18 April 2019

Will pharmacy scripts trial be thin edge of wedge?

Pharmacy Political RACGP

The political influence of the pharmacy lobby has been on full display this month with two key decisions on primary care being made in its favour.

Following a Queensland parliamentary committee inquiry last year, the state’s parliament has accepted recommendations to allow pharmacists limited scope to vaccinate and prescribe.

Pharmacists in the state will now be able to administer influenza, MMR and DTP vaccinations and adrenalin for anaphylaxis. There will also be a statewide trial of pharmacists issuing repeat prescriptions for the contraceptive pill and for antibiotics for urinary tract infections.

But the RACGP has called on the Queensland government to reverse the decision.

College President Dr Harry Nespolon said pharmacists were not trained to treat UTIs, which could spread and pose danger, and whose management might be complicated by other health issues. Extending prescriber rights would also undermine antibiotic stewardship.

“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.”

The pharmacy lobby has also won another concession from the commonwealth, which has rethought a plan to enable patients to collect two months’ worth of scripts in one visit.

Sixty-day dispensing would have halved the number of patient visits to pharmacies to collect regular medicines, which the RACGP and Consumers Health Forum of Australia say would have been safe, practical and convenient for patients.

The Pharmaceutical Benefits Advisory Committee last year recommended that 143 medicines would be suitable for optional dispensing in larger quantities for stable patients, saying this “would allow clinicians to exercise greater choice and provide patients both financial and convenience benefits”.

Health Minister Greg Hunt’s office did not respond to questions from The Medical Republic on the grounds for the decision and whether it was made in response to lobbying from the Pharmacy Guild of Australia.

There is no love lost between the college and the guild, which have taken the opportunity to trade barbs about who is more self-interested, GPs or pharmacists.

Dr Nespolon said the guild had opposed the move because it would have dented pharmacy profits.

“We are extremely concerned that government has backed down on a decision that was in the best interests of Australian patients, after intense lobbying by the guild,” Dr Nespolon said.

“The public needs to be aware that when it comes down to pharmacy profits or patient benefits, the patient comes second to the guild.

“We don’t want to see a positive initiative for Australian patients dismissed because it doesn’t suit the financial interests of one particular lobby group.”

The Pharmacy Guild of Australia did not directly confirm whether it had lobbied the government, but it welcomed the decision.

“The proposal to double quantities for some PBS medicines has been raised without consultation and without regard for the possible unintended consequences for patients in terms of quality use of medicines and for pharmacies in terms of patient care and contact, and pharmacy viability,” spokesman Greg Turnbull told The Medical Republic.

“It might be time for the RACGP to focus on general practice and the impact of corporatised medicine rather than meddling in pharmacy matters.”

He said it was “a bit rich for the RACGP to talk about putting profits ahead of patients when they’ve launched a campaign threatening to abandon complex patients because they don’t pay enough”.

This was in reference to a call from Dr Nespolon for more federal investment in general practice, in which he said: “As a GP for over 30 years, the last thing I ever want to do is turn away a patient because they cannot afford it, but if something doesn’t change soon that is going to become a reality.”

CHF CEO Leanne Wells said the about-face went against advice from the Pharmaceutical Benefits Advisory Committee.

“This policy reversal takes little heed of PBS and the expert, multidisciplinary advice of the PBAC and is counter to undertakings from both sides of politics that PBAC advice will be acted on,” Ms Well said.

Meanwhile, the Pharmacy Board of Australia’s proposal for wider pharmacist prescribing has also met a barrage of objections from the RACGP and the AMA.

The college in its submission opposes all three proposed models – autonomous prescribing, prescribing under supervision and prescribing under a structured prescribing arrangement – saying it “does not support the expansion of pharmacists’ scope of practice beyond their core function of medicine advice and dispensing, into prescribing”.

It says pharmacist prescribing “could direct patients away from their general practice and reduce opportunities for essential preventive care”.

Both organisations said pharmacist prescribing was a solution to a non-existent problem, since the supply of GPs had increased since the figures the PBA uses, with the AMA noting that maldistribution applies to all health professionals: “It is highly likely that an area with shortages of general practitioners will also have limited access to pharmacists.”

The AMA says it supports “non-medical practitioner prescribing within collaborative models of health care where non-medical health practitioners work as part of a medically led team”.

But it does not support independent or autonomous prescribing by any non-medical practitioners except dentists, and it especially opposes any prescribing “by pharmacists employed by, or working in, or associated with, a retail pharmacy”, citing conflict of interest.

The AMA cites Cochrane review evidence that non-medical prescribers prescribed more drugs and in higher doses than medical prescribers. This risked increasing PBS expenditure while worsening antibiotic resistance and the opioid crisis.

It takes serious issue with the PBA’s suggestion that prescribing is already within pharmacists’ scope of practice, with little additional training required. It calls this “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”.

The AMA also dislikes what it sees as the attempt to circumvent the Guidance for National Boards on the use of scheduled medicines, developed by AHPRA and agreed to by the Australian Ministers’ Health Advisory Council.

“The AMA cannot comprehend why the Pharmacy Board is contemplating pursuing prescribing rights for its health practitioners outside this transparent, robust, and nationally consistent process.”