning but also the middle (again female gPs have had enough) and at the ehd with early retirements. There is a big glut of gps now earning elsewhere due to the broken system of today.
Generalism as a specialty is under recognised and therefore under respected.
Those that see generalist healthcare as a series of tasks do not understand healthcare.
In SA 1000 pharmacy workers are being sent to Mental Health First Aid (MHFA) training. How do you see this translating into client/customer support given the pressure and poor space options in so many pharmacies.
Congratulations on such a sensible, well balanced and presented argument. It would be very helpful to publish this in a mainstream newspaper to reach more members of the public and promote reasoned and informed discussion.
Ophthalmologists have similar issues with optometrists wanting to expand their scope of practice without sufficient training. Your comment ‘you don’t know what you don’t know’ rings very true.