Docs want to ‘break the retail-medicine link’

doctor makes "stop" gesture with hand - ama

The RACGP has slammed pharmacy professional services and complained that doctors saw no cash back from the risk share solution

The group is urging the King Review panel to break what it sees as the “retail-medicine link” in community pharmacy, particularly in relation to complementary medicines.

The RACGP, which represents more than 90% of Australian GPs, has released its formal submission to the Review of Pharmacy Remuneration and Regulation following the Panel’s interim report.

The submission slams pharmacy services such as pharmacist vaccination and the now-defunct Amcal pathology program, and reiterates the doctors’ desire to see location rule reform.

“Our submission focuses on key areas including complementary medicines and homeopathy, breaking the retail-medicine link, the role of pharmacists and access to pharmacies for Aboriginal and Torres Strait Islander people,” says Dr Bastian Seidel, RACGP president.

“When it comes to complementary medicines and homeopathy we would argue that taxpayers’ money should only be used to support access to evidence based medicines.

“The option presented in the interim report to move non-evidence based complementary and alternative medicines to a separate area in a pharmacy simply isn’t enough to protect patients from being recommended unnecessary medicines.

“We would argue that supplements that are not supported by high-quality evidence should not be sold from the same location as evidence‑based, taxpayer-subsidised medicine,” he says.

“This would be consistent with the report’s option recommending that pharmacies should not sell homeopathy products, which we strongly support.”

If patients are required to go to two separate locations if they want to purchase both evidence-based and non-evidence-based medicines, they may gain a better understanding of the difference between the two types of products, the submission states.

“For example, in the Netherlands there is a distinction between pharmacies and chemists; with prescription medicines only available from a pharmacy and non-prescription medicines, complementary and alternative medicines and other retail goods available from a chemist.

“The retail-medicine link is not only confusing for patients– it causes an unnecessary conflict of interest for pharmacists.

“Pharmacists are required to balance both profit making in their retail environment and health priorities of the medical environment.”


‘Inappropriate’ diversification of services

The RACGP’s submission says that failure to support the dispensing role could have “adverse consequences” – such as pharmacists expanding their scope of practice.

“Failure to adequately support the dispensing role could have adverse consequences and may incentivise pharmacies to inappropriately diversify their services in order to sustain their viability,” the submission states.

“This is evident in the recent attempts by community pharmacies to widen the range of services they provide–offering core medical services such as health screening and the ordering and interpreting of tests.

“It is inappropriate for pharmacists to conduct these medical services.”

The submission refers to pharmacist vaccination as an “ad hoc” service which differs “significantly” from such a service provided by a GP, in which it states GPs “assess the patient’s overall health by taking a history and provide a range of preventive services”.

It says pharmacist services duplicate care, waste valuable health resources, create inefficiencies, fragment health records and risk patient safety.

The RACGP wants the Review Panel to consider moving Community Pharmacy Programs funding under the CPA to “better support the dispensing role of pharmacists” instead.

It says it also “strongly supports the views expressed in the Report that aspects of the pharmacy location rules are limiting competition and are unnecessary” and despite pharmacy having been given some certainty over these rules by the Health Minister, still wants to see changes reflected in the Review’s final recommendations.

The RACGP wants to see future CPA’s limited to dispensing arrangements only, and supports the option to have other stakeholders, including the RACGP, to comment on it.

The submission claims that GPs did not receive any cash back from the risk share solution after a shortfall in script volumes.

“For example, as a consequence of the annual community pharmacy and wholesaler reconciliation clause within the CPA, the 2017-18 Federal Budget showed $225 million would be provided to community pharmacies and pharmaceutical wholesalers as a result of a reduction in the volume of dispensed medications.

“Part of the reduction in the volume of dispensed prescriptions is likely due to changing prescribing practices by GPs–in spite of this, the general practice sector did not receive any portion of the resulting savings.”

These issues would be “partly mitigated” if other stakeholders had a say in the CPA, the RACGP says.

The RACGP also stated its support for another option not presented in the interim paper: its proposal that dispensing and other community pharmacy fees could be “cashed out” to support a general practice-based pharmacist.

This pharmacist would take responsibility for medication governance within general practices and be responsible for:

  • medication issues, including face-to-face patient education;
  • practice audits for quality medication management;
  • dispensing emergency medication; and
  • facilitating improved population medication management based on the electronic records of the general practice.

