Those pushy pharmacists are at it again

Pharmacists say they have the knowledge and skills to prescribe. Not everyone agrees

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The pharmacy regulator has reopened discussion on whether pharmacists should be able to prescribe, but has failed to say why this change is needed or address conflict-of-interest concerns, the RACGP says.

A discussion paper released last week by the Pharmacy Board of Australia sets out three possible models: prescribing under a structured prescribing arrangement; prescribing under supervision; and autonomous prescribing.

It says pharmacists would have to “complete the required education and training”, obtain recognition from the board and authorisation from their state or territory, prescribe within their scope of practice, and maintain their competency to prescribe.

The paper is seeking submissions on the public need, evidence base, education and training and regulation required for the changes.

It says non-medical prescribing “may contribute to the delivery of sustainable, responsive and affordable access to medicines. It may reduce costs, increase access, and improve outcomes for patients without compromising safety and quality.”

RACGP president Dr Harry Nespolon said the proposal failed to make the case why pharmacists should prescribe in the first place.

“It doesn’t answer that fundamental question,” Dr Nespolon told The Medical Republic. “The vast majority of Australians can access a GP within 24 hours. It’s a solution looking for a problem.

“It says pharmacists who want to prescribe will need a significant amount of upskilling, so the report admits that prescribing is way out of their scope of practice.

“Then there’s this real issue about being both a prescriber and a supplier.”

The paper says any model of pharmacist prescribing will have to meet the Quality Use of Medicines standards, in which use of medications must be judicious, appropriate, safe and efficacious.

But Dr Nespolon said the commercial incentives would inevitably create a bias towards pharmaceuticals.

“Most GPs try to limit the amount of medication a patient is on, so there are fewer problems and interactions. But pharmacists will be making money off it, and they’ll do what they do all the time, which is try to sell you things. They should stick to their perfumes and probiotics and let doctors do the prescribing.”

In October a Queensland parliamentary inquiry recommended extending prescribing “low-risk” repeat prescriptions.

Dr Nespolon said that if patient convenience was a genuine motivation, pharmacists would not oppose situating dispensaries inside doctors’ practices or in supermarkets.

Pharmacy Guild of Australia spokesman Greg Turnbull told The Medical Republic that pharmacists already had the skills to prescribe, and that further online training could be provided on a per-drug basis.

He said the changes were needed “to ensure the skills and medication knowledge of pharmacists are put to best use and to make sure pharmacists are able to practise to their full scope of practice. We’re not asking for anything that pharmacists aren’t able and trained to do.”

He said commercial motivations were not unique to pharmacy.

“Doctors don’t work pro bono. But you’re talking about the separation of prescribing and dispensing, which is a principle that’s always had wide support. We believe there are cases where for the benefit of patients pharmacists should be able to dispense a prescription medicine without a prescription, subject to the ethical obligations that pharmacists sign up to when they join the profession.”

He said pharmacist prescribing already existed in the form of Schedule 3 medications, which can only be sold with the active involvement of a pharmacist but do not need a prescription. “There are many examples of those, we think there should be more. If someone’s on a medication for a long period of time then the dispensing should be able to continue without a piece of paper from the doctor. Obviously there are some drugs that would not be appropriate for.

“We’ve got a common-sense approach, we’re not trying to encroach on the turf of doctors that they’re so protective of.”

He said the aspiration was not to diagnose but only to dispense for minor ailments and infections such as recurring UTIs.

“We’re not extending into diagnosing complex medical conditions. It’s about a collaborative approach to best outcomes for patients.”

The paper cites New Zealand, the UK and some provinces of Canada, where pharmacists have some scope to prescribe. As of June 2016, there were 15 pharmacist prescribers in New Zealand, or 0.42% of the workforce.

A 2017 Cochrane review of non-medical prescribing in the UK, which has been in place since 2006 for pharmacists, nurses, podiatrists, optometrists, and physiotherapists, found generally positive outcomes against a backdrop of low doctor availability under the NHS.  Outcomes were comparable with medical prescribing on a range of measures including blood pressure, cholesterol, medication adherence and patient satisfaction, but there wasn’t enough evidence to draw conclusions about adverse outcomes.