Pharmacist full scope an insult, says AMA

doctor makes "stop" gesture with hand - ama

The Australian Medical Association says pharmacist prescribing would be a ‘fundamental conflict of interest’

The AMA has published its response to the Board’s discussion paper Pharmacist Prescribing, which proposed that pharmacists could prescribe via autonomous prescribing; prescribing under supervision; and under a structured prescribing arrangement.

It says that independent prescribing of S4 and S8 medicines should only be practised by health practitioners whose core training “fully and comprehensively” achieves competencies set out in the NPS MedicineWise Prescribing Competencies Framework.

Pharmacist prescribing would be a “dramatic” change to pharmacy practice, says the AMA, adding that it is “very concerning” that the Board’s paper suggests that prescribing under supervision and under protocol was already within pharmacists’ scope of practice.

“To suggest prescribing of S4 and S8 medicines under supervision or under protocol is already within the scope of pharmacists’ practice is false and an insult to medical practitioners, and all non-medical health practitioners endorsed to prescribe who have undertaken additional, nationally consistent, accredited education, training and assessment, and met the further prescribing standards and competencies set by their Boards,” says the AMA.

The doctor group says it “cannot comprehend” why the Board is considering pursuing prescribing rights for pharmacists outside the Guidance for National Boards, a process it describes as “transparent, robust and nationally consistent”.

“If the Pharmacy Board supports its practitioners to pursue a jurisdiction-by-jurisdiction authority to prescribe it will lead to inconsistent and ad hoc practices and approaches to education and training, standards and prescribing practices, practitioner competence and continuing professional education requirements,” says the AMA in its submission to the Board’s consultation.

“At a minimum it creates confusion for health practitioners and patients moving interstate, as highlighted in the Board’s own discussion paper when referring to pharmacist prescribing in Canada.”

Pharmacists in various Canadian provinces and territories currently have differing prescribing rights.

“At worst, this poses a risk to patient safety,” says the AMA.

“From a workforce perspective, it will limit pharmacist mobility across jurisdictions and possibly within jurisdictions, and its impact on other registered health practitioners, for example, nurse practitioners and registered nurses endorsed to prescribe, cannot be adequately assessed and addressed.

“Jurisdictions and health practitioners working in silos is not an appropriate way to design the health care system to meet the future needs of the community.”

The AMA goes on to discuss its opposition to pharmacist vaccinations when these were introduced in Queensland in 2013-4, saying its concerns were around initial introduction in Queensland not being underpinned by a national approach to education, training, standards or guidelines.

“The Pharmacy Board will recall that the AMA wrote to it on 20 February 2014 about the lack of adequate and appropriate accredited training for pharmacists to prescribe and administer vaccines or deal with adverse events arising from vaccinations,” the AMA says.

“The Pharmacy Board itself stated in a 5 December 2013 communique that work on competencies and training was required before vaccination by a pharmacist should occur.

“And yet the Queensland government implemented pharmacist vaccinations without requiring that pharmacists prescribing and administering vaccinations had completed an accredited education and training program approved by the Board.

“Instead, the Pharmacy Board had to ‘play catch-up’, with appropriate accredited training only developed and implemented after several jurisdictions had already introduced pharmacist vaccinations.

“Does the Pharmacy Board really want to encourage a return to this kind of ‘model’ for prescribing S4 and S8 medicines?”

The AMA says it does not support independent or autonomous prescribing of S4 and S8 medicines by non-medical health practitioners, with the exception of dentists.

“The Pharmacy Board’s paper indicates that ‘access’ is the primary driver of need. The AMA considers that safe, high quality patient care depends on multidisciplinary teams of health practitioners, led by a medical practitioner, working together within their scopes of practice.

“It relies not only on ‘access’ but on a patient-centred ‘medical home’ which provides continuity, coordination, comprehensiveness and accountability. Fragmentation of care decreases the patient experience, increases risks and increases costs.

