‘Pot shot’ doesn’t help GP-pharmacist relationship

doctor wearing boxing glove

A GP and regular pharmacy critic has claimed there would be “regulatory incompetence on a grand scale” were pharmacist prescribing permitted

Dr Evan Ackermann, a Queensland GP and chair of the RACGP’s national standing committee on quality, has gone on the attack against pharmacist prescribing in Medical Observer magazine.

Pharmacist prescribing rights have been on the agenda for some time.

PSA president Dr Shane Jackson recently said that it is a “travesty” that they do not yet have them, while suggesting such rights are likely to be extended to pharmacists by 2020.

Pharmacist scope of practice is also currently being examined by a current Queensland Parliamentary Inquiry, and the Pharmacy Board recently held a stakeholder event at which three models of pharmacist prescribing were examined.

But giving pharmacists these rights would open a “Pandora’s Box,” Dr Ackermann says.

“The term ‘pharmacist prescribing’ is a clinical oxymoron, one I imagine many of us would never have expected to hear, let alone experience, when we entered medicine,” he writes.

“Why raise the issue at all? The pharmacist scope of practice is being rapidly automated and, with financial changes in the pharmacy sector, community pharmacists are looking at role expansion in order to stay relevant.”

Medication reviews and pharmacy-led health screening offers have “serially failed” to show a positive impact on health outcomes, argues Dr Ackermann.

Pharmacist prescribing is a “fundamental tool” for other concepts including Minor Ailments Schemes and the monitoring of chronic diseases, he adds.

“In fact, many pharmacists see the development of My Health Record and the data it will make available as overcoming some of the key obstacles to prescribing — namely not having to make a diagnosis and having access to a patient’s personal health information.”

He says that rather than Australia needing to catch up to the international landscape on prescribing rights, “Australia has a much more advanced primary healthcare system than many other countries and this results in better health outcomes.

“Simply copying the actions of health systems with poorer outcomes is no justification for new services.”

The retail nature of community pharmacy is “not conducive to professional services,” he says.

“If recent history with codeine has taught us anything, it’s that the presence of a pharmacist does not ensure safe and effective use of pharmacist-only medications.”

He also refutes that pharmacist prescribing is “for patients,” saying that “if the policy intent is safe and convenient access to medication, pharmacy bodies and regulators could easily increase dispensing amounts”.

“In my view, prescribing is for pharmacists, not for patients. And adding prescribing rights in the context of decreasing income from PBS dispensing would be a recipe for overprescribing,” Dr Ackermann writes.

“Society gives the responsibility to prescribe to many health professionals, including doctors, nurses and allied professions. These prescribing rights are based on societal need, provided by qualified groups and in settings conducive to professional services.

“Pharmacy prescribing is a quantum difference on many levels. Inadequate training, a progressively poor environment and lack of oversight should all weigh heavily against the introduction of this service.

“The risk-to-benefit equation looks very bleak and it would amount to regulatory incompetence on a grand scale if pharmacist prescribing was sanctioned in a retail setting,” argues Dr Ackermann.

PSA’s Dr Jackson expressed disappointment at the piece, saying that it was unfortunate that individuals including Dr Ackermann were attempting to derail collaborative efforts by “throwing rocks”.

“I get frustrated at trying to refute these points, but I will say that prescribing is within the scope of practise for pharmacists and has been for a long period of time,” Dr Jackson tells the AJP.

“As a profession, and certainly the PSA understands that, we will need to navigate the concerns about separation of the prescribing function and the dispensing function. Absolutely, that needs to be addressed.

“But we’re talking about a collaborative model, where the pharmacist will enter into arrangements with medical practitioners. If you look at it from a community pharmacy perspective that would likely be potentially limited to start around prescription extension and prescription modification – again, all within the collaborative framework.

“There may well be a more independent process that occurs where there is that separation from the dispensing function: for example, pharmacists working in the hospital setting, or in a general practice, or in an aged care setting.

“But there are prescribing models that can be implemented across the whole spectrum of pharmacy, from community pharmacy to more independent practice, and this latest pot shot is not helpful for the relationship between doctors and pharmacists.

“This should be about partnerships, about collaboration and working together on models of care that actually benefit patients – and we will continue to do that.”

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  1. Debbie Rigby

    Canadian Pharmacist Ross Tsuyuki says it better than I can in this open source article “FAQs (frequent asinine questions) on pharmacists’ scope of practice”
    #groundhogday #respect #professionalism #evidence #conflictofinterest

  2. Jarrod McMaugh

    When will the RACGP realise how embarrassing it is for them to have this individual speak for them?

    This person is the chair of the RACGP standing group on quality, yet he continually produces opinion pieces that aren’t evidence-based, and relies heavily on bias & logical fallacies in attempting to persuade people that his opinions are facts.

    What are the standards that a person needs to meet for RACGP to put them in charge of “quality”?

    • FakeMoralOutrage

      See above; sorry, I couldn’t help myself

      • Jarrod McMaugh

        you’ll need to specify what you want me to see?

  3. Glen Bayer

    It’d be interesting to get Dr Ackerman’s perspective on nurse practitioners being able to prescribe. Clearly those studying medicine would never have contemplated having a lowly nurse prescribe for patients, so I can only imagine his disgust at the practice….

