Pharmacist prescribing by 2020? What you need to know


pharmacist hospital

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.

pharmacist GP collaboration pharmacists in general practice patient
“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.”

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. 

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14 Comments

  1. pagophilus
    12/05/2018

    If pharmacist prescribing ends up being allowed to prescribe a narrow range of drugs in a very specific setting – not interested. I remember reading an article several years ago about a pharmacist prescribing only oral chemotherapy. How unfulfilling would that be? Or adjusting people’s warfarin doses. Likewise, not interested. Prescribing inpatient meds on admission would be better, however my take on the inaccuracies in doctor-initiated medication reconciliation and inpatient prescribing on admission is they don’t appreciate the importance of it and therefore don’t do it properly. Doctors need proper training in prescribing. Pharmacist prescribing is of secondary importance.

    What I’d like to see is a further separation of roles. Today we have prescribers and dispensers. I’d like to see 3 separate roles carried out by 3 separate people: diagnosers, prescribers and dispensers. One doctor could diagnose and then say to another doctor, or pharmacist prescriber “this is the diagnosis, now prescribe something”, (for example, patient has MRSA, here are the sensitivities, prescribe an appropriate antibiotic), and if it is the pharmacist who prescribed then the same pharmacist shouldn’t be allowed to dispense.

    • Lintaro Steiner
      12/05/2018

      Causes of inpatient prescribing errors can be complex- there are environmental, organisational, personal and patient factors at play. Pharmacist prescribing might solve some of these issues (better therapeutic knowledge and experience) but unless there is a concerted effort to address the other causes (high workload and poor communication are frequently implicated) then errors will continue to occur regardless of who does the prescribing.

      > What I’d like to see is a further separation of roles.
      Diagnosis and management are integrated processes and introducing a middleman is unnecessary, inefficient and would only increase risk to the patient. I cannot think of any potential benefit that would justify it. We already have enough problems with communication between prescriber and dispenser, for example scripts not even having indications on them.

  2. Bryan Soh
    12/05/2018

    Question is will the guild see this as “a significant net addition” to a pharmacists workload??? My 2 cents is probably not.

    • United we stand
      13/05/2018

      Guild will fight with teeth and nails for the prescribing fee to come out of the 7CPA. Pharmacy premise gets the cash for the consultation and the owner will decide whether to pass down the money to the prescribing pharmacist. In reality, it’s gonna be just part of your job description and not negotiable.
      #guildalwayswins
      #5dollarscripts

      • Sam Turner
        13/05/2018

        in light of your point – a typical GP arrangement would be to get a % of any $ made from consultations. what’s stopping a prescribing pharmacist from negotiating a similar arrangement with their employer if you’re utilising an acquired, higher competency skill/accreditation?

        • United we stand
          14/05/2018

          Unlike a GP, a prescribing pharmacist is not going to be only writing prescriptions. It will be an additional role just like MedsChecks and administration of vaccines.

          Looking at historical trends, whenever an additional role was rolled out for pharmacists, they turned into what’s expected of pharmacist on duty and were used as Key Performance Indicators (KPIs) to assess your performance. These new roles didn’t increase the salary of pharmacists and any attempt to increase the award have fallen to the side thanks to the Guild stepping in to prevent it.

          Nowadays, it is common place for your job offer/ contract to include minimum expectations such as 8 Medschecks/month, 15-20 clinical interventions/month, and 150-200 flu vaccines administered per flu season.

          If the historical trend isn’t good enough for you to forecast how it will be rolled out, just look at the language Guild’s Anthony Tassone is using in the comment above to gauge the future of pharmacist prescribing services.

          • Bryan Soh
            14/05/2018

            yea pretty much sums up the so called extended scope of practice, additional training and responsibilities for next to no increase in remuneration. I do not think there is any industry like this in Australia to be honest

          • Anthony Tassone
            14/05/2018

            United we stand

            My language is not meant in any way evasive but based on not wanting to speculate too broadly given we do not have all the facts of what pharmacist prescribing would look like in the coming years as it is still in development for hopeful implementation.

            Anthony Tassone
            President, Pharmacy Guild of Australia (Victoria Branch)

    • Anthony Tassone
      13/05/2018

      Hi Bryan

      I assume you mean ‘significant net addition’ in relation to a work value sense from the perspective of the Fair Work Commission assessing any potential claim for an increase to a minimum award.

      Whether there is a significant net addition for work value reasons or not would depend on whether there had been a significant change in; skills and responsibility, nature of the work and conditions under which the work was performed.

