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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15 Comments

  1. John Wilks
    27/11/2019

    Setting aside the evident commercial conflicts of retail pharmacists prescribing, I would be keen to hear the views of Drs apropos of experienced hospital pharmacists or accredited HMR/RMMR prescribing under protocols or guidance (be it via progress notes, sms, omitted writing of discharge scripts).

    • Jarrod McMaugh
      27/11/2019

      conflict of interest in the community pharmacy setting is no different from any other professional working in any other setting, other than the fact that their income is generated from a physical product rather than an intangible product.

      Any professional who thinks they operate without risk of CoI is at significant risk of capitulating to it.

      • John Wilks
        27/11/2019

        There is no commercial conflict of interest for a pharmacist working in a hospital. We make no money from the medications we (could) prescribe. A few recent examples from this week.
        1. Dr charts Coloxyl with Senna – 2 bd. Should be 4 bd. I have to call the CMO to correct.
        2. Dr forgets to write a discharge script for Endone, but it is in the patient notes and the Drs d/c letter. I also have a confirming SMS for specialist for Endone. Now I have to call the CMO to write the Rx. CMO is very busy with a canulation for Remicade. Pt has to wait 35 minutes. Bed block occurs from the surgical ward transfer as a result. If I could write the script …
        3. Dr charts Clexane 40mg for a 125 kg patient with a BMI of 41. Dose should be weight based for BMI > 40, at 0.5mg/kg/day i.e 60mg Clexane. I contact CMO who everntually contacts surgeon to change dose. Much time wasted.
        4. Pt has had a bilateral TKR. Anaethetist charted aspirin 150mg. Not appropriate due to pt age, weight and bilateral TKR. I have previously confitrmed with surgeon that bilaterals have Xarelto 10mg but CMO has to call surgeon. Everyones time is wasted.
        5. Pt has a vitamin D= 30 (>50). CMO has to be called to chart Ostevit 7000iu 3/week. More time wasted.
        6. Dr charts verapamil SR 120mg daily. Pt’s med list from GP says 120mg BD. CMO has to be called. Very busy. Chart correction takes some hours to amend.
        And on and on I (and hundreds of other hospital pharmacists) could go.
        In short, for hospital pharmacists (and accredited pharmacists who have no fiscal link with a pharmacy) there is zero potential for a commercial COI.
        The only consequences of hospital pharmacists prescribing is a smoother discharge, less frivalous work for the CMO, and less interruptions for the specialists.
        For accredited pharmacists, a pts life is made easier if they don’t need to visit the GP for a lost statin script, or a script can be provided via a phone call with the GP.
        The benefits of pharmacist precribing in the hospital, HMR and RMMR milleau are extensive. So let get this done please.
        Cheers.

        • Jarrod McMaugh
          27/11/2019

          I have no doubt about your examples being valid. I have no issue with the fact that a pharmacist in hospital (or any other setting) would have efficiency gains from being able to use prescribing as a tool in their work.

          This doesn’t change the fact that all professionals – in all settings – are subject to a conflict of interest in the decisions they make. This is unavoidable.

          Capitulation to those Conflicts is what people need to be cautious of; assuming that a pharmacist working in a community setting is somehow more likely to capitulate to a conflict of interest just because they recommend a physical product is illogical.

          • John Wilks
            27/11/2019

            I disagree. What conflicts of interest does a prescribing hospital pharmacist have to traverse? I don’t gain financially, so money doesn’t influence my decision. I would be (de)prescribing on the clinical metits of a case before me. Is this drug indicated? Is there a prior ADR to it? Is dosing appropriate for renal and hepatic function? Are there any relevant drug interactions? Does the patient understand why a drug is (de)prescribed by me?

            Where is the conflict of interest in this process?

          • Paul Sapardanis
            27/11/2019

            True John but in my experience hospital pharmacists lack the motivation to do anything above what is deemed to be an absolute minimum. This is not the fault of the individual pharmacist but in which they are paid. I apologise as I know this a generalization but if it were not true the Soviet Union would still exist.

          • John Wilks
            27/11/2019

            Hi Paul. It is sad that this is your experience with hospital pharmacists. It certainly is not my modus operandi, nor I can confidently state, that of others with whom I work across two Sydney hospitals. One is a small 93 bed, the other is 450 beds.

