Defining roles: Part 1


prescription

The thought of pharmacist prescribing may present concerns to the average GP, but evidence shows it may improve access to healthcare for patients. Could such a model work in everyone’s favour?

It’s no secret that a significant number of pharmacists would love to have prescribing privileges.

According to Australian surveys, most believe such privileges would enable them to provide more efficient and improved pharmaceutical care. They also believe there is potential for reduced healthcare costs and better access to medicines.

However many from the medical profession have expressed unease – and sometimes outright hostility – at the idea of pharmacists having the right to prescribe medications.

But what does a “pharmacist prescriber” actually look like?

Prescribing involves selecting the most appropriate drug from a range of drugs, initiating, monitoring, continuing, modifying and administering drug therapy.

While doctors are the only health professionals fully trained diagnose a range of conditions, there are different ways pharmacists could prescribe that would allow them to support – rather than hinder – doctors’ role as independent prescribers.

This role would allow pharmacists to be “dependent”, “non–medical” or “supplementary” prescribers.

Dr Andrew Hale, a pharmacy researcher from the Royal Brisbane and Women’s Hospital’s Pharmacy Department, emphasises the importance of defining these prescribing roles.

He says an important tenet that should always be remembered is that the doctor should always be involved.

“There are several different models of pharmacist prescribing to learn from, which have been implemented safely in other countries, such as UK and Canada, but it’s important to acknowledge that pharmacist prescribing needs to be in collaboration with doctors, so [it’s] a supplementary model of care,” says Dr Hale.

“By establishing that, you have the senior medic in the team to assist in defining scopes of practice for the pharmacist, and importantly, referral points when a medical officer needs to be consulted.”

Need vs want

While some pharmacists may want to add prescribing to their list of competencies, we need to look at the ‘why’, says Dr Chris Freeman, Clinical Senior Lecturer at the University of Queensland’s School of Pharmacy.

“We should consider what drivers there are to develop a model of pharmacist prescribing,” says Dr Freeman, whose research looks at the integration of pharmacists into the general practice setting.

In the UK for example, there is a significant GP workforce shortage and enabling pharmacists to prescribe helped improve access for patients to care.

“We do not have the same level drivers here in Australia (except in perhaps rural and remote parts of Australia),” says Dr Freeman.

“This should not be a one-size-fits-all approach and we need to consider the need for pharmacist prescribing, and other factors specific to the environment in which the pharmacist is to prescribe.

“If a model of pharmacist prescribing is established in Australia, we need to have a better understanding of what the model will look like in primary care, including any potential unintended consequences,” he tells AJP.

Dr Hale believes pharmacist prescribing would improve medications access for Australian patients.

“In the face of a chronic healthcare workforce shortage, pharmacist prescribing is about utilising the current members of the healthcare team in the best and most efficient way, and it would better use pharmacists’ skills as medication experts,” he says.

“It would also improve access for patients, by giving patients more choice in how they access safe and appropriate medications to meet their healthcare needs. And finally, it has the potential to free up considerable doctor time to be better utilised in other ways.”

Wider recognition of the contribution pharmacist at all levels can lead to the improvement of medicines use in the community, says Professor Lisa Nissen, Head of the School of Clinical Sciences at the Queensland University of Technology.

“Pharmacist prescribing is a good idea, where the skills and abilities of pharmacists are used to enhance medicines use in the community,” she says.

“This would include a greater involvement in managing chronic diseases and acute conditions. There are numerous opportunities for this to occur in a system already under pressure from the burden of chronic disease and an aging population.”

What you said: AJP readers

E.B.: “I could not possibly be the only one who constantly experiences frustration as a result of the limitations which we have placed on us when it comes to prescribing medications.

How often do you see consultants and registrars delegate discharge prescription writing to that graduate intern that knows little more about prescribing medicines than the average Joe Blow?

“How often do you have to spend half an hour trying to track down that one prescriber whom so insistently chose to inappropriately prescribe azithromycin with a dose regimen that reads ‘take 500 tablets daily for 3 days’ just so that you can get them to reluctantly grant you permission to annotate the script so that it reads a much safer, ‘take 500mg daily for 3 days’? Why is it that Australia is choosing to ignore the overwhelming evidence which supports integrating prescribing pharmacists into healthcare systems?”

 

P.C.: “A young doctor I know well says she and her friends don’t understand why pharmacists don’t have prescribing roles in hospitals.  The trainee doctors don’t believe they’re competent to do it and find it the most stressful part of their work.”

