Two years after plans to expand community pharmacists’ scope were leaked to the press, it’s nearly showtime.
Despite countless petitions and relentless campaigning from medical organisations, from next week 300 pharmacists in North Queensland will be allowed to diagnose and prescribe for 17 different conditions.
In September last year, state Health Minister Shannon Fentiman announced that the trial was to be expanded statewide, rather than being limited to the north. The first tranche of community pharmacy training was already well under way when the announcement was made, meaning that North Queensland will still go live before the rest of the state.
The controversial pilot program has undergone significant delays since it was first leaked to the press in January of 2022, and half a dozen medical conditions have been dropped from the list.
Over the past two years, there have also been dramatic shifts in the wider primary care landscape.
Queensland’s UTI trial, the claimed success of which formed the basis for the expanded scope of practice pilot, was made permanent and every other state and territory has since launched its own version of pharmacist-led UTI prescribing.
Victoria, the ACT and NSW both went a step farther and allowed pharmacists to prescribe the contraceptive pill, with some pharmacists in NSW also given the power to prescribe for ear infections and minor skin ailments.
There’s also a national scope of practice review under way, which is due to report later in the year.
The conditions
Participating Queensland pharmacists will be able to autonomously prescribe for these 17 conditions:
- Gastro-oesophageal reflux and gastro-oesophageal reflux disease
- Acute nausea and vomiting
- Allergic and nonallergic rhinitis
- Impetigo
- Herpes zoster (shingles)
- Mild to moderate atopic dermatitis
- Acute exacerbations of mild plaque psoriasis
- Mild to moderate acne
- Acute minor wound management
- Acute diffuse otitis externa
- Acute otitis media
- Acute mild musculoskeletal pain and inflammation
- Smoking cessation
- Hormonal contraception
- Oral health screening and fluoride application
- Travel health
- Management of overweight and obesity
Six conditions were dropped from the original 2022 list, including asthma, COPD, hypertension and type 2 diabetes.
Pharmacists will still be managing all these conditions, but only under structured prescribing protocol and as part of a chronic disease management program.
The pay
Asked in the first week of February, Queensland Health was unable to confirm what the consultation fees will be, but it’s understood there will be three time-based levels.
Proposed costings included in the original leaked documents put the out-of-pocket payment for the lowest tier at $20 and the highest tier at $55.
Patients treated under the pilot will be required to pay fully out of pocket, with no help from either the MBS or PBS.
A Queensland Health spokesman told The Medical Republic that the fee schedule would be available on the pilot website when finalised.
Any pathology is also at the patient’s expense.
As part of the informed financial consent process, pharmacists are required to advise patients on where they could obtain the service for a subsidised price (i.e. their general practitioner).
“This pilot is designed to supplement, not replace, existing services and give consumers more choice,” a Queensland Health spokesman said.
“Pharmacists are highly trained, qualified and regulated healthcare professionals and this pilot will ensure their expertise is used to its full scope.”
The medicines
Unfortunately, there is no single central list of the medicines that pharmacists will be allowed to prescribe as part of the trial.
The Extended Practice Authority approved by the Director-General of Queensland Health only specifies which section of the Therapeutic Guidelines to consult for recommended medicines for each of the 17 conditions.
The guideline volumes referenced range from dermatology and rheumatology to oral health and addiction.
In six cases – wound management, otitis media, otitis externa, shingles, musculoskeletal pain and travel health – the EPA refers to more than one volume of the Therapeutic Guidelines.
Information on which guidelines are to be used in specific situations, along with flowcharts and “red flag” warning signs, are in a separate set of clinical practice guidelines developed specifically for the pilot.
While it wasn’t possible for TMR to do a comprehensive audit of all medicines, here are some that we do know:
- Orlistat, liraglutide and naltrexone with bupropion can be prescribed for obesity
- Topical corticosteroids can be prescribed for atopic dermatitis, acne and psoriasis
- Proton pump inhibitors can be prescribed for reflux
Participating pharmacists are required to communicate with the patient’s GP and healthcare team.
Related
Queensland Health would not specify how this communication would be achieved, other than “through a secure messaging platform”.
There are non-pharmaceutical management options for some conditions. Most are limited to advice and education, but pharmacists will also be empowered to clean and dress minor wounds and refer to QUITline.
The tests
Pharmacists are expected to do certain tests before prescribing, such as otoscopy for otitis media or otitis externa.
For rhinosinusitis, it’s a physical examination of the nose, throat, ears and eyes. If asthma or lower respiratory disease is suspected, pharmacists are instructed to do a chest examination using the clinical protocol from the Improved Asthma Symptom Control Program.
Obesity management comes with the largest battery of tests for pharmacists to consider, including HbA1c, the STOP-BANG questionnaire, the Australian type 2 diabetes risk assessment tool and the Kessler Psychological Distress Scale.
The acute minor wound management guideline requires pharmacists to initiate pathology testing for Gram stain, culture and sensitivity testing at the patient’s expense before antibiotics can be prescribed.
The training
In addition to holding general registration with the Pharmacy Board, participating pharmacists must complete a two-part prescribing course as well as a foundational training course on First Nations cultural competence.
Part one of the prescribing training was delivered by the Queensland University of Technology and included a 120-hour work integrated learning component wherein the pharmacist is supervised by an authorised prescriber.
Part two was delivered by James Cook University and covered clinical assessment, diagnosis and management of the conditions included under the pilot.
The first part runs over a 13-week semester and the second component takes about six months part-time.
The evaluation
Consulting firm Deloitte has a contract to undertake a “comprehensive service evaluation” of the pilot.
It will assess the program on six criteria: accessibility, continuity, effectiveness, efficiency/sustainability, appropriateness and safety.
Queensland Health advised that an online feedback form will be available on the pilot website that will allow both patients and clinicians the opportunity to provide feedback regarding their experience of pilot services.