“Any ‘savings’ from fewer GP consultations would be short-term as savings would be undermined by a reduction in preventive health care and subsequent downstream costs resulting from later presentations of established illnesses.”

The AMA also says that there should be a “clear separation” between the prescribing and dispensing of medicines.

“If pharmacists can both prescribe and dispense it represents a fundamental conflict of interest as they derive a direct income from the sale of medicines.

“In addition, there is the opportunity and motivation within a retail pharmacy setting to ‘upsell’ additional products that may not be necessary for the patient.”

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  1. Andrew

    If prescribing is limited to pharmacists practicing independent of a retail pharmacy (as per the proposal) the conflict of interest issue doesn’t exist.

  2. luis trapaga

    “Safe, high quality patient care….lead by a medical practitioner” resulted in the opiode crisis. Every death from a prescribed opiode came with a script signed by a doctor. Before the medical profession criticize any other practitioner or profession, it needs to understand how far it has strayed from the fundamental principal of therapy, “above all, do no harm”.

  3. Michael Ortiz

    Evolution not Revolution!!!

    It should be noted that both the RACGP and the AMA are strongly opposed to community pharmacy professional services. Dr Kidd of the AMA recently wrote “…best practice care starts with the right assessment and diagnosis by a medical practitioner and, in the case of general practice, a longitudinal relationship with the patient. Despite this, we see ceaseless ambition of some pharmacist groups for prescribing rights and a greater role in the provision of health services, such as preventative health, disease screening, detection and chronic disease management.”

    As seen above, pharmacists find themselves involved in an acrimonious turf war with medical practitioner professional organisations, over the evolution of their professional services when this brings them into competition with current medical practice.

    In Australia, as well as in other countries, there are now a number of health professionals who can prescribe medicines within their scope of practice. An advisory group to the National Prescribing Service (NPS) developed a list of key prescribing competencies in the context of the risk potential risks of adverse events due to polypharmacy for people who have multiple prescribers. The NPS prescribing competency framework describes the knowledge, skills, and behaviours of practitioners. As such, this framework describes the key competencies essential for autonomous prescribing:
    1. Understands the person and their clinical needs
    2. Understands the treatment options and how they support the person’s clinical needs
    3. Works in partnership with the person to develop and implement a treatment plan
    4. Communicates the treatment plan clearly to other health professionals
    5. Monitors and reviews the person’s response to treatment
    6. Practices professionally
    7. Communicates and collaborates effectively with the person and other health professionals

    Australian trails the UK, NZ and Canada in allowing pharmacists to prescribe to patients. Pharmacists have been prescribing in the UK since 2003. New Zealand allows prescribing by other health professionals. A small number of experienced clinical pharmacists are allowed to prescribe in NZ.

    Pharmacist prescribing differs among Canadian provinces, with most provinces allowing emergency prescribing and renewal or adaptation of prescriptions by pharmacists, while only 4 provinces allow prescription initiation. Pharmacist prescribing in Canada includes the following five components:

    a. Emergency Prescribing and Renewing a Prescription
    The majority of provinces had similar definitions for emergency prescribing and renewing a prescription and enabled pharmacists to perform these functions.. Pharmacists can renew a prescription for up to 90–100 days or no longer than what was previously prescribed;

    b. Adapting Prescriptions
    All provinces had regulations in place allowing pharmacists to adapt prescriptions, yet adapting a prescription was found to be the most heterogeneous area of prescribing, with differing provincial definitions.

    c. Initiating a Prescription for a Chronic Disease
    In some provinces pharmacists were able to initiate prescriptions if they worked in a specific practice area and had a collaborative practice agreement (CPA) in place with the physician(s) or institution.

    d. Ordering Laboratory Tests and Accessing Results
    Legislation in the majority of provinces allows access to laboratory test results

    e. Administering Injections: Vaccinations and Drugs
    All provinces that enabled pharmacists to administer injections required the pharmacists to take a locally approved injection-training course before receiving certification.

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