“This model would really benefit patients with chronic disease and limited mobility, people who arguably face the most complex health challenges,” says Dr Seidel.

“The model also provides an independent career prospect for community pharmacists, giving them greater opportunities to work as part of a collaborative primary healthcare team.”

Read the full submission here.

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  1. Andrew

    This is interesting

    >>>GPs already have the knowledge of medicines required to prescribe – minimal training would be required to support GPs to dispense.

    A Pharmacy degree ain’t minimal training and my experience is that most GPs have only a shallow understanding of medicines, as pharmacists do with medicine.

    Let’s give some GPs a trial of dispensing, put your money where your mouth is RACGP – I predict tears and cries of “we can’t afford to do this anymore!” within days. Not to mention the non-productive time wasted in the actual dispensing when they could be seeing and diagnosing more patients as is their specialty.

  2. Nicholas Logan

    I don’t get this bit ““We would argue that supplements that are not supported by high-quality evidence should not be sold from the same location as evidence‑based, taxpayer-subsidised medicine,” he says.” What tax payer funded medicine is in the vitamin section these days?? Or do they mean not from the same store?

    • Jarrod McMaugh

      G’Day Nick

      you’re right, few of the medicines in any herbal/vitamin section of a pharmacy have any funding from taxpayers.

      In fact, the only non-evidence based medicines that are tax-payer subsidised are those that have been prescribed during an MBS funded consultation, such as when a doctor uses medicines off-label, or when a GP prescribes (or recommends) these medications. This occurs from time to time with some GPs, and is even formalised within the RACGP as part of their standing committee on integrative medicine, wherein the prescribing of herbal products and bio-similar hormones is common.

      Unless of course patients are not bulk-billed or provided with an MBS-eligible consultation. I’m sure that the RACGP would encourage all of it’s members to privately bill any patient for all consultations in which a non-EBM medication or intervention is recommended.

      • Andrew

        I reckon this is a bit disingenuous, Jarrod.

        I’m yet to see an off-license prescription that doesn’t have some evidence along the “levels of evidence” continuum – even level 3 if we’re being generous. Can’t say the same about a lot of the CAMs – either the efficacy has not been adequately tested or it’s shown to be outright useless.

        We gotta practice according to the evidence, wherever it exists.

        • Jarrod McMaugh

          Fair point, but at what point do we set the threshold for “non EBM”

          Homeopathy – that’s easy.

          Evidence for a lot of CAM/Herbal stuff is questionable (especially when lumped as a whole). Some specific CAM modalities have evidence that’s pretty comprehensive.

          On the flip side, some schedule 4 medications have pretty poor evidence, or evidence that can’t be relied upon due to the manner in which not all data is published.

          For off-label use, sometimes it’s off-label because the evidence is more on the side of harm than it is for lack of effect (ie clonidine in kids), and other times it’s because a sponsor hasn’t applied for the indication.

          So let’s take an arbitraty point for “evidence” being something for which TGA has given an Aust-R number for specific indications.

          Based on this, we could say that there are things that are evidence-based, there are things that are non-EBM, and there are things for which evidence is pending/controversial/non-financially-viable

          It’s then a simple thing to say that the first category would be eligible for MBS funding for consultations in which these are prescribed/recommended. For those items that aren’t Aust-R (including for indications that aren’t approved), then the consultation shouldn’t be MBS funded.

          Any other process wouldn’t be appropriate under the arguments that the RACGP has made….. or at least they would be hypocritical.

          • Andrew

            Is the MBS relevant in this? The billing for the consultation doesn’t relate to a product eventually prescribed? Not sure where you’re going with that.

          • Jarrod McMaugh

            It is based on the argument that RACGP is making with regards to CAM being subsidised by taxpayers if it is sold in a pharmacy.

            If CAM is taxpayer subsidised by being sold (without direct subsidy) in pharmacy, then any recommendation a GP makes for non-EBM interventions is also taxpayer funded if the patient received a MBS benefit for that advice.

  3. fiquet

    RACGP 100% on the ball about CPAs and the industry. Would love to see their suggestions implemented for the benefit of pharmacists and patients.

  4. PharmOwner

    If the RACGP thinks it is within it’s rights to make suggestions about CPA’s and the role of pharmacists, then they must agree it’s ok for the Pharmacy Guild to negotiate with the government about the funding and role of general practitioners.

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