Pharmacist prescribing: what the stakeholders said


The Pharmacy Board has now published the individual submissions it received on pharmacist prescribing… revealing doctor and specialist opposition

In its latest communique, the Board says that it encourages all interested pharmacists, stakeholders and members of the public to review the submissions, here. Any further comments can be provided by email to PharmBAfeedback@ahpra.gov.au.

The Royal Australian and New Zealand College of Ophthalmologists submitted that “in many cases pharmacists do not have the equipment or skill to be able to determine the appropriateness of prescription medications used in ophthalmology”.

“The Pharmacy Board of Australia’s discussion paper refers to education and training considerations however, RANZCO does not support pharmacist prescribing for ophthalmic medications as medical training cannot be condensed into a pharmacy education program or scheduled endorsement,” wrote CEO David Andrews.

As previously reported in AJP, the Royal Australian College of General Practitioners wrote that it strongly opposes all three models of pharmacist prescribing proposed by the Pharmacy Board.

“The RACGP does not support the expansion of pharmacists’ scope of practice beyond their core function of medicine advice and dispensing, into prescribing,” it said.

“The provision of medical services by health professionals lacking the necessary medical training or registration is an inappropriate and unsustainable solution to address the health needs of Australians.”

It said there was a risk that the business needs of a pharmacy could be prioritised over patients’ needs.

Meanwhile the Australian Medical Association said the Pharmacy Board had made “gravely worrying” assumptions, including “the proposal to bypass the nationally agreed process for applications to prescribe; the denial that the proposals represent a significant expansion of pharmacists’ scope of practice; and a lack of acknowledgement that its proposals will impact on the broader health workforce”.

But there was also significant support for the Board’s proposals.

Alfred Health submitted that “there is evidence internationally and locally which indicate that prescribing models for pharmacists must be adopted in Australia to ensure that prescribing is safe, patient-centered, timely, effective, efficient and equitable”.

“We have shown [with evidence included in the submission] that patient care can be improved by having pharmacists, working within the healthcare team, and alongside doctors, taking responsibility for prescribing within their scope of practice.

“These models, implemented and evaluated within Victoria (described as partnered charting) provide the evidence required to support prescribing by pharmacists.”

The Centre for Medicine Use and Safety, Monash University said it preferred the collaborative prescribing model.

“Pharmacists should be allowed to prescribe within their scope of practice to increase patient choice, improve access to medicines, improve continuity of care, and assist in addressing issues confronting the health-care system.

“However, clear governance arrangements are needed covering roles and responsibilities to avoid fragmentation of care.

“A Cochrane systematic review of Australian and international literature suggests pharmacists prescribe as safely and effectively as medical prescribers in both primary and secondary care settings.

“No published evidence suggests that pharmacists as ‘non-medical’ prescribers are not safe.

“Pharmacists should meet the competencies designated for all prescribers. The level of training required for pharmacist prescribers will likely depend upon the scope of practice, the degree of specialisation and consultation skills required and the autonomy in decision making.

“It is likely that a basic level of prescribing training is required even for a limited level of pharmacist protocol prescribing with training broadening out to a post graduate certificate for collaborative and autonomous prescribing that incorporates a period of supervised practice.”

And the Grattan Institute recommended a mixed model.

Pharmacists are “key members of the health teams in hospitals. Improving the ability of the sector to deliver efficient, high-quality care to all is crucial to making Australia’s health system more sustainable,” it submitted.

“Using pharmacists’ skills better – by allowing suitably prepared pharmacists to prescribe – will improve people’s access to health care, facilitate better medication management, reduce costs, and ease the burden on general practice.

“We recommend that pharmacists be allowed to prescribe under all three models proposed in the Pharmacy Board discussion paper: autonomous prescribing, prescribing under supervision, and prescribing under a structured prescribing arrangement.

“Autonomous prescribing should be restricted to pharmacists employed in large hospitals, and prescribing under supervision should be restricted to hospitals and selected larger practices.”

The Board published its discussion paper on pharmacist prescribing, which posed several questions about this potential role, in March 2019.

“The discussion paper was intended to facilitate the profession, stakeholders and the public to explore opportunities for pharmacist prescribing, through one or more of the models of non-medical prescribing outlined in the Health Professionals Prescribing Pathway 2013,” it says.

“The Board is currently reviewing the feedback and will publish a report to inform all interested parties about the views articulated in the broad range of submissions. A publication date for the report has not yet been set and further updates will be provided by the Board in due course.”

