Moving beyond turf wars


agreement decision government question debate contract solution

Sniping and insults from GP representatives will not stop advocacy for evidence-based role expansion of pharmacists to deliver more accessible healthcare, writes Anthony Tassone

The decision by delegates at the recent AMA conference to rule out dispensing for profit would on the surface appear to be an uncharacteristically altruistic move by the peak body representing the medical profession.

However, any warm feelings patients may have had about this decision were soon dispelled by the chair of the AMA’s ethics and medico-legal committee, Dr Chris Moy, AMA Council member, who wrote in Australian Medicine that he was “thankful” doctors had decided not to compete with pharmacists in this area.

The ‘thankful’ Dr Moy’s real intentions were soon revealed as he quickly reverted to the usual attack on the community pharmacy sector, that seems to be a hobby horse of both past and presently elected officials of the AMA.

He wrote that GPs feel “under assault” from pharmacists whose work in areas such as vaccinations and sick certificates was little more than a move into the medical territory.

Those GPs who felt this way he believed might see the no-dispensing for profit as a “surrender to the pharmacists”.

With pharmacists still in the crosshairs he wrote: “As the AMA we consistently highlight the conflicts of interest of pharmacists who sell a wide range of therapeutic (and other) products to consumers. Should we be in a race to the bottom to do the same?

“Thankfully our… delegates said ‘no’.”

Dr Moy and his AMA colleagues who persist in accusing pharmacists of a conflict of interest in selling products to patients could well do with a little refresher on what a conflict of interest is.

By definition, it is “a situation that has the potential to undermine the impartiality of a person because of the possibility of a clash between the person’s self-interest and professional interest or public interest”.

By any stretch, and the AMA is very adept at such stretching, the way community pharmacies conduct their business falls so far short of this definition as to make the claims ludicrous.

Pharmacists are regulated by the Pharmacy Board of Australia supported by the Australian Health Practitioner Regulation Agency (AHPRA).  Under the Pharmacy Board’s latest version (March 2014) of the Code of Conduct for Pharmacists it states:

Practitioners have a duty to make the care of patients or clients their first concern and to practise safely and effectively.

To suggest pharmacists do not have a patient’s wellbeing or interests in mind is just false, misleading and insulting.

Provision of a product to help meet the needs (and is in the interests of) a patient is not a conflict of interest, it is delivery of care. How does this differentiate from a physician or dentist who is paid to perform a procedure for a patient that they recommend? 

Exactly.

So why put up a smokescreen around the delegates’ decision? Are we to be grateful for the AMA ruling themselves out of ‘dispensing for profit’, despite probably never being seriously considered for such a role?

Given the AMA’s track record in its approach to community pharmacy, one view may be that the recent decision is a pre-emptive tactic to undermine any attempt to potentially expand the role of pharmacists into prescribing.

The Pharmacy Board of Australia is currently undertaking a broad consultation on pharmacist prescribing, and as according to a recent communique of theirs to ‘bring stakeholders together to explore pharmacist prescribing as a means of improving access to medicines to meet public need.” 

This is following previous work undertaken by Health Workforce Australia in Health Practitioner Prescribing Pathways (HPPP) which is a constructed framework that is already in place for prescribing for all professionals. HPPPs help provide a path of how professionals can prepare for prescribing, the necessary standard for training and the overarching governance framework of that practice.

As medication experts, why shouldn’t pharmacists have a greater role in this space?

Rather than concentrating on whether a profession ‘feels under assault’, what is beneficial in the patient’s interest must be the priority. Part of this consultation will assess what collaborative models can be explored without pharmacists ‘taking over’, particularly in an ever-stretched system with an ageing population and the increasing burden of chronic disease.

In many respects, pharmacists already prescribe. To ‘prescribe’ as defined in the Health Practitioner Regulation National Law Act (otherwise known as ‘the National Law’) is; “to authorise the supply or administration of a medicine to a patient.” Pharmacists already do this in the community pharmacy setting particularly with Schedule 2 and Schedule 3 medicines and for some Schedule 4 medicines under continued dispensing arrangements.

