9 November 2021

Geriatricians oppose limits on aged care prescribing

Aged Care Clinical PBS

GPs are the primary carer, says one peak body, and the plan to restrain their prescribing is ‘full of holes’.

It’s unlikely that GPs will lose their ability to prescribe antipsychotics to aged care patients, as a majority of stakeholder groups come out against the proposed change.

The Department of Health confirmed it has consulted with five major industry bodies in deciding whether to accept a Royal Commission recommendation to limit antipsychotic prescribing in residential care facilities to just psychiatrists and geriatricians. 

The Medical Republic understands that at least three of the groups, namely the RACGP, AMA and the Australian and New Zealand Society for Geriatric Medicine, are opposing the move.

It is unclear where the Royal Australian and New Zealand College of Psychiatrists and Aged Care Quality and Safety Commission stand.

The recommendation itself originally came out of the Royal Commission into Aged Care Quality and Safety back in March, after it found that a quarter of Australian aged care residents had at least one active antipsychotic prescription. 

According to Australian and New Zealand Society for Geriatric Medicine President Professor Vasikaran Naganathan, the recommendation to limit prescribing is based on a misconception of how aged care health services operate.

“We work on the principle that GPs are the primary carer, and we’re coming in to provide support for the GP and the residential care facility staff,” Professor Naganathan said.

“We’re coming in there with, in a way, the GP’s blessing and [an understanding] that we’re not going to take over the primary care of the patients.”

In its response to the Royal Commission, the government accepted the recommendation in principle but deferred the decision to the Pharmaceutical Benefits Advisory Committee (PBAC).

While the commissioners recommended that these changes occur no later than 1 November, the PBAC only recently finished consultations and will publish its response mid-December. 

Separately, amendments were made to the Aged Care Act 1997 in July, which essentially put the onus onto facilitiesto prove that chemical restraints are being used as a last resort. 

Professor Naganathan said there were gaping holes in the plan to limit prescribing. 

“If this came in, you wouldn’t want to then see rapid deprescribing – it would be a whole bunch of people coming off antipsychotics without the support to work out whether that’s appropriate,” he told TMR

“You’ve then got people who have longstanding mental health issues – people with schizophrenia or intractable depression who need antipsychotics. 

“So then you need amendments to the recommendation.”

Given the fact that geriatricians and psychiatrists are fewer and farther between than GPs, the amendments wouldn’t stop there.

“Then you’ve got people who might find it difficult to actually get to a geriatrician and psychiatrist for physical or behavioural reasons, so then you’d have to say it’s okay for them to be reviewed by telehealth,” he said.

“And I’m not sure telehealth is always a great way to review people with serious behavioural problems, so then you need another amendment to say that.”

Professor Naganathan called instead for an approach that leveraged the GP-patient relationship, rather than discounting it.

“We would support a model where GPs did regular medication reviews, which would include some documentation about whether it’s working or not, and whether people are getting side effects, with the involvement of substitute decision makers,” he said. 

That kind of system would rely on tighter regulation at a facility level, falling outside the PBAC’s remit. 

RACGP President Dr Karen Price told TMR that, should the change go through, it would exacerbate existing access issues.

“Because we have an ongoing relationship with our patients, if we were to eliminate the barriers for GPs to provide care to residential aged care residents rather than erect new ones, we could reduce inappropriate prescribing,” she said.

“This is why the RACGP is continuing to advocate for sustainable GP-led care for older people, including blended funding models to support medical services caring for older people in residential aged care facilities and the community.”

The AMA also praised blended-funding hospital outreach models, which are used to facilitate geriatric reviews of patients in some areas of Queensland and New South Wales. 

“The reviews are initiated by GPs, who can also reach out to the service to ask for advice on specific issues,” the AMA PBAC submission reads

“These are examples of good practice, that should be encouraged and expanded, as they provide collaborative and coordinated care without undermining the role of primary medical specialists in the care of older people – their GPs.”

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Karen Wayne
Karen Wayne
9 months 10 hours ago

I am a GP who has worked in Aged Care for nearly 4 decades. I think it is actually ridiculous to disallow the GP psychotropic prescribing and supervision in the first instance. by GPS. The best, and likely most economical solution to care of the elderly resident with behavioral issues is INCREASED EDUCATION AND SUPPORT OF, AND INCREASED NUMBERS OF PERSONAL CARERS, AND TRAINED NURSING STAFF with regular review and discussion with staff about the resident’s behavioral management by the GP. Consultation with an expert can be a last resort.

Ken Lambert
Ken Lambert
9 months 3 days ago
these people have no @#%*!* idea. GPs having their ability to prescribe antipsychotics to the elderly. The whole residential age care system would break down. Elderly people will die. Many would go crazy. I have a number of residents who have long standing mental health issues, schizophrenia, bipolar disorder and well as organic brain syndromes. They would be left untreated, distressed, their families would be besides themselves, many would end up in emergency departments around the country. Access to psychogeriatrics is either zero or extremely limited in most juristictions. Geriatritians are in critically short supply. I have been a psychiatrric… Read more »