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14 Comments

  1. Kevin Hayward
    29/06/2019

    I have found that a collaborative approach obviates the need for me to wield the prescribers pen. I now have proposed new GP consults set up for me to see patients in surgery, nothing unusual here, but in these clinics the GP will join me at the end of the consult, to discuss with the patient, share information, validate and reinforce any proposed actions, including any prescribing issues. Similarly if I see a patient in their home or facility, I will regularly meet with the GP and other primary care team members, and address issues such as prescribing needs.
    I am certain that, given the opportunity and incentive other primary care Pharmacists in different roles could come up with equally suitable solutions.

    • Jarrod McMaugh
      29/06/2019

      It’s great that you have such an arrangement that puts you in a position of making recommendations to another health professional, rather than taking responsibility for those decisions yourself.

      Out of interest, should other pharmacists not have access to an accredited pathway to prescribing?

      • Kevin Hayward
        29/06/2019

        1. “Responsibility” therapeutic decisions are documented in progress notes, as with HMR/RMMR, I understood that the premise of joint culpability prevailed in the event of misadventure, as reflected in our indemnity.
        2.”Other Pharmacists” I would not be so presumptuous to comment on the needs of my professional colleagues, probably best to ask them what is best for their patients and their working environment.

        • Jarrod McMaugh
          29/06/2019

          I ask about the second point because you’re comments on this topic across various articles seems to imply that your position on pharmacist prescribing is that you feel it isn’t necessary.

          So my question remains – should other pharmacists not have an accredited pathway to prescribing?

          • Kevin Hayward
            29/06/2019

            Over many years, working as a pharmacy owner, prison service manager, practice support pharmacist, and latterly I have always managed to find a resolution to the issue in hand, which did not need me to prescribe, usually through a proactive approach to collaborative practice.
            I have worked in an organisation where dependent and independent prescribers have successfully fulfilled professional roles which needed the authority and competencies to prescribe, but I am not in a position to comment on how successfully this would translate to Australian primary care generally.

          • Kevin Hayward
            30/06/2019

            Prior to Pharmacists prescribing in the UK, a method of addressing medication supply issues was developed in the form of the patient group directive, https://www.sps.nhs.uk/articles/what-is-a-patient-group-direction-pgd/ maybe this would provide an alternative , less contentious approach, which may help address some of the concerns raised in Australia.

          • Jarrod McMaugh
            01/07/2019

            I don’t disagree that this would be a useful model. I have been involved in a pilot of this concept in Victoria. The concept was initially supported by stakeholders, but due to political pressures, it collapsed, and the victorian DHHS has been very quiet about the outcomes since.

            I believe this demonstrates that collaborative care models are not less contentious (perhaps relatively speaking, but certainly non “without contention”).

            Besides this, I don’t see why pharmacists should NOT discuss their scope of practice just because other stakeholders are threatened by this. There is international evidence that pharmacists are capable prescribers (some work suggests superior, but I find the study sizes a bit modest for making such claims). If the evidence suggests that prescribing is withing the scope of practice of pharmacists, and that accreditation pathways are developed, then opposition to this from other stakeholders (ie contention) would seem to be driven by irrelevant considerations (ie financial, pride, etc).

            If the evidence showed that pharmacists were incompetent prescribers that caused harm or waste, then I would support those stakeholders who oppose pharmacist prescribing. But evidence is evidence. It’s clear that harms and waste are not the result of pharmacists prescribing.

          • 01/07/2019

            There already is an accredited pathway to prescribing. It’s called a MBBS.

            Should other pharmacists not have an accredited pathway to fly a plane?

            Should other pharmacists not have an accredited pathway to build a dispensing robot?

            If you want to argue that our profession is on par with competence for diagnosis and prescribing then you are fighting a losing battle. We are experts in our own field which has yet to be fully utilised and recognised in our health care system.

          • Jarrod McMaugh
            01/07/2019

            When the pharmacy board is seeking consultations on flying and robotics being withing the scope of practice of a pharmacist, then I am sure to provide a submission on those points.

            With regards to MBBS, I take it that you don’t see any other prescribers as being adequately qualified – ie dentists, nurse practitioners, podiatrists, optometrists, midwives, (or even Vets)?

            or that the role that pharmacists undertake now in making a clinical decision to provide schedule 2 and 3 medicines is prescribing?

            It should be noted that the pharmacy board is seeking consultative feedback from stakeholders on the pathways that would be appropriate to implement for pharmacists to prescribe, and the qualifications needed to undertake this.

