There’s some ugly truths about how little control we have over our ability to monitor, develop and regulate the safety and efficiency of our healthcare system
You don’t have to read far into last month’s report on the Inquiry into the establishment of a pharmacy council and transfer of pharmacy ownership in Queensland to get the feeling that something isn’t quite right.
In fact, the first major anomaly is the title itself.
Despite the title, at least half of the report is devoted to explaining why the scope of the pharmacists’ role might be extended to include prescribing, which has been source of all the subsequent controversy and press coverage. And if you delve into the report’s terms of reference, the potential for pharmacists prescribing is buried inside a sub-clause in four words.
No wonder the report and its findings seem to have taken the medical fraternity by surprise.
But it didn’t take the pharmacy lobby groups by surprise.
The submissions, and public witness hearings, that form the basis of the report are very heavily weighted to the pharmacy sector.
Of course, you’d expect a pharmacy inquiry to contain a lot of pharmacy-based submissions, but the numbers tell a story of what might be viewed as an unhealthy imbalance in evidence presented to the committee.
Just over 50% of the submissions are from pharmacies, 34% are from individuals, the majority of whom are connected in some way to pharmacy, being pharmacists, academics or related in some other way, 8% are non-medically aligned, not-for-profit health groups, usually representing a condition, such as asthma or diabetes, and just 2% are from doctor organisations such as the RACGP or GP practices.
Somewhat strangely, there are no declared submissions from the PSA, Pharmacy Guild, or The Pharmacy Board. There are four confidential submissions which could have involved these lobby groups, but nonetheless they were involved extensively in the witness hearings that were included in the report.
And in addition to pharmacy-flavoured submission line-up, two out of the six member committee of parliamentarians chosen to oversee the inquiry, including the chair, had potential situations of serious and undeclared conflict, each likely to favour the pharmacy lobby.
The chair, Mr Aaron Harper, State Member for Thuringowa in North Queensland spent much of his career as a paramedic, and his wife remains a senior figure in the paramedic community of Northern Queensland.
Like pharmacists, the Paramedic Association has been lobbying for some years now to get governments to legislate for this profession to have non-medical prescribing (NMP) powers.
Mr Harper’s electorate includes the region of The North Queensland Primary Health Network, the chairman of which was, until mid-last year, the current Pharmacy Guild vice- president, Trent Twomey.
How well these two know each other is unknown, but in their respective roles as a politician and key health executive in the same region, they are likely to have met a few times – as in the picture above – where, during a pharmacy vaccination launch, Mr Twomey has his arm around Mr Harper, and coincidentally (we guess) another committee member, MP Mark McCardle, is pictured in front. In the rear is long-time Pharmacy Guild apparatchik, Kos Sclavos.
Another committee member, Joan Pease is the sitting member for the electorate of Lytton, which covers most of the Metro South Hospital and Health Service (MSHHS), which for the last five years has been chaired by Mr Terry White.
Mr White is the founder of one of the most influential and powerful chemist franchises in the country, an ex-Queensland health minister and former Queensland liberal party leader.
During her tenure as the member for Lytton, Ms Pease has come into contact on several occasions with Mr White. And Mr White, as the chair of one of Queensland’s major HHSs, effectively reports to the Queensland Health Minister.
In the Inquiry, Terry White Chemists submissions were the number one single organisational submission source by a factor of four to the nearest other lobby group. Terry White Pharmacy is referenced in the report no less than 37 times in the 100-page report.
The Medical Republic is not alleging any wrongdoing in identifying these relationships. Just the potential for conflict, which are not identified in the report of the inquiry.
Which brings us to:
Ugly Truth No 1 – If you’re organised, you’re powerful
The pharmacy lobby is highly organised, and highly connected. That’s not illegal. Neither is a “shock and awe” carpet-bombing submissions campaign targeting a state government inquiry that might provide pharmacists with the best chance in five years of accessing the world of prescribing. Something they’ve been pushing now for nearly decade.
Less than a handful of doctor groups or individual doctors were represented in this Inquiry making the case against pharmacy prescribing. As stated earlier a major reason for this could have been that the ‘scope of the pharmacists’ in the terms of this Inquiry didn’t seem to be the major focus of the Inquiry at all.
But the pharmacy lobby knew what was happening.
And they were organised to the point where nearly 90% of all the submissions were arguing in favour of changes that would see the pharmacists’ role expanded
If you haven’t had time to read the report, following are three excerpts from the executive summary which paint you a picture of just how far in favour the committee are of extending the scope of community pharmacists. They also demonstrate how the protestations of the few doctor groups that put in a submission have been dismissed with little or no evidence to justify such dismissals.
