Pharmacist prescribing will enable ‘super bugs,’ say docs


angry woman

Doctor groups have responded with outrage to the announcement that Queensland will trial limited pharmacist prescribing

Following the recent inquiry into the pharmacy sector in Queensland, the state government has announced a trial allowing pharmacists to prescribe repeats of the oral contraceptive pill, and antibiotics for urinary tract infections.

The RACGP and the AMA have both condemned the plan.

RACGP president Dr Harry Nespolon said that the move was a “misguided solution to a problem that doesn’t exist” and that it fails to acknowledge the health care needs of patients.

Patients may have other health issues which impact on the type and dose of antibiotics used to treat a UTI. Dr Nespolon said that pharmacists do not have the medical training required to safely deliver these health care services.

He said that prescribing contraceptives is an “invaluable” opportunity to assess a patient’s overall and sexual health, a service only GPs can provide.

“While it may sound like a straightforward matter to prescribe medications for contraception and urinary tract infections, the Queensland Government clearly has not taken into account the complexities that can be involved in a patient visiting their GP for a script for antibiotics or the pill,” Dr Nespolon said.

“General practice is so effective in Australia because GPs treat the whole patient, not just a symptom.

“When a woman comes in for a repeat prescription of a pill, I make sure to check her blood pressure and look into any possible any side effects. I provide advice on if a longer term contraceptive may be best, check if she is due for a cervical screening and discuss her long-term fertility plans.

“These are conversations that will simply not happen in a pharmacy.”

Dr Nespolon said allowing pharmacists to prescribe antibiotics for UTIs also drastically increases the risks of community resistance of antibiotics and the creation of ‘super bugs’.

“Antimicrobial resistance is a real community risk, which has seen GPs become the stewards of antibiotic prescribing. Increasing the amount of professionals able to prescribe antibiotics will do nothing but exacerbate this issue,” Dr Nespolon said.

“The Queensland Government is thumbing its nose at antibiotic stewardship.  Even the World Health Organisation sees this as a major health problem. Governments should be trying to decrease the number of prescribers of antibiotics not flippantly increase them.

“When you have a pharmacist dispensing and prescribing rights you remove all of the needed checks and balances on medications, leaving the system open for increased human error or worse, risk of manipulation for business purposes. Ultimately, it is the patient who suffers.

“I call on the Queensland Government to reconsider their decision, before any patient suffers the potential negative effects of this decision.”

The Australian Medical Association’s Queensland branch also weighed in, with state president Dr Dilip Dhupelia calling the decision “irresponsible and reckless”.

“Pharmacists do not have the medical training required to determine the various factors involved in ensuring patient safety when it comes to medication,” he said.

“This is a blatant push by the pharmacy sector and the State Government has condoned the move. Patients are set to be the biggest losers in this transaction.”

Dr Dhupelia said that the reason doctors require a consultation for repeat scripts is “because they are qualified to ask the relevant questions and take account of what things may have changed since the medication was first prescribed”.

“How will a pharmacist determine that the oral contraceptive pill continues to be the most appropriate contraceptive for a specific woman?

“Will a patient’s usual GP even be informed that medication has been dispensed to them without their doctor’s input?”

He called the establishment of a committee to evaluate the trial a “waste of more health dollars”.

“I don’t understand why the State Government is wasting money on such bureaucratic processes, when we already have highly skilled GPs who can do this work.”

He also said that the recommendation that pharmacists rely on the Government’s 13 HEALTH hotline and the My Health Record database for medical advice when unsure about dispensing medications that normally require a doctor’s prescription was “reckless and dangerous”.

“The Government’s 13 HEALTH phone service is a nurse-led hotline with one GP assigned for all of Queensland,” he said. “The Queensland Government’s own website concedes that 13 HEALTH ‘is not a diagnostic service and should not replace medical consultation’.

“And when it comes to relying on patient’s information from My Health Record, that fact that nearly one million Australians have opted out of this database makes it a highly unreliable source of information.”

Dr Dhupelia said the Queensland Government’s move to roll out the trial would require legislative changes and placed the state at odds with the rest of the country that abided by a national governance framework for prescribing standards and training.

He said Queensland doctors had called for a new system where pharmacists worked collaboratively with GPs within GP practices.

“The public health system would save $545 million over four years by having pharmacists working within GP practices but that saving has been ignored,” he said.

