The Pharmacy Guild has insisted its proposed ‘full scope’ trial will only bring Australia into line with other countries. That’s not quite accurate.
Throughout the buildup to the North Queensland pharmacy scope of practice trial, the Pharmacy Guild has maintained that the pilot it proposes will “bring us back up to speed with the modern world”.
In the press and in its own media, the Guild cites three countries as examples of places with successful pharmacist-led prescribing: New Zealand, the UK and Canada.
“Pharmacists practising to their full scope is not a new concept,” Queensland branch president Chris Owen told a committee meeting last month.
“The pilot will bring North Queensland pharmacists in line with pharmacists practising in parts of Canada, New Zealand and the United Kingdom and is expected to provide North Queenslanders the same positive health outcomes received by those countries’ residents.”
Yet at least one New Zealand pharmacist prescriber tells The Medical Republic she is “horrified” by the lack of understanding evident in the proposal.
So what is supposed to happen in North Queensland and how does it really compare to those other countries?
The Queensland pilot
Documents leaked earlier this year revealed that the Queensland government had green-lit a “scope of practice” trial for community pharmacists in the rural and regional northern end of the state.
The draft documents describe an expanded role that would allow pharmacists to manage potential diagnoses and management of type 2 diabetes, acute infective conditions like otitis media, wound management, COPD diagnosis and medicine initiation, GORD, atopic dermatitis and more.
All up, they would be allowed to diagnose and prescribe across 23 medical conditions.
To participate, pharmacists would have to do a graduate-certificate level course, including 120 hours of supervised prescribing practice.
In that speech to the committee meeting last month, Mr Owen estimated that the training would take about 18 months.
Under the scheme, community pharmacists can charge $20 for consults under 15 minutes, $30 for consults 30 minutes or less and $55 for everything thereafter.
They will also be able to dispense the medicine they have just prescribed via a private script.
The Guild has declined to clarify whether any of the conditions which were originally proposed have been cut from the scope, and which country the Queensland pilot will be modelled on.
So let’s take a look at just how pharmacy prescribing in New Zealand, the UK and Canada actually works.
New Zealand
Becoming a prescribing pharmacist in New Zealand is tough: in the nine years since it was written into law, only 37 have qualified.
Pharmacist prescriber hopefuls must hold a postgraduate clinical diploma or equivalent and have several years of clinical experience working in a particular area of practice – this might be diabetes, pain management or general practice – before even applying for the 12-month postgraduate course.
The course itself involves a 250-hour practical along with an academic component and finishes with a multi-station OSCE.
Even once they’ve qualified, pharmacist prescribers can only work within the specific clinical area of practice they trained in.
A pharmacist who specifies paediatrics as their area of prescribing scope, for instance, could expect to work in the paediatrics ward of a hospital.
New Zealand’s pharmacist prescribers see these standards as a badge of honour.
“It’s very rigorous, and it needs to be because we have a huge responsibility,” Hamilton-based pharmacist prescriber Penny Clark tells TMR.
“We receive a huge [amount of] trust from trust from our patients and our medical and nursing colleagues.
“When they ask us things, they expect us to be able to answer not just with something from a textbook or from a formulary about something that’s evidence based, but something that’s actually clinically assessed for the person in front of us.”
Importantly, the New Zealand pharmacist prescriber system is not set up for people working in a siloed environment like community pharmacy.
Ms Clark, who is chair of the country’s Clinical Advisory Pharmacists Association, chose general practice as her specialty.
Pharmacist prescribers can take on different roles in general practice, like repeat prescribing or post-hospital discharge medicine reconciliation.
“You’ve got other people around you if you need to [get] a second opinion,” Ms Clark says.
“For example, there was someone who presented this morning … a patient on dialysis who came in to see me about his diabetes and blood pressure medication, and I ended up getting the doctor because he was having chest pain, and we did an ECG and we consulted together and sent him to hospital.”
General practice pharmacist prescriber Dr Linda Bryant – whose colleagues regard her as a mentor and leader in the field – put it more bluntly.
“We’re not a mini-doctor, we’re not a mini-nurse, we actually have a unique contribution and that’s the depth of our understanding of medicine and the ability to make those clinical decisions,” Dr Bryant tells TMR.