            I am daily in contact with VMOs directly as we do ward rounds or at the weekly case conferences, via SMS and often after hours, and I am not alone in these practices. Perhaps I am just very fortunate to have a management that allows me to work in a manner that best assists the patients. There are no KPIs etc. If an interview and attendant problem solving takes 1.5 hours, I incur no criticism. But from what your are intimating I should be even more grateful than I already am. Cheers and best wishes for a restful and peaceful Christmas,

          • Paul Sapardanis
            27/11/2019

            True John you are fortunate . But the debate here is that a hospital pharmacist has a CoI. What I am trying to say is that by paying a pharmacist an hourly rate can lead to a pharmacist taking more time than needed. You write that if an interview and problem solving takes 1.5 hours then so be it. What I am saying is that there is an incentive to take longer than needs be. I am not saying that you or the majority of pharmacists do this but it is a possibility

          • John Wilks
            27/11/2019

            Hi again Paul. Might I ask for further expansion from you as I do not understand how a CoI arises? I am not paid by the number of patients seen, but rather, by the hour of work done. Is it different for other hospital pharmacists? I simply don’t know.

            As for accredited pharmacists who work independently of a pharmacy – that is, they are not employed within the community pharmacy – again there is no CoI.

            I recommend to the GP to increase/decrease/cease/change medications and OTC products. Whether the GP accepts my recommendations has zero fiscal impact on me. I receive no recompense from the CP. I am only paid by Medicare. So again, how can a CoI arise? I have no ‘interest’ – fiscal or otherwise – in the CP, nor in the GP. There is no fiscal nexus between me, the CP and the GP. My deliberations are only made in the best interests of the patient. My only interest is the patient. None other exists.

            Kind regards.
            John

          • Paul Sapardanis
            27/11/2019

            Sure John happy to explain. As you have clearly stated you have NO financial advantage in over servicing BUT the way you are paid ( no fault of your own ) may create a situation where you work well within yourself. I mean no offense yet you believe that prescribing by community pharmacists will be solely for financial purposes without the wellbeing of the patient coming into any consideration.

          • John Wilks
            28/11/2019

            “you believe that prescribing by community pharmacists will be solely for financial purposes without the wellbeing of the patient coming into any consideration.”

            Hi Paul, I didn’t say the above.

            My two questions remain unanswered and perhaps others might contribute.
            Q1. Precisely how does a COI occur for a hospital pharmacist and what are the examples.
            Q2. Ditto for a HMR/RMMR pharmacist operating independently.

            Cheers
            John

          • Dr E Ackermann
            29/11/2019

            1. There is no financial COI for a hospital pharmacist in the examples you provide.
            1.a There is a misalignment of clinical responsibilities. The consultant or acting physician in the hospital is ultimately responsible for medical care – they can delegate prescription authorities/responsibilities to medical staff – but they have no oversight/delegation to pharmacists.Hence you can only advise. I think by law only medical staff can prescribe on the medication sheet (with exception of nurse initiated tabs)

            Hospital pharmacists generally like to ensure continuation of community medicines into inpatient care (same on DC) – medical staff are focused on what is essential.I have seen very good pharmacists evaluation of med charts, but some shockers too – mainly because they did not understand the nuances of the admission.
            In the end it is valuable to maintain the separation.

            2. I do not see a financial COI in and “independent HMR/RMMR. There is more than 20yrs of research to show they have no or limited value. Time to move on.

          • Janis Williams
            08/01/2020

            There are also medications that are “pharmacist prescription” available. Why should hospital pharmacists not prescribe these in the same way as nurses “initiate” medications? eg Salbutamol inhalers

          • Jarrod McMaugh
            27/11/2019

            John I believe you are missing the intentional generalisation Paul is making of hospital pharmacists… which is a reflection of your generalisation that all community pharmacists capitulate to a conflict of interest since they sell a product….

            Do you see the comparison?

            Of note, the majority of community pharmacists also have no fiscal benefit in the sake of a product. Only a small percentage of pharmacists workingnin community own their own pharmacy, and KPIs are not as common as you might think.

            Despite this, both community pharmacists must balance the remaining conflicts of interests the encounter every day.

            The difference, it seems, is that community pharmacists are acutely aware of their conflicts of interest, because every person seems to want to highlight how special community pharmacists are for having a conflict of interest compared to any other health professional.

            Btw that last part is ironic – every health professional encounters CoI, including hospital pharmacists…. including yourself.

  2. Greg Kyle
    27/11/2019

    I get so depressed when I continually see members of the profession selling themselves so short. Why do we kowtow? We (pharmacists) call ourselves “the medication experts”. If we really believe this to be true, why are we continually running ourselves down and (currently) saying from the “peak professional body” down that we should only prescribe “under supervision”???? Even the Board has taken the ‘path of least resistance’ and put autonomous prescribing in the ‘too hard’ basket. It seems no-one is really interested in taking the profession forward. The guild want autonomous prescribing, but are pushing it only in a retail pharmacy (read member) environment.

    Another worrying thing in this article is the quote “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.” I would certainly hope that no pharmacist would give away such consultation services free, but then again, pharmacists in retail land are in a race to the bottom to see who can give await the most of a pharmacist’s skill free…

    Time to break out (or up the dose of) the antidepressants…

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