Are pharmacists too overworked and underpaid to prescribe? What would pharmacist prescribing even look like? Dr Shane Jackson and Professor Lisa Nissen answer your questions
Following PSA national president Dr Shane Jackson’s announcement at APP2018 that in his view, pharmacist prescribing is “imminent” and could be in place by 2020, AJP readers responded in droves: both with great positivity, and with many questions.
Here we follow up your questions with Dr Shane Jackson and pharmacy academic Professor Lisa Nissen from Queensland University of Technology about pharmacist prescribing: how it could look and why pharmacy leaders think it’s a good idea.
1. What are some ways prescribing rights for pharmacists could be extended past what they currently have with S2s and S3s?
Dr Jackson: In December last year, the TGA released the updated Scheduling Framework which had a new Appendix M category. What Appendix M allows is for medicines to have additional controls placed on them. These might be recording; education requirements; providing it for only certain indications and for certain characteristics of individuals who present in the pharmacy; and excluding other types of people – as per a protocol.
And so Appendix M will allow medicines that might need to have tighter scrutiny with regards to who actually receives them, it allows the TGA to have some comfort around when they can be provided within a pharmacy environment, and ensures the level of training of the pharmacist – that they’re certified that they’ve attended training – how it’s going to be provided, and what the reporting arrangements might be.
That’s what we will see in a number of years, in my view a larger number of medicines that perhaps could have been downscheduled in the past, like erectile dysfunction drugs and the oral contraceptive pill, might well go into the Appendix M category, because the Advisory Committee on Medicines Scheduling (ACMS) can have some comfort around how they’re going to be provided in the pharmacy environment.
That’s going to be quite significant over the next couple of years and there are probably 10 classes of drugs that could be provided by Appendix M classification. So the erectile dysfunction drugs being one of them, the oral contraceptive pill, perhaps trimethoprim, triptans for migraine, etc. Those types of medicines.
Appendix M – Additional requirements for Schedule 3 medicines
The Secretary may, in consultation with ACMS, require additional controls or supply requirements for certain Schedule 3 substances to enable them to be provided by a pharmacist. This Appendix is intended to facilitate down scheduling from Schedule 4 to Schedule 3 where, for example, there is community need for access to a medicine but additional controls and oversight, including by the dispensing pharmacist are needed.
2. Could pharmacist prescribing open the floodgates for doctors to then branch out into dispensing?
Dr Jackson: Our view is that where there’s an independent decision to start a medicine, it’s probably best that that’s separated from the supply consideration. This has been one of our principles. There will be a point where community pharmacists may adjust doses, extend the life of prescriptions, but you may well have more independent prescribing i.e. commencing a medicine, that’s done at arm’s length of the supply arrangements.
And that’s a fundamental separation of prescribing and dispensing, we need to decide what that line is from the pharmacist’s point of view. That’s why the more independent-type prescribing activities are probably ideally suited to a pharmacist within a general practice environment.
Pharmacists are already extending prescriptions through continued dispensing, for example, so that’s a natural continuation of that if you’ve got an appropriate framework to do that. You also need to have an agreement to do that with the medical practitioner.
It’s not unreasonable within certain parameters for the pharmacist within the community pharmacy to adjust the doses because they’ve probably seen that person more regularly as well. It’s all about that agreement with the prescriber to do things within certain parameters.
It’s about working together, and there’s trust and there’s a relationship there, and the trust is actually built on the expertise of the pharmacist and the recognition of the GP in that expertise of the pharmacist.
That’s why the Pharmacy Board is conducting a consultation. I’ve given you the PSA’s view around that. We always try and take a sensible balanced approach.
3. We’ve had some readers say pharmacists are already too busy, they already feel underpaid – how are they supposed to find the time and incentive to add prescribing to their workload?
Dr Jackson: The first thing is addressing that remuneration discussion. It’s clear that pharmacists feel undervalued, they’re feeling like they’re not remunerated adequately. So we need to do better with remuneration as a profession. That’s really clear.
We shouldn’t see remuneration preventing people from doing the things they should be able to do and, to be frank, that they would enjoy doing if they were more adequately remunerated.
Remuneration should be facilitated, not a barrier to pharmacists doing practice.
It’s really terrible if we’ve got people saying that and it just shows that we need to improve the remuneration for pharmacists if they see that as a barrier. It’s not ideal, to be honest with you.
With regards to workload, let me talk about collaborative prescribing. Collaborative prescribing is where you actually enter into an agreement with a medical practitioner around prescribing, and the prescribing can be as broad or as narrow as the agreement you enter into. So simply it might be that you can extend the life of the cardiovascular prescription medicine from six to 12 months.
It might then be a little bit more complex, and it might be that you could adjust the dose up or down within certain parameters for that cardiovascular medicine. Or it might well be that the doctor’s made a diagnosis of hypertension and you make the decision to start the medicine.
4. Why is pharmacist prescribing a good/bad idea?
Professor Nissen: Pharmacist prescribing is a good idea, where the skills and abilities of pharmacists are used to enhance medicines use in the community. It’s not about pharmacists “taking over”, it’s about collaborative models of care for the betterment of health outcomes and care for patients. There are numerous opportunities for this to occur in a system already under pressure from the burden of chronic disease and an ageing population.
5. Who should be able to prescribe: community pharmacists / hospital / accredited consultant pharmacists?
Professor Nissen: All pharmacists who have the appropriate competencies should be able to prescribe. This isn’t something that should be limited to hospitals or acute care facilities. The important factor is the way in which prescribing by a pharmacist could add value to the health system and to patients, regardless of the setting. It is about the value proposition provided by adding a pharmacist prescriber to the team.
6. How can the government ensure that pharmacist prescribing is well controlled and done in a safe manner?
Professor Nissen: There are well-constructed frameworks already in place for prescribing for all professionals. The Health Professionals Prescribing Pathway (HPPP) provides a clear view of how practitioners should prepare for prescribing – including the NPS Prescribing competencies which show the standard of training that should be met and the HPPP also provides the governance framework that overarches prescribing practice.
State and territory legislation and registration standards would pull this all together. The key is to have appropriately trained and competent practitioners who work collaboratively.
7. When could extended pharmacist prescribing happen?
Dr Jackson: In my view, pharmacist prescribing is imminent. There’s a number of processes that need to be undertaken, but it’s well within the scope of practice of pharmacists and under our competency framework to be able to prescribe so, there’s no reason we shouldn’t have it pretty shortly. There’s no reason it shouldn’t be in place by 2020.
Professor Nissen: While aspirations are always good (timeline 2020) we must be cognisant of the consultations and processes that will be necessary for the profession to go through to ensure that we are all aligned and supportive of this move. The Pharmacy Board’s symposium is the start of this process and it will be critical that the profession supports this as a future role for all pharmacists to participate in.
The value we can contribute to the system as medicines experts is significant and this is a key part of progressing that in the future. Consultation and collaboration with the whole health care team and particularly consumers will be paramount to shaping the approach that will work best for the future.