“The environment is super important – it’s just silly to segment a patient into pieces … when I see people, I see them and I cover all their conditions.”
She also is firm about the need for advanced training and study before even qualifying to train as a prescriber.
“Sometimes someone says ‘I’ve got lots of experience because I’ve been in pharmacy for 20 years’, but that’s possibly just one year repeated 20 times,” says Dr Bryant.
She also dismisses the idea of bringing prescribing into the business environment of community pharmacy.
“I really can’t understand why the pharmacy profession seems hell-bent on restricting pharmacists to work in a community pharmacy environment,” she says.
“I believe in pharmacy and pharmacists, but this idea that it is the only place … it’s a business model, and it’s people wanting to expand their business.”
Both pharmacists say that the proposed model for North Queensland can’t be compared to New Zealand.
“It’s a big step up to include clinical decision-making and responsibility,” Ms Clark says.
“If you don’t know what you don’t know, you won’t know what you don’t know.”
Her colleague does not mince words either.
“I guess from the pharmacist prescribing perspective, I’m probably quite horrified at the lack of understanding of what’s actually involved, but also the level of clinical knowledge that’s required,” Dr Bryant says.
This goes to the heart of why organisations like the Royal New Zealand College of General Practitioners embrace pharmacist prescribers.
“It’s a joint partnership for the benefit of the patient and we really make sure that it is an integrated approach,” RNZCGP president Dr Samantha Murton tells TMR.
“Our prescribing pharmacists who work within GP practices are just amazing.”
Because prescribing pharmacists do their placements in a clinical setting, there’s a real chance for mentoring and camaraderie, which Dr Murton says increases the ability of everyone to do better for the sake of the patient.
The college views these pharmacists very differently from community pharmacists in New Zealand who have done a shorter course to be able to independently dispense trimethoprim for suspected UTIs.
In a message that will alarm those citing antibiotic resistance as a mark against pharmacist prescribing in Australia, Dr Murton says resistance to trimethoprim in New Zealand “has gone up quite a lot”.
A study published in the New Zealand Journal Medical Journal in 2020 found that trimethoprim only worked for women 15-55 with uncomplicated cystitis about 74% of the time, and that it therefore should no longer be recommended as a first-line treatment.
Dr Murton has some stern words for this subset of community pharmacists without the full prescriber training: “They’re putting themselves in jeopardy by taking on roles that they may not be skilled for.”
The UK
The pharmacy prescriber program in the UK is similar to New Zealand’s in that pharmacists work within a defined area of practice.
There are some pretty significant differences, too, starting with the name: they are often referred to as pharmacist independent prescribers or independent prescribers.
The training program is also far shorter, with a minimum standard learning time of 26 days’ worth of structured learning activities and a 90-hour practical.
In the past, anyone wanting to apply for pharmacist prescribing postgraduate studies had to have at least two years of experience as a qualified pharmacist under their belt, as well as previous experience in their specified clinical or therapeutic area.
In May this year, the entry requirements were lowered to allow pharmacists with less than two years of experience to apply, so long as they have relevant experience in a pharmacy setting and can “recognise, understand and articulate” the skills and attributes required by a prescriber.
The program began in 2006, and there are now over 7000 independent prescribers working in the UK.
They aren’t required to be part of a multidisciplinary team like they would in New Zealand, although it is encouraged.
An investigation published last year by The Pharmaceutical Journal found that the bulk of pharmacist independent prescribers in England were working in general practice.
In fact, for bureaucratic reasons, it’s one of the only settings where the qualification can actually be used.
“Getting hospital systems to talk to primary care systems is challenging enough,” GP practice pharmacist and community pharmacy locum Hannah Syed is quoted in The Pharmaceutical Journal as saying.
“The technology is there, but for pharmacists in the community to be able to take on patients and prescribe appropriately, they’re going to need access to more patient records and blood tests, which at the moment, there’s just not the facility for them to have.”
Like its sister organisation in the Pacific, the Royal College of General Practitioners supports pharmacist prescribers, but specifically the role that they play within a team.