“The Health Minister is duty bound to protect patients, not bow to the pharmacy lobby’s greed and make it easier for people to buy drugs without a prescription or seeing a doctor.”

The comments also follow the release of submissions by the AMA and RACGP to the Pharmacy Board’s consultation on pharmacist prescribing, in which both groups slammed the concept.

In this week’s edition of Guild newsletter Forefront, national executive director Pam Price foreshadowed the doctor groups’ reaction to the Queensland trial.

“More in sorrow than in anger, we expect the usual predictable naysaying from certain doctor groups, whose knee-jerk concern for their business model masquerades as concern for patient safety,” Ms Price wrote.

“What we say to them is: recognise the potential patient benefit and convenience this represents within a safe framework, and work with pharmacists to ensure it is implemented in a collaborative and expeditious way. Put patients first, and give patients more control of their own health.

“We are sure most GPs will adopt this positive approach, regardless of what their peak body may say.”

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44 Comments

  1. I’m going to have an unpopular opinion here but as a profession why do we even want to go down this “pretend to be doctor” route.

    Let’s not kid ourselves, we cannot properly diagnose. Does anybody know how to conduct a physical exam? If I wanted to diagnose, I would’ve gotten a MBBS.

    What we can do, is theoretically prescribe and advise on treatment on par or better than some of the best specialists in the country. I would be more inclined with a collaborative model with the GP where after diagnosis, the GP can let the pharmacist prescribe OR the pharmacist clinically checks every script that comes out of the clinic and has the authority to change the agent if agreed/understood by the doctor beforehand (and have them notified).

    The Medication Management specialist is what we should be pushing. Think of it as another medical specialty. “I’ll send you to the medication use specialist.” Doctor’s do not assess medication use the same way that pharmacists do. Our knowledge on most up to date treatment evidence, products, PBS, supply issues, formulations, strengths, aids in compliance, interactions etc. etc. are arguably second to none.

    • Gavin Mingay
      19/04/2019

      Your opinion might be suitable for big city situations, but what about the poor people in the bush?? I know us bushies don’t usually matter – especially to legislators, but pharmacist prescribing for urgent medical issues is pretty important for us.

      It can take days to be able to see a GP out here. And if you are lucky enough to be able to find a house-call type Doctor, they generally spend less than five minutes with the patients and have no access to any history or other details. So late night pharmacies would be perfect for pharmacist prescribing in emergency situations. Urinary tract infections, infected wounds, shingles are all situations where the pharmacist could give a suitable medication, and have the patient follow up with a GP at the earliest possible appointment. The Easter long weekend is a perfect example, with many places not open for four days, so the wait at the hospital and any surgery which does open will be many hours.

      I don’t want to be able to start a patient on chemotherapy, or blood pressure medication, epileptic medication, but I do want to be able to help my patients when in need in an emergency situation. I don’t want to open up a pharmacist prescribing clinic, which I am sure certain pharmacy groups would look to twist to their own benefit, but patients’ health, especially after-hours should be a priority, rather than all this “they are stepping on our toes” mentality…

      • Hi Gavin, thanks for providing perspective. I travel to regional towns often and am told frequently about the issues of healthcare serviceability.

        If it’s to address this issue of ease of accessibility, then shouldn’t down scheduling certain meds to S3 with smaller quantities (similar to famvir) be sufficient for this cause? This also fulfils your intention of covering them empirically for suspected UTI until they can be formally diagnosed by the GP. This also ensures that all cases will be followed up by the GP.

        It’s a fact that Australian pharmacists are just not trained to diagnose. I have taught third year medical students about pharmacology and they know a lot more about diagnosis and differential diagnosis then us. For example, the initial assessment for a UTI may involve a flank/abdominal examination to rule out pyelonephritis. Is any pharmacist going to do this?

        Don’t get me wrong, I’m not against pharmacy at all. I just think that we should be championing a different route.
        Medication safety, Clinical pharmacy and Quality Use of Medicines. These are our skills and they are so under-utilised in our healthcare system. For example, why don’t community pharmacies have a more active role in antimicrobial stewardship? Tracking antibiotic use from the local clinic, having programs to ensure they align with best practice. Here a pharmacist could “prescribe” by changing to the most appropriate agent. Community pharmacies should and must be funded to provide such programs as it will benefit public health and the vital issue of antimicrobial resistance in the long run.

        This is money better spent in my opinion.