“Following the recent success of pharmacists administering vaccinations in Queensland, there are significant potential community health benefits from extending the scope of practice of pharmacists further.
These benefits include:
• Improved accessibility, convenience and satisfaction for patients
• Lower out-of-pocket costs for consumers and lower costs to the health care system
• Better health outcomes for patients, and
• Improved job satisfaction for health care workers
“Many of the issues raised by medical practitioners and medical associations could be addressed by a shared or collaborative prescribing model. It is the committee’s understanding that the Pharmacy Board of Australia is exploring options for a collaborative prescribing model in Australia.
“…there would be increased risk of negative patient outcomes if pharmacists were permitted to independently prescribe medication because of the increased risk of medication mismanagement and fragmentation of care, amongst other concerns. However, with sufficient safeguards in place, such as establishing consultation through 13HEALTH as per Recommendation 2, and appropriate additional training, these concerns should be allayed.”
13HEALTH, if you don’t already know, is a Queensland government phone service manned 24 hours primarily by registered nurses. Even if there is a GP on the other end of this helpline, this doesn’t feel like a best practice approach to a potential adverse medication management issue.
Ugly Truth No 2 – There’s no evidence base
The conclusions reached by the report are made primarily on the say-so of the submissions of the interested parties and the assessment of the committee.
Submissions from the doctor lobby groups are largely dismissed in favour of the arguments made by the many pharmacy submissions and witnesses.
It is all done on the assessment of the committee members, none of whom have any particular expertise, experience or background in non-medical prescribing, and two of whom are quite feasibly seriously conflicted being on the committee.
There appears to have been no review of the scientific evidence when assessing the validity of some of the significant claims made in the various submissions. And even if this review was done and simply not reported, the question could be asked as to the committee’s qualifications to be able to assess the relevant literature.
Had even a cursory look at the literature been taken, what you would find is that there is no firm evidence base to prove that non-medical prescribing by pharmacists can achieve any of the goals that are put up as reasons for recommending that the Queensland government extend the scope of pharmacists’ role in that state.
To be fair, there is no evidence that non-medical prescribing is associated with poor outcomes either, although there is some evidence suggesting that non-medical prescribing does not create any efficiencies in the system.
A key finding of most of the recent literature reviews is that a significant proportion of the trials could not be assessed because they contained bias.
Simply put, not enough scientifically robust research has been done and so no firm conclusions can be made that non-medical prescribing, particularly by pharmacists is a good i or bad idea for any healthcare system.
This is despite non-medical prescribing being implemented for many years now in quite a few countries including the UK, New Zealand and the US.
As a recent literature review summed up the situation:
“Despite the largely positive findings on a variety of outcome measures, the review authors all highlighted the absence of well-designed randomised controlled trials (RCTs) and high levels of bias associated with many of the studies included in their reviews that often resulted in the outcome findings being downgraded. In addition, the review authors noted the issue of often-poor definition and description of ‘prescribing’ and the ‘prescribing process’ within many studies, and the difficulty in separating NMP effects from the contributions of other members of the healthcare team. Review findings should therefore be interpreted with great caution.” 1
Another recent evidence review put it this way:
This systematic review has identified limited evidence with moderate quality and unclear risk of bias evaluating the clinical effectiveness of NMP across all professions and clinical settings…. The benefit to the health economy remains unclear…2
This review and all other reviews of the scientific literature on non-medical prescribing did not form any part of the committee’s findings. Neither strangely, did any of the attempts at trials on non-medical prescribing in Australia, including quite a bit of preparation work which was undertaken by the Queensland government in 2014 for such trials.
The UK, New Zealand and particularly the US systems of healthcare have significant variations to the Australian system, and therefore any report from these countries should be treated with a significant degree of caution. However, the evidence from these countries is that pharmacist-prescribing has not become a significant part of any of these health systems. In the UK, only 6% of pharmacists have been registered to prescribe, and even then in very restricted collaborative frameworks.
In New Zealand, despite introducing legislation to allow pharmacists to prescribe as far back as 2013, as of 2016, only 15 pharmacists out of a total cohort of over 3500 in the country, had prescribing rights.
Given the complexity and cost of allowing pharmacists to prescribe, not to mention the controversy such a decision would attract, why doesn’t this report make some attempt to assess why pharmacy prescribing isn’t actually working in these other countries?
The key logic of the inquiry committee in arriving at their recommendation to allow community pharmacists to start prescribing, even if only in a limited capacity, is as follows:
• Improved accessibility, convenience and satisfaction for patients
• Lower out-of-pocket costs for consumers and lower costs to the health care system
• Better health outcomes for patients, and
• improved job satisfaction for health care workers
• A “collaborative prescribing model” and a 1300 24 hour health line will sort out any medication management issues in the field
There is no conclusive evidence in the scientific literature, nor from any non-medical prescribing trials in Australia, which support this logic.
