The latest views published by the AMA seek to take Australian healthcare policy back into the silos that hampered it for so long, says Anthony Tassone

The latest article published on the AMA website by the association’s Vice President Dr Chris Zappala seems to be seeking to realign the nation’s healthcare policy back into the silos which so long dogged this country and weakened the delivery of healthcare.

Dr Zappala’s piece is so full of misconceptions and factual faux pas that a forensic analysis of it is warranted.

Dr Zappala opens with a salvo at what he clearly regards as a despicable erosion of the medical profession’s dominance by those who seek to continue driving collaboration in the healthcare system. He writes: “Collaboration and ‘team-based’ care are words used when the role of the medical practitioner is to be diminished or their leadership subverted – usually without any reduction in their responsibility or liability.” 

Patients and consumers expect that health professionals involved in their care work together as a team for their benefit based on the needs and preferences of them. This is true ‘patient centred care’.

Initiatives such as the Health Care Homes program and many indigenous programs clearly are to be thrown out the window under Dr Zappala’s utopia where the only concession to be a part of a team is if the doctor is the captain and makes all the calls without regard to other health professional colleague input. 

He then asserts that “prescription by other groups or conduct of non-medical endoscopy are good examples of these ‘collaborative’ models of care. Often there must be medical ‘supervision’ i.e. the doctor bears responsibility but is moved further away from decision-making, the conduct of a procedure or direct patient care. Clearly, this is not in the patient’s best interest”.

I am somewhat loath to point out the obvious that all registered health practitioners are accountable for their own decisions and actions. It’s not only doctors who are responsible. All of us are and this why there is a thing called indemnity insurance that pharmacists are required to hold in order to maintain registration for their practice.

The real target

But Dr Zappala is only getting warmed up and his true target – pharmacists – come in for special attention when he writes: “The desire for pharmacists (and others) to push beyond trained scope of practice straying dangerously into medical territory is conceivably a strategy of self-defined job redefinition in order to improve market share and profit, given how aggressive the pharmacy retail market has become.”

It is bemusing and bizarre to see Dr Zappala assume he has the right – or credentials – to define and dictate the scope of practice of another autonomous health profession. It is up to the relevant national board, policymakers and patients to help define the scope of practice of a health practitioner, not a colleague from another health profession.

He suggests “all” pharmacists face a conflict when offering ‘medical advice’ to patients because “when a doctor writes a script (or not) there is no change in the consultation fee. By contrast, whenever a pharmacist/retailer persuades a shopper to buy something as a result of their advice, they make more money.”

The contradictions in Dr Zappala’s arguments are obvious because clearly, he doesn’t want pharmacists to have access to the MBS.  But while he is probably happy to disallow access for another practitioner to the nation’s universal health insurance scheme he then says there is a ‘conflict’ if a recommendation of purchase of a medicinal product is made. 

Let me be clear on this point. Pharmacists are accountable to patients and their professional board and operate to standards of practice which state they should not make recommendations that are not in the best interests of patients. 

Are the facts in the way?

Dr Zappala also suggests there is often no evidence that the various models of care suggested “offer any advantage (in some cases, such as non-medical endoscopy, there is evidence to the contrary). Moreover, the diversion of more routine/simpler work deprives an increasing number of medical trainees of opportunity to gain basic skills and achieve appropriate training exposure”.

I commend Dr Zappala on his concern for medical trainees and their appropriate training but point out that as health professionals our primary responsibility is towards the patient, and the patient’s best interest is about accessible, safe and affordable delivery of care. Allowing other health professionals to practise to their full scope doesn’t by definition deprive Doctor of Training opportunities and Dr Zappala raising this as an issue is merely obfuscation.

Taking aim at specific work undertaken in pharmacies, he writes: “The Victorian Government funding of pharmacies to provide the MMR vaccine and the truly perplexing $100 pain consultations are policies that push the patient out of GP-centred care i.e. away from the trained and experienced professional able to genuinely help.”

Not letting the facts get in the way of a good story is dangerous practice, so I must point out that a simple fact check would have revealed that the Victorian Government is allowing pharmacies to access National Immunisation Program (NIP) stock for eligible patients and are not ‘funding pharmacies to provide the MMR’. 

As it stands, a pharmacy generally charges an out-of-pocket fee to the patient for administration and delivery of the vaccine for a NIP eligible patient as there is no other funding source currently.  This should and must change – but let’s return to Dr. Zappala’s flawed arguments. 

Another fact check would have made it clear to Dr Zappala that the Pain MedsCheck program is a trial and is a Federal initiative, not a Victorian one. But this hasn’t stopped him claiming that at “$100 a pop for potentially ill-advised direction from a pharmacist who lacks detailed anatomy or pathology knowledge or any greater sense of medicine or what else might be wrong with a patient seems awfully expensive compared to the cost of any engaged, family GP who costs less and is able to achieve a better, holistic outcome.”

No waiting lists!