      Some may argue that prescribing would constitute a significant change in skills and responsibility. This could require consideration of a different classification under the Pharmacy Industry Award as it is an activity that may not be undertaken by all pharmacists necessarily.

      This is all speculation, as there is more work to be done to demonstrate formally how it is within the scope of practice of pharmacists, what additional training or credentialing may be required and how pharmacists would fit into the Health Professionals Prescribing Pathway framework.

      I understand your comment had an intent of cynicism and frustration given the ongoing work value claim from APESMA before the Fair Work Commission. My response is genuinely looking at it against the criteria that would need to be satisfied and the considerations that may need to be taken into account.

      Anthony Tassone
      President, Pharmacy Guild of Australia (Victoria Branch)

      • Bryan Soh
        14/05/2018

        Hi Anthony,

        You can argue it is cynism, but I’d like to think of it as realism. Have a good day.

        Bryan

      • United we stand
        14/05/2018

        Anthony I’d love to hear what your plans are to increase pharmacist remuneration since you clearly don’t believe it should be done through the award rate. I think Dr Jackson is also eager to hear your reply.

        • Anthony Tassone
          14/05/2018

          United we stand

          Below is an excerpt of a message that I sent to Victorian Guild members just under two weeks ago on Thursday 3rd May in the lead up to the hearings for the Work Value case:

          “I am aware that many Victorian Members are unhappy with the approach the Guild has taken in this matter and believe that wage rates for Pharmacists should be increased. While I don’t disagree with many of the sentiments that have been expressed, it is not up to the Guild, but rather it is the responsibility of the Commission as an independent umpire to decide whether wage rates should increase.

          I personally believe the pharmacist award rate should be higher than it currently is and have never paid the award rate for a pharmacist employed in my team (as is also the case for many of you). However, this case is not about what we believe an award rate ought to be, it is comparing the criteria since it was last assessed under this legislative framework. That is the system in which we operate.”

          Accelerated price disclosure has significantly impacted and reduced community pharmacy’s ability to remunerate their staff more than what they have been able to manage. Historically, and there is evidence to demonstrate this, when the gross profit dollars per prescription increases, pharmacy proprietors have passed some of this on to their team in wage growth. This has been very difficult to do in recent times.

          To answer your question – along with my colleagues within the Guild, we advocate as strongly as we can to increase opportunity, remuneration and recognition for the community pharmacy network. With more remuneration flowing to the community pharmacy network there is a greater opportunity to reward quality staff appropriately and recognise them.

          I know I would take the earliest opportunity to do so, and do the best I can in my pharmacy to do so as do a number of proprietor colleagues.

          As stated above from the excerpt of an email broadcast to Victorian members, I believe the pharmacist award rate should be higher and have never paid a pharmacist in my employ the award rate no matter the classification.

          Under the Australian workplace relations system the intent of the award rate is not meant to necessarily represent a market rate for remuneration of a position but at least act as a minimum safety net.

          The Work Value case – brought to the Fair Work Commission under the criteria allowed under the act to review remuneration for ‘work value reasons’ is not simply a discussion of what the award rate ought to be or what we think it should be. It is about demonstrating substantive evidence to satisfy the criteria and test of significant net addition to work value.

          Anthony Tassone
          President, Pharmacy Guild of Australia (Victoria Branch)

          • United we stand
            15/05/2018

            With regards to your statement:
            “I personally believe the pharmacist award rate should be higher than it currently is and have never paid the award rate for a pharmacist employed in my team”

            You must understand as a Guild president your actions no longer affect the lives of a handful of pharmacists working for your business but over 20,000 pharmacists across Australia and many more who are undertaking their studies as we speak.

            Even if you pay above award, the sad fact is many discount chains do actually follow the award rates. A matter that the Guild is well aware of. The Guild represents the entire community pharmacy not a dozen of pharmacies that are Guild representatives.

          • GlassCeiling
            19/05/2018

            Bluster.

            You proudly represent the Guild as a state President. Your organisation makes submission to deny your colleagues and employees a rise in the ‘ safety net’ but you personally approve of a raised award.

            It is great you pay your pharmacists above award . The award is so low any above award payment is likely to be meagre.

            ” Thoughts and prayers” comes to mind . Actions speak louder than words and your actions in representing the Guild clearly indicate your apathy toward employee welfare and worth.

            The exodus of pharmacists continues- Many Guild members had better return to work to learn how to be pharmacists again to ensure continuity of care.

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