Don’t fear pharmacist prescribing, says health economist

One expert has taken aim at comments from the latest high-profile doctor to attack the concept of pharmacist prescribing, Kerryn Phelps

Greg Merlo, a Postdoctoral Research Fellow at the University of Queensland’s Primary Care Clinical Unit,  is researching the intersection of health economics and implementation science.

He writes in The Conversation that pharmacist prescribing is “nothing to fear”.

He cites an August 2019 tweet by Dr Phelps, a former AMA president, in which she said that “If pharmacists think they should diagnose without medical training, maybe doctors should start dispensing to save patients the time and inconvenience of going to the pharmacist for common medications such as antibiotics?”

This was in response to an AMA Media tweet which claimed that “It would be irresponsible and dangerous to have pharmacists move way beyond their scope of practice to perform specialised roles currently undertaken by GPs”.

“Phelps has a point,” writes Dr Merlo. “Studies in countries where doctors have dispensing roles have found evidence of financial profits influencing prescribing behaviour.”

Dr Phelps has since remained critical of the concept of pharmacist prescribing, telling The Australian this month that, ““Pharmacies are not set up with appropriate privacy for consultations; there is also a perverse incentive for pharmacists to diagnose and prescribe because they will benefit from it”.

“GPs might make it look easy, but it’s not,” she said.

In opposition to Dr Phelps’ Twitter comments, Dr Merlo cited a Swiss study that “found physician dispensing leads to a 34% increase in drug costs per patient, as doctors overprescribe and prescribe more expensive medications”.

Meanwhile a study of pharmacist prescribing in the UK was found to be generally “safe, clinically appropriate, and was generally viewed positively by patients,” while Canadian data on pharmacist prescribing showed it led to better outcomes in UTIs and heart condition risk.

“Extending the scope of practice for pharmacists has the potential to lower costs to the health system because of fewer GP visits, be more convenient for consumers, and free up busy general practitioners to spend time on high-value care,” Dr Merlo writes.

He lists three economic concepts which he said give a risk-benefit profile of pharmacist prescribing.

The first is supplier-induced demand, which “occurs when a health professional shifts the demand that a consumer has for a drug or medical service beyond what they would demand if the consumer had perfect information”.

“What Phelps is suggesting is that a pharmacist may manipulate a consumer into purchasing an unnecessary drug.

“When there is no information asymmetry, supplier-induced demand disappears. Paracetamol, for instance, is unlikely to be subject to supplier-induced demand despite direct sale from pharmacists because consumers have experience of using the product regularly and understand its effects.

“There is no reported evidence of inappropriate prescribing by pharmacists in any countries that have introduced regulated, controlled models of pharmacist prescribing.”

The second economic concept is product bundling, reflected in claims by the RACGP that if pharmacists are able to prescribe items such as the oral contraceptive pill, patients would not be given the opportunity to access other GP interventions when accessing it.

But pharmacist prescribing could result in debundling, he argues.

“In this scenario, the pharmacist’s expanded role may result in prescribing being decoupled from the product bundle that is a GP consultation. Healthy women may not see the value of a GP consultation if they can obtain a prescription for oral contraceptives from their pharmacist with no consultation fee.”

The third concept is externality: a wider implication of a particular structure.

“Any increase in pharmacists’ scope of practice needs to be introduced with caution, with clear protocols and limited prescribing rights,” Dr Merlo argues.

“It also requires consideration of potential problems arising from increased availability, and robust monitoring and evaluation of the appropriateness and volume of prescriptions.

“Neither side of the doctor-pharmacist turf war is showing signs of giving up. Rather than sweeping statements about conflicts of interest, we need an evidence-based framework to determine where it’s appropriate to extend pharmacists’ scope of practice.”

Conversely in the UK, independent pharmacist prescribers in general practices have been linked to several serious incidents and cases where patient deaths have been reported.

Read the full piece on The Conversation here.

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