  4. Robert Broadbent

    Do we encourage this person by responding? He obviously has an axe to grind – and we simply feed his anger. I don’t believe as a profession we have anything to defend. We are highly trained, we are intelligent, and well received. I am well aware the playing field is not level – but that doesn’t mean we still can’t play the game and be involved as others decide who does what, and to whom.

    • Glen Bayer

      Imagine if Evan Ackerman and Sue Dunlevy got together – the anti-pharmacy vitriol would be amazing!

      • Robert Broadbent

        Sure would, and even less worthy of a response.

        • Michael Khoo

          He desperately needs a response. In detail, Tear each point down! Shouting boo does not win the game. You say he’s wrong….Convince the humble reader of your point of view.

  5. Michael Khoo

    … waiting patiently for a rational and reasoned debate on this subject. Name calling and belittling do nothing to convince me. The standard of debate on this subject has degenerated to dogma vs dogma, and I have not seen any actual detail regarding the proposed mechanism for pharmacist prescribing, and so I remain unconvinced that “certain elements” of our profession can fulfill the role of prescriber/dispenser without self-interest.

    As for RossT.Tsuyuki,BsC(Pharm),PharmD,msC,FCshP,FaCC,FCahs, who discounts conflict of interest concerns as “Insulting” and therefore somehow irrelevant, well I am concerned about precisely this, knowing the state of our profession at the moment. Sorry to hurt your feelings Ross, but I think some of the major players in Australian Pharmacy would not hesitate to wipe their feet on ” our solemn oath to the community”, if it earned them a few bucks.

    Oaths and Morality will only do so much, so prescribing regulation needs to account for the worst possible behavior.

    “It’s all about money…ain’t a damn thing funny….” Grand Master Flash

  6. FakeMoralOutrage

    An open letter to Dr. Ackermann and any pharmacists reading this thread.


    In order for you to cast such widespread aspersions on the integrity of an entire professional community, it would require you (and by extension, your colleagues one and all) to have an unblemished reputation which is beyond reproach and robust enough to withstand the closest scrutiny. Every field of work (including medicine) has its dedicated workers who strive to uphold their practice as well as a contingent of rogue operators.

    To say that medicine is independent and unswayed by corporate interests would be incorrect as every field of work is subject to corporate pressure from one source or another. In pharmacy, we too have corporate powers tapping our collective shoulders, but with the exception of the rogue operators, the majority of pharmacists still act with integrity and discretion. There are vested interests in every aspect of life and it would be foolish to pretend that they do not exist. It is up to the individual to decide how to conduct themselves in the face of it.

    Your comments are also insulting and disempowering to a workforce that is already drastically underpaid and unrecognised, especially by one of its own national bodies. Many of us already feel devalued and ripped off which affects the very quality of life that your healing hands aim to preserve. It is also very discouraging for those coming through the ranks to practice to know that such a poor view of their efforts is still prevalent in these more informed times.

    As for a “cut, sling, backhander, kickback, perk or rort” of any sort – forget it. If pharmacist prescribing were to eventuate, it would simply become yet another task within the already tall order that we have for our outrageously generous $20-something per hour. The average pharmacist WILL NOT SEE A SINGLE CENT from any of this; I wager you a drink of your choice on that one.

    The same professional body that has held back our hourly rates and benefits to pre-GFC levels and who has also recently advocated for a cut in penalty rates will ensure that the practicing pharmacist will not benefit one iota from this.

    The idea of pharmacist prescribing does hold some technical merit, especially for commonplace conditions which do not need to clutter up the public health system but I doubt if it would be the massive conflict of interest that is predicted. This is simply due to the fact that pharmacists are not idiots and therefore will not expect to enter specialised fields (eg: oncology, psychiatry) and that there will be limitations on what can be done for the sake of commonsense and indemnity insurance.

    Nobody, not even Dr. Ackermann knows everything and therefore, there will be limits and safeguards on this which will undoubtedly evolve over time.

    I often wonder why articles like this even make it onto the AJP only to further sadden an already disgruntled community. Whatever happened to all the teachings we had in our ethics units about collegiality, respect for other practitioners and refraining from spurious claims ?

    Personally, I do not care, there’s enough to do in a day already but derogatory statements like those detailed have no place in what is supposedly a professional forum.

    • Andrew

      To me, this plays right in to Evan’s argument about the brokenness of the retail pharmacy system.

      • Red Pill

        Nevertheless, our trusted pharmacy body will undoubtedly allocate resources for any new service such as this one into the hands of the pharmacy owners NOT those actually getting the qualifications and doing the service. Hence, the complete lack of interest shown by Australian pharmacists. No one wants anymore responsibilities. We already have enough on our plate and still can’t afford to buy our first home after 10+ years working.

  7. Gavin Mingay

    Do we allow pharmacist prescribing, but limit it to pharmacy groups/independent pharmacies who can still act professionally and be trusted to not rort the system? Certain sectors of the profession have helped to fuel the mistrust in the pharmacy profession and have misused the MedsChecks and other payment schemes.
    Genuine pharmacists, especially those working late-night pharmacies or remote pharmacies would be able to provide a fantastic service to their communities with limited prescribing rights. Trouble is that the majority who are doing the right thing are restricted due to the few who rort the system.

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