            It is NOT seeking to implement changes that would require all pharmacists to prescribe. This isn’t the outcome in any jurisdiction that has recognised that prescribing is within the scope of practice of pharmacists.

            The outcomes – if implemented – would involve the development of a prescribing framework, competencies, accreditation pathways, residencies, supervision requirements, collaborative models, and CPD standards.

            This isn’t about flicking a switch that results in 30 thousand new prescribers overnight.

          • 01/07/2019

            With regards to MBBS, I take it that you don’t see any other prescribers as being adequately qualified – ie dentists, nurse practitioners, podiatrists, optometrists, midwives, (or even Vets)?

            How did you arrive at this conclusion?

            The role that pharmacists undertake now in making a clinical decision to provide schedule 2 and 3 medicines is prescribing?

            You are right. This is prescribing. But not all diagnoses and the risks involved are equal. This is the precise reason as to why they are S2 and S3.

            Appendix M and down-scheduling will broaden the scope of “prescribing”.

            The outcomes – if implemented – would involve the development of a prescribing framework, competencies, accreditation pathways, residencies, supervision requirements, collaborative models, and CPD standards.

            This is definitely what is needed. But to what extent? An investment to go through an entire training framework. If by the end of it, we are not as skilled as a medical intern, then this will be entirely unnecessary.

            There are a lack of GP’s in our healthcare system. It may be more efficient to just retrain or offer a pathway for pharmacists to re-train.

          • Kevin Hayward
            01/07/2019

            Often overlooked is the fact that since the days of Physicians and apothecaries, the chemist or druggist, now known as the Pharmacist has been prescribing, and continues to do so. In my early career it was known as counter prescribing. A client visited the Pharmacist and asked to be supplied with a homely remedy, which was chosen appropriately for them, usually from a schedule of medicine not available generally. The choice of medicine available has long since expanded beyond homely remedies, with many more potent and efficacious products the Pharmacist is prescribing over a much broader therapeutic area. So the question is not should Pharmacists prescribe, but WHAT should Pharmacists be able to prescribe and HOW? It is pointless being a Luddite, the inevitability of change cannot be avoided, we must instead, manage the change appropriately.

          • 01/07/2019

            I should clarify. I’m not against pharmacist prescribing. Out of the 3 models proposed, I am all for collaborative prescribing. I have been involved with a model of collaborative prescribing throughout my clinical career.

            I do have an issue with the push from certain groups of the profession that support the independent prescribing route eg. Antibiotics for UTI. I understand that it provides choice for the patient, but I would argue that it does not provide the best outcome. If the plan is to regulate the provision of antibiotics for UTI to a very small subset of patients, then down-scheduling to S3 achieves exactly the same result. (Similar to Famvir)

            In terms of prescribing independently in general, we are absolutely not ready. I have close working relationships with medicos from interns to consultants and I respect their skill set and they respect mine.

          • Jarrod McMaugh
            01/07/2019

            Alexander – I’m not sure if my responses come across as confrontational, but they aren’t intended to…

            I too have respect for the skill sets of other health professionals.

            I also have respect for the skill sets of our own profession, and I strongly support this being recognised in our scope of practice.

            One thing I would point out, is that no one is (seriously) suggesting that pharmacist prescribing is something that would turn on overnight (ie the “flicking a switch” analogy I used above)

            The first step is determining that it is within scope. The next step (just like HMR and vaccination) is to develop the correct mechanisms to introduce it in to practice.

            At this point in time, very few pharmacists in Australia are in a position to step in to prescribing, since the necessary frameworks aren’t in place… but there are quite a few who would rapidly move through those frameworks and be in the first cohort of pharmacist prescribers.

            If at any time my commentary has implied that all we need is regulatory barriers to be removed, let me state clearly that this isn’t the case.

          • 01/07/2019

            Jarrod not at all, I thoroughly enjoy discussions, the only issue being it consumes my time to get back a response. After all, a collection of views provides the best result.

            My qualm with independent prescribing is that, for a fact, medicos and pharmacists just have a different education framework. While we focus on chemistry and therapeutics, the medicos focus on anatomy and diagnosis. This is for their whole MBBS full-time equivalent study.

            So you are right, if we can provide a framework that can provide for an equivalent amount of study and knowledge. We can definitely independently prescribe (and focus a significant amount of resources to make this happen).

            Otherwise, it is purely a shortcut that jeopardises both the health of the patient and the relationship with our medicos.

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