Then comes a statement which really beggars’ belief: “Contrary to what some believe, there is also absolutely no difficulty in getting access to a GP at any time.”

This surely must be tongue-in-cheek. No one in the health sector believes this, least of all doctors and definitely not patients themselves so why make such a demonstrably false claim? And if he wants any evidence of it being a falsehood I would recommend he venture into rural and regional areas and speak to patients there. It would clearly be an eye-opener.

Dr Zappala merrily continues on and having set up the parameters for all health professionals doing nothing which may upset doctors, he then blithely suggests doctors should be dispensing medicines.

“If doctors dispensed medications while only covering the cost of the dispensing, there would be less cost to the patient and system, and no perverse profit incentive as exists for the pharmacist.”

No, I didn’t make this up, this is what the Vice-President of the AMA wrote, displaying a breathtaking ignorance of the work pharmacists do.

Is Dr Zappala claiming that pharmacists have a perverse incentive in dispensing medications that are prescribed by a doctor?  Does Dr Zappala have any understanding of the costs associated with maintaining the infrastructure and dispensing of a prescription to decide on whether his alternative is more cost effective?

How long should patients expect to wait to see a GP if they commence assuming responsibility for dispensing a prescription as well as prescribing – if of course you actually can get in to see a GP?

He conveniently forgets – or ignores – community pharmacies are the most frequently visited and accessible primary healthcare destination in Australia. He compounds his misinformation by stating that “This [doctor dispensing] represents the ultimate in efficiency and convenience for our patients and the healthcare system.”

Conferences questioned

To his credit, Dr Zappala anticipated his suggestions of doctor dispensing would incite some reaction and so has tried to head that off at the pass: “I can hear the usurpers citing benefits from drug companies to doctors as a prescribing incentive. This is nonsense, but let’s examine it nonetheless. Non-educational benefits from industry to doctors is non-existent. It is acknowledged that all professionals are required to attend conferences that are supported by industry, there is however no evidence that this support of educational activities changes prescribing activity or causes any harm to patients.

Pharmacists and nurses also attend the same conferences. Conferences in all industries (medical and non-medical) work similarly and there is no endemic problem with professionals the world over managing their decision-making adequately.”

I will leave the rebuttal of these statements to a British Medical Journal titled Interactions between physicians and the pharmaceutical industry generally and sales representatives specifically and their association with physicians’ attitudes and prescribing habits: a systematic review

This review concluded: “Physician–pharmaceutical industry and its sales representative’s interactions and acceptance of gifts from the company’s PSRs have been found to affect physicians’ prescribing behaviour and are likely to contribute to irrational prescribing of the company’s drug. Therefore, intervention in the form of policy implementation and education about the implications of these interactions is needed.”

I recommend Dr Zappala read this and similar articles before he starts throwing stones. No profession is perfect, and GP’s play an absolutely critical role in our primary health care system.  But this holier than thou righteousness is very misplaced and ignoring international evidence has no place in proper discussion and debate.

It is also worth comparing evidence available for the scenario’s Dr Zappala raises.

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.

A pharmacist prescriber is not necessarily one that works in the community pharmacy setting and would not necessarily be supplying the medication.

On the other hand, there is no compelling evidence for a medical dispensing programme that has the same impacts in patient satisfaction and efficiencies in time, financial or otherwise.

Given the lack of evidence for this thought-bubble, we can recognise it for what it is – an attempt to create a cold-war style stalemate where the AMA believes they hold a nuclear response that would deter pharmacists from operating to their full scope of practice.

Finding the cream

As he runs out of steam Dr Zappala reiterates the title of his article that “Collaboration is a euphemism for role substitution and we (Government included) need to stop allowing it under any guise, no matter how seductive the model looks on the surface. What usurper groups manage to gain, they should be solely and proportionately responsible for – they cannot take the cream but leave the real work and responsibility to doctors given the training and experiential requirements of future generations of doctors.”

Referring to patients as “cream” really says it all, doesn’t it?

Not surprisingly, Dr Zappala signs off with a volley at the AMA’s traditional target, the Pharmacy Guild by saying if “the Guild wants to be truly collaborative, put profits aside and help embed pharmacists in general practices to perform medication reviews and support a true multi-disciplinary, doctor-led team.”

And there it is, put profits aside. If doctors want to employ pharmacists in their practice, go right ahead and do so, but does it need to be on the public purse through an allied health professional incentive program? Pharmacists can play a role autonomously and as part of a team, not just within the four walls of a general practice clinic. 

From the rhetoric, I assume Dr Zappala is implying a general practice doesn’t make any profit for ‘administration’ of an allied health professional practice incentive.

The whole article needs to be dismissed as what it is – predictable babble disguised as didactic discourse. It is in fact a manifesto for health autocracy, with the power concentrated solely in the hands of doctors.

It would be useful if the AMA President, Dr. Tony Bartone came out publicly to condemn these divisive remarks from his Vice-President.  Without doing so, we can only assume he and the AMA broadly supports these sentiments.

[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