“Pharmacists are highly trained and highly trusted healthcare professionals who can play a vital role in supporting people with a range of minor ailments, freeing up GPs’ time for patients with complex health needs,” RCGP chair Professor Martin Marshall tells TMR.
“GPs work very closely with our pharmacist colleagues, and increasingly pharmacists are working in general practice as part of the GP team.
“As such, the RCGP supports pharmacists being able to prescribe independently when it is within their scope of practice and with the relevant training, so it’s vital they are able to access this.”
Canada
If the UK and New Zealand are somewhat similar, Canada is a completely different kettle of fish.
Saying that Canada allows pharmacist prescribing is a bit of an overstatement.
While pharmacists in 10 of the 13 territories have limited powers including emergency prescribing and extending prescriptions, some community pharmacists in Alberta can independently prescribe for any Schedule 1 drug.
Every Albertan pharmacist can adapt a prescription or prescribe in an emergency, but it’s the pharmacists with an additional prescribing authorisation who can make the big calls.
To qualify for that additional authorisation, pharmacists must have at least a year of full-time experience, have strong collaborative relationships with other health professionals, have pre-existing clinical judgement skills and have access to information, communication and documentation processes.
The Alberta College of Pharmacy assesses whether pharmacists can become independent prescribers on the basis of an application, in which the prescriber hopeful explains their preparedness and judgement and gives three examples of patient care.
Once successful, Alberta’s pharmacist prescribers are just expected to “limit their prescribing to situations where they have an adequate understanding of the patient, the condition being treated and the drug being prescribed”.
The only drugs off limits are controlled substances like narcotics, benzodiazepines, barbiturates and anabolic steroids.
Pharmacists can dispense the medicine they prescribed themselves, so long as the patient requests it.
All information is expected to be relayed back to that patient’s doctor.
Further, if a pharmacist prescribes a medicine for a new condition, they must also refer that patient for formal diagnosis and treatment.
The College of Family Physicians of Canada, which represents the country’s GP-equivalent doctors, has always maintained that prescribing should be limited to doctors and non-physician health professionals who have completed an equivalent amount of education and training.
“It is worth noting here that limited research is available regarding real-world impact of pharmacist-initiated prescribing in Canada and how it compares with physician prescribing,” a college spokesman tells TMR.
“Pharmacists continue to be valuable integrated members of primary care teams, but available evidence to support expanded roles (such as pharmacist-initiated prescribing) is limited.”
There is also no reliable data to measure whether pharmacy prescribers are actually communicating their actions back to patient’s main healthcare providers, as they are supposed to.
The Alberta pharmacy prescribing model is not necessarily popular.
“Many family doctors are supportive of pharmacists being involved in prescription renewals, but independent prescribing outside of a clinic setting (for example, community pharmacies) is not well supported,” the spokesman says.
“Our words of advice: seek collaboration with pharmacists and those on a patient’s care team who monitor and manage medications; note that the body of evidence isn’t particularly robust when it comes to expanded prescribing roles … [and] that pharmacists should be part of interprofessional teams.”
And back to Australia
To recap:
- New Zealand: pharmacist prescribers must have extensive post-graduate training and work in a clinical setting, not community pharmacy.
- The UK: pharmacist prescribers have to do some postgraduate training and tend to work within multidisciplinary teams, although they could technically work in community pharmacy.
- Canada: pharmacists in one province can apply to prescribe, but don’t necessarily have to do any additional training beyond their regular practice.
Whether the North Queensland model will most closely resemble New Zealand, the UK or Alberta is anyone’s guess.
It is worth noting, though, that the official Pharmacy Guild website for the pilot contains a video interview with the University of Alberta’s pharmacy researcher Dr Ross Tsuyuki, who visited Australia for a pharmacy conference in July.
For what it’s worth, Dr Tsuyuki says that there is a wealth of evidence in favour of pharmacist prescribing coming out of Alberta. He did not respond to our request for an interview.
“The reason why it’s so interesting to be here in Queensland right now is because of what pharmacists are doing and really pioneering, leading the way, and that’s so inspiring,” he tells the camera in the conference video.
“It’s something we went through a few years ago, and to see others stepping forward for patient care is really inspiring to me.”