        • Gavin Mingay
          19/04/2019

          Down-scheduling would be great! But then there is the problem of not being PBS listed. For pensioners or CTG patients, having to pay upwards of $15 for an S3 item will mean they will refuse to take it – I even have a lot of CTG patients refuse to pay for prescriptions written by the hospital emergency department because they have to pay $6.50 each for them.

          What is your view on nurse practitioners and midwives then? Should they have their prescribing rights taken off them because they have not done the six year medical degree? We either need thousands more GPs in Australia (especially in the bush) or we need to broaden prescribing rights.

          • 19/04/2019

            Valid point. But I suppose the cost is applicable to any medication isn’t it? The solution there is broader than pharmacy in general.

            I shall take the time to consider your questions. NPs and midwives are at least trained to conduct physical exams, interpret various tests and actually conduct the investigations asked of them. It is also routine for them to assess patients for their wellbeing. So in this regard, then it is arguable that they more qualified to make a diagnosis.

            I do not think they should have their prescribing rights taken off because a very experienced NP is probably on par to a HMO/Registrar. Although I’m a little taken aback at the type of medications a NP can prescribe eg. Amiodarone and Apixaban.

            In regards to your last point, there is no easy answer. However you have somewhat implied that pharmacists should play the role of GPs simply because there is not enough of them. With the same logic, GPs should play the role of cardio thoracic surgeon since they’re also in urgent short supply.

            Pharmacists could fill the gap, however there would either need to be a complete reform of pharmacy education in Australia to align to US and UK standards (post grad pharmacy +/- clinical residency) or a post grad qualification that is equivalent to the hundreds of hours spent on placements and patient contact from nurses and medicos.

          • Gavin Mingay
            20/04/2019

            “NPs and midwives are at least trained to conduct physical exams, interpret various tests and actually conduct the investigations asked of them. It is also routine for them to assess patients for their wellbeing.”

            So why can’t a pharmacist conduct physical exams? We are required to have private consultation rooms in every pharmacy. Why can’t a pharmacist undergo training to be able to conduct such exams? Interesting…

          • 20/04/2019

            Gavin that’s the point. We are currently under qualified to do so. We would need immense training to do it properly. I have pretty much zero knowledge of anatomy and I would imagine this would be similar for majority of the profession.

            I’m also being respectful to our health professional colleagues. I’m not simplifying the endless hours of training involved in their education and their subsequent responsibility when it comes to patient care.

            Let’s just take a huge step back here. What we first need to do is ensure that our profession is actually seen as a health professional and clinician before we even start thinking about taking over the GP’s role. And let’s not forget about the skills that we can and are qualified to provide which have yet to be fully utilised. Why don’t we get that right first?

          • Jarrod McMaugh
            20/04/2019

            In what article, document, policy, position statement, or opinion piece has the term “take over the role of the GP” ever been used in relation to pharmacists and prescribing?

            Much of the commentary around pharmacist prescribing – by many people – seems to be coming from a place of assumption.

            Policy development, clinical frameworks, and scope fulfillment requires discussion by people who are all on the same page.

            I would recommend reading the background information that the Board has made available.

          • 20/04/2019

            Hi Jarrod, why does it matter if those exact terms are used or not, if that is what is being implicated? Why are the GPs shouting in defiance? Are they also on the same page?

          • Jarrod McMaugh
            21/04/2019

            My point is that pharmacist prescribing is not about taking over the role of the GP.

            If it were, I would not support it.

            Why are GPs shouting in defiance? I’m not sure anyone can answer that with any coherent logic without getting to the core issue that some vocal GPs have with the health industry & their role within it.

            Are they also on the same page? I’m not sure this is a relevant question – the scope of practice of pharmacists is not & should not be defined by another health profession. Perhaps some doctors will not like it, but this isn’t a criteria that needs to be addressed in any framework for the clinical role of an autonomous health profession.

          • 21/04/2019

            It may not be about taking over the role of the GP but factually it is taking away from the GP. Simple economics. The collaborative models of prescribing are less combative and work in the favour of both professions in my opinion.

            Ask any medico why they’re shouting and it will be a simple answer.

            Your third point I just absolutely don’t believe in and I consider to be somewhat arrogant. We have to work with doctors whether we like it or not. I choose to be diplomatic but unfortunately this does not seem to be the way that the profession is heading (and with dire consequences I predict)

          • Jarrod McMaugh
            21/04/2019

            I think much of what you are saying (apart from the arrogance) goes both ways….. yet no one is addressing the “other way”, are they.

