Pharmacist prescribing blocked from PBS

Leading health economist Professor Stephen Duckett says pharmacist prescribing has a place, but only in healthcare teams.

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Under Commonwealth law, only doctors, dentists, optometrists, midwives and nurse practitioners are eligible to prescribe PBS medicines – a potential fly in the ointment for plans to expand Queensland pharmacists’ scope of practice.

A trial of pharmacist prescribing for urinary tract infections, in which pharmacists can independently prescribe antibiotics to women, is already under way in the state. 

The proposed new scheme, set to be rolled out across northern and central Queensland, would allow community pharmacists to prescribe and dispense medicines for 23 conditions, as reported by Australian Doctor last week. 

Both the RACGP and AMA have opposed the move, with high-profile health economist Professor Stephen Duckett – who has previously voiced limited support for pharmacist prescribing – now joining the chorus.

“I support pharmacist prescribing that in the context of a health team, where they are working with the general practitioner rather than in competition with general practitioner,” Professor Duckett told The Medical Republic.

“You don’t want to undermine general practice, you want to strengthen it.”

At the same time, he said because it was hard to get to see a GP in rural and regional Queensland, it was fair to look at alternatives. 

Under the leaked proposal pharmacists’ responsibilities would encompass diagnosis and management, not just prescribing.

Medical defence organisation MIGA CEO Mandy Anderson confirmed that such an initiative “needs to be supported by indemnity insurance”. 

“Pharmacists are already required to have professional indemnity insurance and the limit of cover they are required to have is the same as that required by doctors (ie. $20m per claim and in the aggregate),” she told TMR. 

Because pharmacist consults would not be bulk-billed, they would cost consumers up to $55, not including the cost of any medicines which are prescribed. 

Deciding which practitioners are allowed to prescribe which medicines is a state and territory responsibility.

When the trial of pharmacist-prescribed antibiotics for UTIs began two years ago, the Queensland government amended legislation to allow pharmacists to prescribe drugs for UTIs only. 

Presumably if the wider trial was to go ahead, more amendments relating to specific drug treatments for each of the 23 conditions would have to be passed. 

While Queensland could make pharmacist prescribing legal, patients would still have to pay full price for all PBS listed medications.

The PBS is a Commonwealth responsibility and does not list pharmacists as eligible prescribers for the scheme. 

Interestingly, NPS MedicineWise received Commonwealth funding just a year ago to update the Prescribing Competencies Framework in an effort to promote the quality use of medicines across all prescribing professions. 

Under the section dedicated to achieving quality use of medicines when prescribing, a key direction is “recognising the medicines may not be the most appropriate management strategy”. 

Other areas of the framework reiterate the society-wide threat of antimicrobial resistance and the need for antimicrobial stewardship. 

NPS MedicineWise did not comment on whether the current UTI prescribing trial or the proposed expanded trial represented quality use of medicines, except to say that the pandemic has shown the value of flexibility and adaptability in healthcare.

“The framework documents the skills required for a prescriber of medicines, regardless of profession, to ensure the quality use of medicines,” CEO Katherine Burchfield said. 

“It ensures that consumers receive a consistent standard of care regardless of the prescriber.”

Professor Duckett believes a pharmacy prescribing model would work best if embedded in general practice. 

He pointed to the CVS MinuteClinic model in the United States, where nurse practitioners or physician assistants diagnose and treat consumers in a co-located pharmacy-style store. 

“It’s not quite [equivalent to] pharmacist prescribing, but it is an example of prescribing done in a pharmacy,” he said. 

“But it’s the same in that it’s saying, ‘look, people are finding it difficult to get access to care, so here’s an alternate way of getting access.’”

While Professor Duckett said he felt the prices listed for pharmacist consults were a bit too high, he feels the initiative would be trending in the right direction, especially given the rural GP staff shortage. 

“[Rural Queensland] general practitioners are hard to get, and the [ones that are out there are] overworked,” he said. 

“Looking at alternate strategies, I think, is a good thing for [the health department] to do.”