Arguing the case


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Leading researchers argue for why pharmacist prescribing should be autonomous, and criticise language surrounding emergency provisions during the Australian bushfires

The case for pharmacist prescribing and what this should look like has been debated extensively in recent years.

Pharmacist prescribing needs to be independent rather than dependent, argue Dr Ross Tsuyuki and Dr Kaitlyn E. Watson in the Canadian Pharmacists Journal this month.

Dr Tsuyuki is Professor and Chair of the Department of Pharmacology, University of Alberta and Dr Watson is a Queensland pharmacist researcher now based in Alberta, specialising in disaster management and pharmacy practice.

Independent prescribing does not require permission or a prior agreement with another practitioner, while dependent (or collaborative) prescribing is when a pharmacist strikes an agreement with a physician.

Dr Tsuyuki and Dr Watson put forward six reasons why the Alberta model of independent prescribing, where the decision on what to prescribe and who to prescribe it to is solely that of the pharmacist, is superior to dependent prescribing.

  1. In a dependent model, you can only prescribe for those patients with a specific condition under that particular doctor. What about those patients who need pharmacist care and intervention who are with another doctor or (as is common nowadays) without one at all? About one-third of patients cannot, will not or do not see a primary care doctor.
  2. In a dependent model, often the physician must make the referral. “This helps very little with the public health problem,” argue the authors. “What about the patients whose hypertension the physician has missed?”
  3. Dependent models perpetuate the subservient relationship of pharmacists to physicians. Essentially, the pharmacist becomes an administrative clerk for the physician.
  4. Independent models provide equal opportunities for patient-centred care—where the information flows in both directions. Dependent models rely on the unilateral flow of information from physician to pharmacist through a referral.
  5. The knowledge and skills required of pharmacists for both models are the same—there isn’t anything additionally required for pharmacists to independently prescribe, argue the authors. “The ability to prescribe a treatment or medication for a patient is the same skill required to recommend the same treatment or medication to a physician for that patient—the only difference is who makes the final decision,” they say.
  6. Is there any evidence for a dependent prescribing model? Where is the evidence to support the benefits of dependent prescribing, they ask.

Dr Tsuyuki and Dr Watson share evidence for the positive impact of pharmacist prescribing vs usual care, which includes improvements in blood pressure, A1c, lipids, cardiovascular risk, urinary tract infections, as well as cost-savings and patient preferences.

However they also take umbrage at the use of language surrounding emergency provisions during the recent Australian bushfires.

“The provision of oral contraceptives and pharmacists’ ability to provide prescription medications under the new temporary emergency supply provisions have been framed as ‘now available from your pharmacist without a prescription’,” they say.

“This terminology makes it sound like pharmacists are being allowed to temporarily bypass regulations.

“While we understand that it may be mostly the media and government who are saying this, why aren’t pharmacists correcting them by saying, ‘Your pharmacist can assess and prescribe the need for ongoing medication supply during the bushfires’?

“The pharmacists have ultimately made the final decision to continue treatment.”

The Pharmacy Board of Australia released its position statement on pharmacist prescribing in October last year, concluding that under the National Law, there were “no regulatory barriers in place for pharmacists to prescribe via a structured prescribing arrangement or under supervision within a collaborative healthcare environment”.

However the Board’s view was that independent (or autonomous) prescribing by pharmacists would require additional regulation via an endorsement for scheduled medicines.

The Board stated it is not making an application for approval of endorsement for scheduled medicines at this time.

Some research has found pharmacists, often hospital pharmacists, excel in the area of collaborative prescribing.

A 2019 study found hospital pharmacists achieved a 90% error-free rate on medication orders compared with 26% for medical officers within a collaborative prescribing model.

However concerning reports on independent pharmacist prescribers have come out of the UK in recent months.

Inappropriate prescribing or poor advice given by independent prescribers working in GP practices has been associated with serious incidents, the Pharmacists’ Defence Association (PDA) in the UK has reported.

“We have seen a number of serious incidents recently and are currently in the early stages of dealing with cases where patient deaths have been reported,” said the PDA in its alert.

“Some of these recent cases are linked in some way to pharmacists prescribing inappropriately or offering poor advice, often underpinned by an assumption of competence which was ill-founded.”

The PDA warned all members that “significant levels of caution” should be used when prescribing a medicine for the first time.

See the full article in the Canadian Pharmacists Journal here (open access)

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