          • 21/04/2019

            Jarrod, where have the GPs tried to take away from pharmacy apart from retaliation (and rightly so) to the self-absorbed interests, as you have mentioned, of our profession? The above article even suggests a collaborative model which was proposed by them. It’s time to sit down and work this out together.

          • Jarrod McMaugh
            21/04/2019

            Rightly so?
            Self-Absorbed?

            I think you have the wrong end of the stick.

            Out of interest, when have pharmacists tried to “take away” from GPs?

            btw you clearly have not understood what my last response was referring to if you think I meant that pharmacy has been acting in a self-absorbed manner.

            Maybe you might want to do some back-reading over the last…. I don’t know, maybe 30, 40, 50 years? or pharmacy and medical media and read the things that medicos say pharmacists should not do.

            One of those things was counselling people about medicines. Measuring blood pressure. Providing advice about health. Telling people what medication is in the tablets they are collecting. Things that are now considered core roles for pharmacists. These roles were opposed when pharmacist’s started providing them.

            Little has changed.

          • 21/04/2019

            If I have misunderstood, would you care to clarify?

            If the opportunity arises to sit down with the medicos, and strategise for the better of our professions, why don’t we pursue this?

            Sure, historically it has always been a uphill battle, but does this always need to be the case?

          • Jarrod McMaugh
            22/04/2019

            I have been in this situation many times.

            the will to work together is lacking on one side of the relationship….. and it’s the side that pharmacists have no control over.

          • 22/04/2019

            That’s interesting. I have always found doctors very rational and fair to work with.

            If the peak medico groups are the true barrier to diplomacy, then I suppose pharmacy has no option but to steam ahead without them. They should know with our power, that this is not a wise move. If the hand is offered to reach a solution together and it is struck away, what option is left? This however does not seem to be the case this time around with the above article.

            That being said, I think the objective of diplomacy with the GP groups is and should be important, and it should be something we aim to achieve.

          • Jarrod McMaugh
            23/04/2019

            Doctors are fair and rational to work with in a health setting

            This doesn’t always translate to politics.

            Diplomacy is always the first, second, and third avenue.

          • 23/04/2019

            Where is the evidence that suggests that diplomacy was sought on this above proposal?

      • JimT
        23/04/2019

        in respect to people in the “bush” with the internet and 5G etc why not use pharmacy as a place for virtual consultation with GP’s integrated with pharmacist prescribing protocols…just putting the concept out there…..

    • Bryan Soh
      20/04/2019

      Doesn’t medicine already have a medication management specialist ie clinical pharmacologist?

      • Hi Bryan, yes there is but it is quite the rarity and from my understanding, a dying speciality. They are also heavily involved in research and policy/guideline development. I don’t think there’s a single practicing clinical pharmacologist in any of the major tertiary hospitals in Melbourne. You are correct however, clinical pharmacy and the activities of a clinical pharmacologist does overlap, each bringing different knowledge of drugs to the table.

  2. TALL POPPY
    20/04/2019

    Pharmacists shouldn’t take more on; they already have enough to deal with (and that’s not even including retailing!). Will this be the last straw to break the back of the donkey pharmacist? More and more things ordinary employee pharmacists are expected to do nowadays. More and more responsibility. All without extra remuneration.
    As an owner, if your business is not profitable then there are fundamental issues that need attention! Trust me.
    There is a danger here that the public will begin to have unrealistic expectations of pharmacists thereby adding extra stress that pharmacists at the coalface simply do not need.
    Alex is right.

    • Well I was actually asserting that community pharmacists should do more, but within the realm of our qualification and skills which are highly under utilised.

  3. Red Pill
    21/04/2019

    In all honesty, none of this would improve the working conditions of pharmacists or their wages.
    Let me give you an example. I’ve worked in several big chain discount pharmacies. During flu season, they are charging $11-13 for a flu vaccination. On average, they would be doing 20-30 vaccinations per day without replacing the pharmacist already preoccupied with vaccinations. Why? Well because when you make close to nothing on it you can’t. The pharmacist not vaccinating will have to take double the workload and expose themselves to potential errors and anxiety. Neither pharmacists in this model will be receiving a pay rise. And both will be under significant amount of stress.

    Add to this additional roles like prescribing and you have a situation where the majority will throw in the towel and change profession.

