The aptly named 'Scope of Practice, who’s right?' plenary session at the weekend’s AMA24 conference – labelled a “very hot topic” by its chair – was nothing if not impassioned.
A GP, pharmacist and nurse walk into a scope of practice plenary…
The GP campaigns against McDonald’s, the pharmacist vows to free 15% of hospital beds and the nurse says not to take it so personally.
Here’s what went down at the AMA24 conference session on scope of practice at the Gold Coast this weekend.
First to the podium was president of the Society of Hospital Pharmacists of Australia Tom Simpson.
“Pharmacy and medicine … we have actually always had overlapping scope,” Mr Simpson told delegates.
“Nothing’s ever been quite so clear as doctors prescribed, pharmacists dispense. We will always be partnered together on medication management.
“But as pharmacists’ scope has expanded to take on more obvious roles in supporting decision making around medication treatments, this has understandably caused some friction in the in the health sector.
“It needn’t be that way.”
Presenting work undertaken at Royal Hobart Hospital on collaborative charting, Mr Simpson said that by mandating an hour of pharmacist-doctor collaboration per patient, patients were 20 times less likely to experience a medication error.
It also contributed to an average reduction of 12 hours of patient time in hospital, with the relative stay index reduced by 15%.
“Imagine if we could free up 15% of all the medical beds in the country,” said Mr Simpson.
The participating health professionals were also surveyed.
“Doctors prefer collaborative charting,” he said.
“It’s like having a buddy to bounce ideas off.
“Every time you look at something to do with medicines, if you add a pharmacist into a collaborative model with a medical officer then you are 4-10 times more likely to get the outcome that we actually want the system to deliver.
“The system needs to be redesigned.”
But while autonomous prescribing models and delegated prescribing models “have a place”, it’s the collaborative model that creates system capacity, said Mr Simpson.
“A rough back of the envelope estimate … hundreds of thousands of bed days [would be saved if] we had this collaborative model in every hospital,” he said.
Australian Primary Health Care Nurse Association president Karen Booth said that hospitals couldn’t provide all the care people need, “even though they think they can”.
“The mainstay of any health system is really strong, robust primary care,” she said.
“Whether that’s a strong GP supported by a really strong nursing workforce or nurse-led clinic models, we know that they increase access to care,” she said.
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“I think we’re all a bit concerned about how [scope expansion] is going to affect us personally.
“If you plan and everyone’s part of the team, there’s a role for everyone.”
GP and AMA ACT branch president Dr Kerrie Aust made an impassioned plea not to sacrifice safety for access.
“I think it’s really important to talk about the fact that some of the barriers to us all working at the top of the scope are about preventing harm to patients,” she told delegates.
While everyone’s working to relieve pressure on hospitals and general practice, with chronic disease on the rise, it’s fragmentation that’s the biggest problem, said Dr Aust.
“My patients are going to all sorts of different places to get their care because of convenience,” she said.
“It’s not actually good for them.
“We should be making sure that the patient is getting the right care, in the right place, at the right time.
“This is not McDonald’s, this is medicine. Very, very different things.”
Dr Aust took aim at nurse-led walk-in clinics, which she labelled “models of attendance”, not models of care.
“[Nursing and medicine training] are not the same,” she said.
“We need to have more conversations about diagnostic medicine and less about convenience management and just a script.
“We know that the amount that the government has invested in [walk in clinics] is somewhere between $100 and $200 per patient.
“What if that went to general practice?”
The Canberra GP also took a swing at autonomous prescribing.
“I love collaborative care where we sit together,” she said.
“But if my pharmacist is prescribing – sometimes giving a Prolia or the flu vax or treating a UTI – and I don’t know what’s going on with my patients, how can I really care for them?”
The continuous, relationship-bases nature of general practice allows a feedback loop, said Dr Aust, but one-off care centres don’t get that feedback.
“I’ve watched someone have a skin consult in the pharmacy, lifting their shirt up in the middle of the pharmacy to diagnose a rash,” she said.
“I couldn’t tell what it was because I couldn’t put my dermatoscope on the skin and I can promise you, neither could the pharmacist.
“When you are trained to prescribe for UTIs, you are going to see everything as a UTI.
“You are going to miss the atopic dermatitis, you’re going to miss the interstitial cystitis, you are going to miss the endometriosis and you are going to miss the HSV which could all present in exactly the same way in the demographics that we’re doing UTI prescribing on.
“When you’re trying to only prescribe the oral contraceptive pill, you are not thinking about family planning, you are not thinking about the benefits of long-acting contraception, you’re not thinking about education around sexual consent and safety.
“I just find it amazing how many of these experiments are about women’s health.
“And I really think that we need to think about that.”