Prescribing could take on different forms such as; autonomous prescribing, prescribing under supervision or prescribing via a structured prescribing arrangement.

The autonomous prescribing model would see pharmacists who are able to prescribe within their scope of practice doing so without the need to be supervised or authorised by another autonomous prescriber.  This already occurs in the UK where autonomous pharmacist prescribers are required to undertake a General Pharmaceutical Council accredited program.

Why couldn’t Australian university programs be aligned to graduate future candidates for pharmacists who would have the necessary training as part of their undergraduate program?

Prescribing via a structured prescribing arrangement requires an established diagnosis by an appropriately trained healthcare professional, usually a medical practitioner.  Protocols would be developed collaboratively and the roles of each member in the team clearly defined. A form of this model is being examined in Victoria under the Chronic Disease Management pilot where pharmacists can dose titrate prescriptions medicines under a GP-led plan for four conditions; asthma, hypertension, hypercholesterolemia and for anti-coagulant patients.

As reported recently British researchers writing for the British Journal of Clinical Pharmacy reviewed 65 studies,[1] “exploring patient, doctor and pharmacist attitudes before or after implementation of pharmacist prescribing in a country.”

The researchers made many findings following the study review that are hard to ignore;

  • Patients see pharmacist prescribing as improving their access to care.
  • Most patients exposed to pharmacist prescribers consider them as competent as doctors.
  • Doctors generally acknowledge that prescribing for limited conditions, including minor ailments, is a “logical step”.
  • Most doctors who have worked alongside prescribing pharmacists in the UK support their new role, believing it’s a good use of pharmacists’ skills.
  • Some policymakers believe pharmacist prescribing may cut costs and doctors’ workloads and improve patient outcomes.
  • Pharmacists agree they need training but have different ideas about their prescribing role.
  • Pharmacists are worried about increased liability, lack of time and resistance from doctors when trying to develop a management plan for a patient. They have differing views on whether independent or supplementary prescribing is best for pharmacists and patients.
  • Pharmacist prescribing is most advanced in Scotland, where around 40 per cent of pharmacists in 2017 were either prescribers or undertaking training.

Pharmacists prescribing makes sense and should follow experiences from international jurisdictions that have produced benefits for their respective health care systems and for patients.

Patients will be the clear winners, but I have no doubt that the AMA and their colleagues at the RACGP will wage a heated campaign to protect what it regards as its “turf” after taking it upon themselves to not intrude on pharmacy’s ‘turf’ in something they were probably not seriously considering or have taken the time to fully understand.

Anti-pharmacy campaigns by peak medical bodies are in full swing with the Victorian Chair of the RACGP, Dr Cameron Loy recently accusing pharmacies as being ‘motivated by money’ and ‘making health a commodity and further fragmenting Australia’s healthcare system’.

Such criticism isn’t new and are coming from the same organisations who issued warnings to the Australian public of the ‘dangers’ of receiving a vaccination service from a pharmacist immuniser.

After two years of having pharmacists being legislated to be able to vaccinate in every state and territory in Australia there has been unprecedented demand for the influenza vaccination across Australia.

Rather than promote the benefits of a team approach and the important role that GPs play, their representatives would rather snipe and insult colleagues.

That cannot and will not stop advocacy for the evidence-based calls for role expansion of pharmacists to deliver more accessible health care and services for the Australian health system.

Surely the time has come to move beyond the turf war paradigm and establish models of care based on mutual respect and better health outcomes.

Anthony Tassone is the president of the Pharmacy Guild of Australia (Victoria)

[1] Jebara.T, Cunningham.S, MacLure.K, Awaisu.A et al, Stakeholders’ views and experiences of pharmacist prescribing: a systematic review (2018) – accessed via: https://bpspubs.onlinelibrary.wiley.com/doi/abs/10.1111/bcp.13624?af=R

Previous 10 pharmacy products consumers don't need: CHOICE
Next Clinical tips: non-evidence-based medicine

NOTICE: It can sometimes take awhile for comment submissions to go through, please be patient.