Time to end anti-competitive pharmacy rules

The Productivity Commission backs expanded scope of practice trials, but wants them to be evidence-based.

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The Productivity Commission has recommended trials expanding the scope of practice for health practitioners such as pharmacists “where supported by evidence”, but has also repeated its call to end the anti-competitive rules around community pharmacies.

“State and Territory Governments should undertake trials for expanded scope of practice in health services where supported by evidence,” it says in its 5-yearly Productivity Inquiry report.

“[They] should undertake similar trials as those run in New South Wales and Queensland with regard to the prescription scope of pharmacists’ providing vaccinations and low-risk medications … the novel arrangements that are the subject of these trials [should be] given equivalent funding through the Medicare Benefits Schedule or the Pharmaceutical Benefits Scheme, where the benefits are substantiated.”

The report also says the government should reduce its regulatory footprint to increase competition, including by “removing anti-competitive regulations on the ownership and location of pharmacies”.

The pharmacy location rules, which exclude pharmacies from being set up within 1.5km of each other, have been enshrined in Community Pharmacy Agreements since 1991, with the details negotiated between the Commonwealth and the Pharmacy Guild every five years. State and territory rules restrict pharmacy ownership to pharmacists and their family members.

The Productivity Commission, which first complained about the anti-competitive rules in 1999, says in the current report that both sets of rules dampen competition at cost to consumers and limits consumer healthcare access rather than ensuring it.

Location rules are usually applied to “minimise adverse social outcomes”, such as gambling in vulnerable communities, the report says. The pharmacy location rules, however, “stand in stark contrast to this. Rather than restricting an activity that could be expected to have an adverse social or environmental outcome, the Government restricts the location of a business that contributes to community health and wellbeing, and thereby limits the scope for getting improved outcomes for consumers”.

Pharmacist prescribing is currently a state-by-state proposition, but in his speech to the pharmacists’ conference APP23 yesterday – in which he spoke of his cherished role as “servant leader” – Pharmacy Guild president Professor Trent Twomey said the group would be negotiating to have “scope of practice” enshrined in the eighth Community Pharmacy Agreement.

“I am determined that the next agreement, whose negotiating effort will be headed by Anthony Tassone, is not a mirror of the seventh agreement but rather builds on the seven other agreements and learns from them, including capturing full scope of practice,” he said. 

Queensland Health is forging ahead with the North Queensland Scope of Practice Pilot, for which expressions of interest closed this week, even though training program accreditation standards have not yet been finalised.

Asked by newsGP on Tuesday about supervision and accreditation, a Queensland Health spokesperson refused to answer, citing newsGP’s lack of independence as a media outlet.

“Your service is a media arm of RACGP, which is an advocacy and membership organisation,” the department told newsGP. “Our team’s scope is to engage with traditional media outlets and journalists independent of these groups.”

TMR, as a proudly independent if not quite traditional media outlet, stepped in and offered to put the same questions to Queensland Health, which included:

• Why is the pilot starting before those standards are available? 
• What guarantees can QHealth provide about the proper supervision of participants in remote locations?
• How will the pilot address workload and stress issues for pharmacists?

Queensland Health barely addressed any of these questions in its response:

“We know from international experience, and from the findings of the Australian Government Productivity Commission, that using pharmacists and other health professionals to their full scope of practice is a safe, efficient and effective way to improve access to healthcare.”

(Click here for a deep dive into that claim.)

“Pharmacists working to their full scope of practice can lessens the impacts of workforce shortages and distribution problems, particularly in regional and rural communities. 

“The workload of community pharmacists was considered during the planning and development of the [pilot].

“Participation in the Pilot is voluntary. Pharmacists who choose to participate must complete a postgraduate training program in prescribing, which includes 120 hours of supervised learning in practice with a designated prescriber.

“The training program aligns with the recognised national Prescribing Competencies Framework and is overseen by the Queensland University of Technology to ensure it is appropriate for the scope of the pilot.”

Meanwhile the RACGP has sought to dissuade South Australia from going down the same path, calling it “a recipe for disaster”.

Citing the Professional Pharmacists Association’s submission to the SA Select Committee on Access to Urinary Tract Infection Treatment inquiry, RACGP president Dr Nicole Higgins said “pharmacists just don’t have the capacity to take on these additional responsibilities”.

“The union’s state director Paul Inglis has said that workforce shortages and demands on pharmacists’ time are already resulting in high levels of work stress and burnout,” she said.

“So, any additional work, such as pharmacist prescribing, will only add to this burden.

“His submission also hits the nail on the head when it comes to why we have always separated prescribing and dispensing powers. Mr Inglis clearly states that his organisation is concerned about how the potential conflict of interest between prescribing and dispensing medications will be managed.

“I couldn’t have said it better myself. Let’s stop this madness before it’s too late.”

The PPA’s submission raised concerns about the UTI Pharmacy Pilot Queensland (UTIPP-Q) trial – the forerunner to the North Queensland Community Pharmacy Scope of Practice Pilot – saying there had been “inadequate consultation with employee pharmacists and Professionals Australia in the design, implementation and assessment” of UTIPP-Q.

“We recommend that pharmacists are fairly compensated for performing additional services,” Mr Inglis said. “We are concerned that professional indemnity insurance premiums for pharmacists could increase as pharmacists assume greater responsibility.

“Any increased insurance costs will unfairly fall on working pharmacists – the impact of insurance costs will need to be monitored and addressed in pharmacists’ remunerations.”

Dr Higgins said she felt the Pharmacy Guild of Australia was driving the issue, rather than pharmacy workers themselves, and did not have their interests at heart.

“Employee pharmacists are among the lowest paid health professionals in Australia and are often under immense pressure. GPs have a very good relationship with our local pharmacists, and we don’t want to see them put at risk because of commercial imperatives.”

RACGP South Australia Chair Dr Sian Goodson agreed.

“There really is no substitute for GP care. If South Australia goes down the path of pharmacy prescribing, including for UTIs, we will see poor patient health outcomes,” she said.

“Along with many other medical bodies the RACGP has also long been arguing about risky moves to allow retail pharmacists to prescribe antibiotics and other medications. It can lead to overprescribing because when your only tool is a hammer every solution is a nail.

“Also, the introduction of more prescribers goes against antimicrobial stewardship efforts so now is definitely not the time to introduce additional prescribers as we fight one of the great public health challenges of the 21st century.

“We need serious investment in general practice care, not band-aid solutions that put pharmacy owner profits ahead of patient safety.”