Pharmacy prescribing? The guild wants it all

Every community pharmacist should be allowed to prescribe autonomously, the industry lobby says, to reduce high out-of-pocket costs from GP visits

---

Every community pharmacist in Australia should be allowed to prescribe autonomously, the industry lobby says, to reduce high out-of-pocket costs from GP visits.

In its submission to the Pharmacy Board of Australia’s discussion paper on three possible models for pharmacist prescribing – under a structured prescribing arrangement, under supervision and autonomously – the Pharmacy Guild of Australia ignores the first two, saying autonomous prescribing “would be the only effective method to fulfil the public need”.

“We do not believe that there are any gaps in the evidence for pharmacist prescribing under this model,” it says. “We do not believe that any further evidence needs to be obtained as this particular model has been proven to be effective and safe in similar countries such as the UK and provinces in Canada such as Alberta.”

The forcefully worded, but somewhat thinly argued submission, says pharmacists in all 5700 community pharmacies should have unrestricted right to prescribe, including Schedule 8 medicines, and should not have to be accredited to deliver medication management reviews in order to do so.

The guild’s suggested requirements, based on the UK model, are “at least two years’ appropriate patient-orientated experience post registration; an identified area of clinical or therapeutic practice in which to develop independent prescribing practice; [and] a designated prescribing practitioner who has agreed to supervise their learning in practice”.

On education, the guild acknowledges further training would be required in some competencies, and then refers the PBA to a 2017 paper on pharmacist prescribing in Australia which the PBA itself commissioned.

“Australians spend [sic] $738 million in out of pocket expenses for Medicare-funded GP visits in 2016-17,” the submission says, citing AIHW data.

“If pharmacist prescribing is to contribute to the delivery of sustainable, responsive and affordable access to medicines then prescribing has to be autonomous. Prescribing under a structured prescribing arrangement or under supervision relies on another healthcare professional and will therefore not be flexible enough to meet the needs of all Australians who for example may live in a rural or remote area where there is no or very limited access to a medical doctor or nurse practitioner.”

The Australian Medical Association, in its submission to the discussion paper, noted that maldistribution of healthcare professionals in rural areas applies to pharmacists as much as doctors.

The AMA and the RACGP strongly oppose pharmacist prescribing, citing lack of need, lack of training, conflicts of interest, incentives towards overmedication, compromised antibiotic stewardship and an increased risk of medication errors.

While the RACGP rejects all three models outright, the AMA supports “non-medical practitioner prescribing within collaborative models of healthcare where non-medical health practitioners work as part of a medically led team”, but opposes any prescribing by retail pharmacists.

The pharmacists have the conditional backing of Professor Stephen Duckett at the Grattan Institute, however, whose submission supported all three models. “Autonomous prescribing should be restricted to pharmacists employed in large hospitals, and prescribing under supervision should be restricted to hospitals and selected larger practices,” he wrote.

Professor Duckett told The Medical Republic that, contrary to the medication errors claim: “With more people with comorbidities, and hence more medication and medication interactions, increasing involvement of pharmacists in medication management and prescribing could plausibly lead to reduction in the risk of medication errors and adverse reactions.” 

The guild says the Queensland pilot of pharmacists administering influenza vaccinations was successful, resulting in more people receiving the vaccination.

“The fact that pharmacists can be trained to administer vaccines safely and effectively in Australia shows that pharmacists can be trained to extend this to other prescription medicines to ensure improved access to medicines for all Australians.”

Under the heading of how the Quality Use of Medicines standard will be upheld, the submission cites two UK studies which found that “overall, nurse and pharmacist prescribing is currently safe and clinically appropriate” and “prescribing pharmacists can provide a valuable role in safely prescribing for a broad range of inpatients in UK general hospitals”.

It does not address how the proliferation of prescribers will ensure the “judicious, safe, appropriate and efficacious use … by minimising overuse of medicines, reducing adverse events” and other elements of quality use.

Asked about potential risks, the guild does not concede any risk associated with autonomous prescribing, but says the other two models will not give Australians sufficient access to medicines.

On the issue of commercial conflict of interest, the guild says the AMA’s policy for doctors who dispense should apply equally to pharmacists who prescribe. It notes a Medical Journal of Australia paper on dispensing doctors, which “found no evidence that Australian dispensing doctors overprescribed because of their additional dispensing role. Likewise, there would be no reason to suspect that pharmacists would overprescribe”.