    The current model of pharmacy is incapable of providing their pharmacists a reasonable wage for all the work they are doing. So why advocate for additional responsibilities.

    Wake up people. This is only good for the business owners.

    • That’s a shame to hear and I empathise with your anecdote.

      If both GPs and pharmacists are at saturation levels then what we should be doing is sitting down TOGETHER and working this out. Quit wasting resources, time and money pursuing activities that other health professionals can already competently provide.

      The AMA, PGA, PSA and RACGP can all win together for the sake of our patients.

      Just look at the exponential growth of hospital pharmacy.

      Then one day, maybe… just maybe we will objectively be seen as a fellow respected clinician within the community.

      • TALL POPPY
        21/04/2019

        Pharmacy Assistant award wages are up to $42/hr ordinary hours full time in hospital. I know of 19 year olds getting between $28-$32/hr as such assistants. With Easter they are getting $70/hr++.
        It’s very revealing isn’t it once you look outside the four walls of community pharmacy – why would any self-respecting pharmacist stay in community pharmacy?
        If a lawyer, accountant or tradesman was asked to do extra work/take on higher skill sets they would demand more remuneration without question.
        Alex: this isn’t just about ‘winning’. This is about getting the fundamentals right for the profession – and that is establishing a minimum award wage in-line with a pharmacist’s level of experience, training and responsbilitiy.
        You can’t ‘win’ and earn true respect without it. For many reasons.
        High remuneration is the key to success.

        • It’s a sad situation isn’t it. When I refer to “winning”, I mean we negotiate together so that it is possible to get the fundamentals right. We work with the GPs to find out how we can both best be utilised in this system of ours. As a result, the system is more efficient, more savings, less wastage and subsequently higher remuneration for all. (As long as the pollies don’t keep it for themselves, and we BOTH have to hold them against this). Again, simple economics.

          • TALL POPPY
            22/04/2019

            Pharmacists could qualify via an employer-led 5-year apprenticeship in the latest news from the UK soon. No uni degree needed. Companies will be responsible for this and would look to upgrading existing techs using this method.
            This is how far the pharmacy profession has sunk there. More and more pharmacy technicians are being used and pharmacists are complaining they are not only earning almost as much as themselves with more defined career pathways, but also taking their hours.
            If Australian pharmacists don’t safeguard their wages and working conditions NOW – then watch out. (I must sound like I’m some kind of unionist but I’ve seen far too much of what goes on in the industry and I’m simply here to Wake ordinary Pharmacists Up!).
            Alex – in an ideal world I totally agree.

          • 22/04/2019

            Just did some reading on the apprenticeship proposal – it seems very unlikely that it will be passed. But it does reflect on the dire situation that community pharmacy is in if such proposition can even exist.

            This shows just how important it is that pharmacist’s role is defined within our healthcare system. And I think that this is best done in a diplomatic, non combative manner, as it has been in the case with our hospital counterparts. #StrongerTogether

          • TALL POPPY
            22/04/2019

            If the new 5-year apprenticeship plan gets passed it won’t be pretty. There is some BIG money behind it & the multiples are pushing for it heavily. They will receive huge Funding for taking on apprentices (that Funding word sound familiar – GP-Pharmacists?)….plus they will be able to lock-in cheap labour for 5 years.
            For the sake of the current trained pharmacists, I hope you are right.

    • Paul Sapardanis
      22/04/2019

      The use of professional services as a way of getting people in store in the belief that they will buy higher margain shop lines is slowly killing our profession. Any good ideas we have is done below cost and kills our enthusiasm to continue offering these services.

      • We should be funded accordingly to provide services that will benefit public health. A proportion of the predicted funds saved from hospital admissions should be coming to us if we had some role in preventing it. Unfortunately they are seperate state and federal budgets so perhaps a whole review of funding is required.

        • Andrew
          23/04/2019

          The problem is that many of the trial programs and pilots show little to no benefit. Gotta show value for money if you want the money, and pharmacy is having a lot of trouble proving that.

          • 23/04/2019

            There’s one core issue identified and the SHPA had that worked out early. Why are we wasting funds expanding our scope?

    • Paul Sapardanis
      22/04/2019

      Last year I was told by an employee of one of the major wholesalers on how disappointed she was with the vaccination training that the pharmacists were undertaking. I was wondering what technical or medical aspect was missing from the training? No the pharmacists were not trained on how to onsell natural therapies like Echinacea or vitamin C during the vaccination process.

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