Ugly Truth No 3 – There’s no government failsafe of non-medical prescribing
The most ugly truth of this whole episode is that six Queensland parliamentarians with no particular expertise or experience, and potentially influenced in an inappropriate manner by a very well-organised and influential lobby organisation, can make a recommendation to a state government that their state start allowing pharmacists to prescribe, and that state government, could accept those recommendations and legislate to make it happen. Within a matter of months, no less.
The federal government has no power to stop it. The only thing it could do is refuse to fund pharmacy prescribing on the PBS.
The Pharmacy Board of Australia – which is the group empowered by federal legislation to oversee and determine if pharmacists could and should prescribe, are unlikely to stop it. They say that prescribing by pharmacists is “within the scope” of their training and qualifications.
If the Queensland government accepts the report’s recommendations and decides to legislate then conceivably, community pharmacists in Queensland, will be allowed to prescribe with very little change to the state’s health system. The consequences of that could be horrific say detractors, as in:
• Patients dying from complications around continuity of medication management, even in a collaborative model, but certainly where the failsafe is a 1300 number, or, the My Health Record of a patient
• Patients starting to pharmacist shop doubling the issue that already exists around doctor shopping
• Funding dilemmas, as the various pharmacy groups have already helpfully suggested that the government will need to top up the funding to the pharmacy agreement to pay their members – they aren’t going to prescribe for nothing after all
• A very serious escalation in the fragmentation of care and an escalation in an already fractured relationship between two very important healthcare professionals, pharmacists and GPs
• Significant additional system expense through the complexity of implementing and monitoring a collaborative prescribing model
• As has occurred already with vaccinations, pharmacists would be free to co-market products, including non-evidence-based products with the heavily regulated, subscription-based products, a situation which represents serious and potentially dangerous confusion for the patient.
• The drug prescriber, will now be the drug supplier, and the conflict in this relationship which has been the major reason doctors cannot dispense, is fraught with conflict of interest.
All that can happen now. We are in the hands of the Queensland Department of Health. Hopefully there is enough common sense and expertise in this department to recognise the issues at hand here and to put a brake on this situation.
Ugly Truth No 4 – The system for non-medical prescribing is a mess and no one is taking responsibility
That there is no oversight or failsafe for implementing any allied health prescribing remains an ongoing issue, and a legacy of the now defunct, and controversial Australian Government Health Workforce attempt to harmonise standards around healthcare group prescribing across the country.
This initiative, which canvassed a nationwide standard for all groups in 2013, quickly became a political football and self-destructed.
The consequence of this failure is the sort of madness that last month’s Queensland inquiry is promoting. There is no national failsafe on non-medical prescribing.
Any state government and recognised allied health professional body can get together and do it, as has already occurred with podiatrists.
The federal government should have some oversight, and should take some role in bringing the situation under control. But it hasn’t, and it isn’t.
The Ugl(iest) Truth. No 5 – Money talks louder than patient safety
The pharmacy lobby may well scream blue murder, but the reality surely is that the push to have pharmacists prescribe, and all the work done by them in influencing this Queensland inquiry, is almost entirely about money.
Pharmacists’ money. And their future.
Pharmacists are facing very serious disruptive market challenges to their identity. Artificial intelligence, web-based information health resources and online buying, in particular, are starting to eat into pharmacy business in a big way. The world is changing, and pharmacists desperately need to find a new place in a rapidly evolving healthcare professionals food chain. An obvious place to go is up the food chain, or in this case the prescribing chain.
Based on all overseas experience, if pharmacists get prescribing rights, this, in itself, wouldn’t necessarily be a windfall. But it would be a further step in including the provision of other low-risk diagnostic and therapeutic services, normally done by GPs, into the remit of pharmacists. With all the potential revenue that could represent.
And importantly, as they have already done with vaccinations, this creates a whole host of other retail up-selling and commercial opportunities.
This leads us to perhaps the ugliest truth of the whole pharmacist prescribing push. It’s about money not the best interests of the patient.
And given the extent of these recommendations from this parliamentary inquiry, and the clear support from the all-powerful pharmacy lobby for a full steam ahead approach, you have to conclude that the most sacrosanct of health professional values – first do no harm – is up for negotiation as well.
References:
1. Ther Adv Drug Saf. 2017 Jun; 8(6): 183–197.
2. PLOS, March 6, 2018 https://doi.org/10.1371/journal.pone.0193286
3. A framework for allied health professional prescribing trials within Queensland Health Allied Health Professions’. Office of Queensland Department of Health. Revised December 2014
