Outdated GP info in case for pharmacy prescribing

Consultancy firm KPMG did not consult the AMA when it reported on areas of little or no GP access.

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Peak doctor groups are holding out hope that Tasmania will be the first state to take a truly collaborative approach to pharmacist prescribing, but are wary of what appear to be Pharmacy Guild talking points becoming official policy.

On Thursday, the state government responded to a KPMG review it commissioned looking into pharmacist scope of practice, accepting the report’s recommendations in full.

The review itself noted the growing national trend toward broadening scope of practice for pharmacists, as well as the relative shortage of both doctors and allied health professionals in the island state.

“There was a shared understanding from health professionals and consumers that ‘no change’ is not a viable option,” the report said.

“Focus should be placed on collaborative, patient-centred disease management and prescribing models in order to improve consumers’ access to high quality care.”

AMA Tasmania president Dr John Saul told The Medical Republic that there were inaccuracies in the report which appear to have been lifted directly from Pharmacy Guild material.

“The key components were pretty much a copy-paste of a 2021 Pharmacy Guild recommendation paper on pharmacy scope of practice,” he said.

“And certainly, in digesting the full report, we’re finding a lot of Pharmacy Guild information is referenced in it, including a report on scarcity of doctors in certain areas of Tasmania.”

Pharmacy Guild economists and publications make up four out of the 84 citations in the report.

State Health Minister Guy Barnett announced that three separate pharmacy trials would be going ahead to explore the options put forward by KPMG: one on urinary tract infections and two looking at collaborative care models in rural and aged care contexts.

Here’s what we know so far.

Rural and remote

For the rural and remote pilot, the government has specified that pharmacists will enter into collaborative arrangements with GPs.

The GPs will make a diagnosis but delegate the function of prescribing a drug to the pharmacist.

Despite being the smallest state, Tasmania has a relatively dispersed population – even its two cities are classified as MMM2 locations.

In a section on access to primary care, the report references 15 suburbs or towns where GPs are not available, referencing Pharmacy Guild health economists.

The problem, Dr Saul said, is that this information on GP availability is at best outdated.

“One area for example … and they’re saying that there’s no GP available [but there is a pharmacy] – but there are at least 20 GPs within 20 minutes of this pharmacy,” he said.

The assertion that GPs are hard to access forms the basis for the recommendation to expand pharmacist scope of practice in rural areas – the one which the government has taken and turned into the rural and remote area collaborative prescribing trial.

“Pharmacist prescribing and/or supply for chronic conditions enhances access to healthcare services, particularly for patients in rural areas or those facing barriers to accessing primary care,” the KPMG report’s recommendation reads.

“Pharmacists can provide timely and convenient management for chronic conditions, improving patient outcomes and reducing healthcare disparities.”

While the report does acknowledge that some areas will have GP clinics within close proximity, it specifically pulls out Campbell Town as a location that requires “significant travel”.

“Campbell Town is now really well looked after by Ochre Medical and does have a regular supply of GPs,” Dr Saul said.

“So the report has some concerning data that it has used to form its conclusions … in terms of the scarcity of GPs.”

Dr Saul said KPMG had not contacted AMA Tasmania to clarify whether those areas were GP deserts or not.

“[KPMG] hasn’t consultant stakeholders like ourselves who know the GP footprint in those areas well,” he said.  

“[The area of] Stanley, for example – true, they don’t have a GP, but 10 minutes away are roughly another 10 or 12 doctors working at Smithton.”

Dr Saul said pharmacies, in fact, were either running at inaccessible hours or shutting up shop.

Urinary tract infections

The government’s media release on the UTI program was extremely light on details.

So far, it has not stated whether the trial will be connected to a university, when it will start or whether women will have to pay out of pocket.

The announcement that Tasmania will kick off pharmacist-led UTI prescribing comes just as Victoria opens expressions of interest for its own pilot.

The Victorian UTI program is not being run as a clinical trial, like NSW’s, but will instead be “guided by expert advisory and clinical groups representing consumers, pharmacists and doctors”, as seen in Queensland and WA.

RACGP Tasmania chair Dr Tim Jackson told TMR that he hoped Tasmania would follow NSW’s example.

“[If] it’s a university designed and implemented, then at the end of that implementation we have some solid information about whether this is a safe practice, which we consider that it is not,” he said.

While the college steadfastly opposes independent pharmacy prescribing for urinary tract infections, Dr Jackson said it would still be putting its hand up to be part of the working group for the trial.

“We think we’re better to be in the tent and trying to make things as safe as possible for our patients,” he said.

Aged care

For the aged care trial, pharmacists can work collaboratively with GPs to prescribe “within the safeguards of a treatment plan approved by the GP”.

“We know many GPs spend valuable time reissuing prescriptions for residents, rather than spending that time addressing residents’ emerging health needs,’’ Mr Barnett said.

The corresponding recommendation in the KPMG report specifically looks at aged care prescribing in an embedded, multidisciplinary care team setting.

“This model proposes a partnership in which the medical practitioner makes the diagnosis and the pharmacist prescribes medication (including dose titration) in accordance with an agreed upon clinical management plan,” it said.

“The prescribing of medicines is likely to take the form of prescribing via a supervised prescribing model or structured prescribing arrangement e.g. via a guideline or protocol.”

Collaborative models where the pharmacist is embedded as part of the care team is something the AMA has long called for, and Dr Saul said that – despite his reservations about certain aspects of the report – the association was supportive of this recommendation.