 

G.K.: “Pharmacists need to develop a strong professional identity and move away from being anally retentive risk averse checkers. Pharmacist prescribing is not a new concept internationally, but the profession seems to kowtow to the medical bullying and turf protection that occurs here, rather than calling it out for what it is – income protection.”

While there may be a need for pharmacists who can prescribe, Advanced Practice Pharmacist Debbie Rigby says this role would need to be within each pharmacist’s area of clinical competence.

“Therapeutic areas could include respiratory (asthma and COPD), cardiovascular, diabetes, and more specific areas such as HIV and hepatitis C medications,” says Rigby.

“Some pharmacists may have generalist prescribing rights for multiple chronic diseases. Ongoing management of some chronic diseases such as asthma, COPD, diabetes, hyperlipidaemia, hypertension and many cardiovascular conditions could be managed collaboratively between GPs and pharmacists.

“The UK model of pharmacists managing repeat prescriptions appears to be working effectively and efficiently,” she says.

A new trial

Managing repeat prescriptions is now on the table for pharmacists in Australia.

Despite GPs’ wariness of pharmacist prescribing, the tide is slowly turning with doctors’ groups coming on board.

While there have been some pharmacist prescribing pilots that have already occurred in Australia, the Australian Medical Association (AMA) has only recently thrown its support behind a new pilot program that will enable pharmacists to renew prescriptions and make dose adjustments to medications.

The Chronic Disease Management pilot program is an upcoming 18-month Victorian trial, which opened to expressions of interest in January.

While the first trial of its kind, the pilot program is part of an ongoing national push by pharmacy groups for pharmacists to work alongside GPs as part of a collaborative primary healthcare model, to ease pressure on the healthcare system.

Acting Health Minister Jenny Mikakos said the move to engage pharmacists in primary care would take pressure off the healthcare system.

“We know that currently more than half of visits to GPs involve managing a chronic condition, rather than diagnosing new conditions,” she said in her announcement of the trial.

“Through this pilot, patients will be able to conveniently manage their chronic condition, in accordance with a GP’s care plan, at their local pharmacy, closer to home.”

The AMA says that while the trial may appear “controversial in many respects”, it is about supporting GP care plans by involving pharmacists within the primary health care team.

“If you look at the detail of it, this is about amplification of care plans that GPs actually make, and pharmacists can be part of a care plan that GPs make with their patients to enhance chronic disease management,” AMA Victorian president Dr Lorraine Baker told ABC Radio Melbourne.

“The proposal within this – and this is what we have to find out, that is why it’s a pilot – is that the GPs will amplify the range of dosing and the specific requirements the pharmacist will have to have gone through to decide whether the patient meets the GP’s required standard for a change of dose, and then will be notifying the GP,” said Dr Baker.

“So let me make it clear, this is actually coordinated through a general practice model of care involving a pharmacist.”

However, the proposal has drawn the ire of some GPs who believe the move fragments rather than supports healthcare.

Readers of the Australian Doctor publication, for example, did not respond positively online to news of the pilot study.

Some referred to the decision as “another nail in the coffin” for GPs and “pure madness”.

“This is dumbing general practice, fragmenting continuity of care,” one reader wrote.

“What a joke! A huge part of my GP work is forming a relationship with the patient and their family. This just fragments care!” said another.

The trial that will allow pharmacists to change drug doses, issue repeat scripts and perform point-of-care tests is a “disaster waiting to happen”, said Dr Evan Ackermann, a Queensland GP and chair of the RACGP’s National Standing Committee – Quality Care.

These comments echo findings from a 2008 study of Australian GPs’ views on pharmacist prescribing, which revealed concerns for fragmentation of care, as well as perceived interference with the GP-patient relationship.

“Why write a care plan to treat HT when the doctor can just do it. Why create a middle man (or woman)? All these examples disjoint the service to the patient…” said one study respondent.

Another said that pharmacists issuing repeat scripts “would impair the doctor-patient relationship as visits [would be] less frequent. Repeat scripts are our ‘catch up’ time either by being a shorter consultation or allowing a general health check of the patient during the appointment.”

The study also found that among participants, “it was recognised that pharmacist prescribing might offer benefits in term of convenience to the patient and improved access to medicines by reducing waiting times, costs and simplifying processes for patients to receive optimal treatment.”

Continue reading Part 2 of this article here.

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