Trials of limited pharmacist prescribing are progressing in NSW and Queensland (and planned in Victoria) despite disagreements between provider groups about whether an increased role for pharmacy could help alleviate pressures on general practice and increase access to care.
To date the consumer voice on this issue has been largely missing from public and media debate, but behind the scenes the Consumers Health Forum of Australia (CHF) has been engaging with member groups and consumers through a range of mechanisms, including a member survey and a webinar held on 28 February.
Croakey editor Jennifer Doggett attended the webinar, and reports below.
Jennifer Doggett writes:
Eighty-five percent of consumers surveyed by the Consumers Health Forum of Australia (CHF) support some form of pharmacist prescribing, a webinar was told last night.
The webinar was hosted by CHF CEO Dr Elizabeth Deveny and included a presentation from CHF Research and Data Policy Officer, James Ansell, on the Forum’s survey on pharmacy prescribing issues. This was followed by a panel discussion and questions.
Findings
The survey revealed that consumers were broadly supportive of some form of pharmacy prescribing with 85 percent of the 131 respondents stating they would be happy to for a pharmacist to prescribe a prescription in some situations.
Only one in four of people surveyed were opposed to any form of pharmacy prescribing and only one in ten did not support a role for pharmacists in providing repeat prescriptions.
The majority of consumers surveyed also agreed that restrictions needed to be placed on pharmacists’ prescribing, and that they should have a reduced scope compared with GPs.
Reasons for support
Reasons given by consumers in the survey for supporting some form of pharmacy prescribing included:
- Trust in pharmacists as medication experts who are well positioned to give advice on medicines
- Familiarity with pharmacists as a first port of call when dealing with minor health problems
- A belief that this could save time and resources
- Experiences of having to wait extended periods of time to see a GP, in particular in rural areas and after hours. Pharmacist prescribing was seen as filling a gap in services for people for health problems which need immediate attention but are not serious enough to require attendance at an ED
- A belief that pharmacist prescribing could reduce demand on GPs and free up their time for other patients with more serious health needs.
Safety and quality concerns
Those who were opposed to pharmacy prescribing mostly cited safety and quality concerns, including:
- A belief that pharmacists do not have the knowledge or facilities to accurately diagnose patients
- Concerns that pharmacists would not have access to consumers’ health history, which would make it difficult to make accurate diagnoses and identify the most appropriate medications
- A perceived lack of appropriate facilities in pharmacies for patient consultations, such as private rooms
- Concerns around financial conflict of interest if pharmacists are both prescribing and dispensing medicines.
Some consumers also stated that they saw a value in pharmacists providing a second opinion and safety check on GP prescribing and that removing this additional scrutiny could increase the risk of adverse events.
In practice
Consumers surveyed by CHF expressed diverse views about how pharmacist prescribing could work in practice.
In general, most supported a role for pharmacists in prescribing low risk medications, with restriction on the medicines they could prescribe and conditions they were able to diagnose and treat.
Many consumers felt that pharmacists should not be able to prescribe medications for new and/or complex conditions or for those which require tests to diagnose.
They also felt that pharmacists should not be able to prescribe certain medications, such as potentially addictive pain medications or those medicines needing close dosage management.
Some raised concerns about allowing pharmacists to prescribe antibiotics, given the need to carefully manage antibiotic use to minimise the development of antimicrobial resistance (an issue of concern also highlighted elsewhere at Croakey this week).
However, others identified the advantages of pharmacists being able to provide antibiotics in limited situations, for example to treat urinary tract infections.
Consumers surveyed also provided suggestions for the effective implementation of pharmacist prescribing including:
- Additional training for pharmacists to ensure they can prescribe safety
- Inter-operable records between pharmacy and other providers, including general practice, to ensure pharmacy prescribing doesn’t add another silo to primary health care
- A private consultation room to ensure confidentiality for patients
- Limits on number of prescriptions able to be issued by a pharmacist until a GP visit is required
- A requirement for bulkbilling to ensure consumers don’t incur out-of-pocket costs or need to use private health insurance
- A health literacy campaign to educate the community about the role of pharmacy prescribing and when it is appropriate.
Some were concerns raised about the impact that pharmacy prescribing could have on broader health system issues. These included:
- Whether pharmacy prescribing is a Band-Aid solution being developed by governments to the problems with access to general practice while not actually solving that problem
- If increasing data linkage between providers could raise risk of data misuse and leakage
- If pharmacists take on additional prescribing roles, there is a possibility this could lead to delays in the provision of other pharmacy services.
Focus on aged care
The webinar also included a panel discussion between a consumer, Aish Naidu, Dr Fei Sim, President of the Pharmaceutical Society of Australia, and Dr Michael Nolan, a GP with particular expertise in aged care.
Panel members provided their views on three different scenarios for pharmacy prescribing: non-dispending pharmacists in aged care; prescribing in rural and remote areas; and prescribing of antibiotics.
Prescribing by non-dispending pharmacists in aged care is already occurring on a trial basis in some areas and in an online poll conducted during the webinar, it was supported by a majority of participants. (61% yes, 19% no, 22% not sure)
However, Nolan disagreed with this practice, stating that this was asking pharmacists to step outside their skill set as it would require them to diagnose conditions without the requisite skills in clinical examination.
He suggested that it could only work in very limited situations; for example, providing COVID antivirals at weekends when the GP is not available.
Sim clarified that pharmacists would never say they have the same scope of practice as GPs but said that they may still have a role in working at their full scope of practice to address current access problems in primary healthcare.
Sim argued that giving pharmacists prescribing rights for chronic condition already diagnosed and stable would free GPs to do more urgent and complex care.
She suggested three key conditions for successful pharmacy prescribing:
- A clear consumer need
- Multi-disciplinary collaboration between pharmacists and GPs.
- No compromise in the safety of medicine use.
Aish Naidu reflected on her own family’s very negative journey with healthcare and pointed out that coordinated and seamless care was not always provided currently.
She supported pharmacy prescribing for repeat prescriptions but expressed concerned about the possible risks for vulnerable patients and those without good health literacy.
Rural and remote
In considering the role of pharmacy prescribing in rural and remote areas, Sim pointed out that pharmacy infrastructure already exists in these areas so it is well-placed to address the current inadequate access to GPs, due to long wait times and a reduction in bulkbilling.
Naidu also expressed support for rural pharmacy prescribing and highlighted the need for private consultation spaces, particularly in rural communities where everyone knows each other.
Nolan acknowledged that rural pharmacists in towns without a GP have a special role and could potentially take on some additional responsibilities from GPs on an interim basis.
However, he questioned the need for pharmacists to provide repeat prescriptions given that GPs are able to provide prescriptions for 6-12 months where appropriate.
He also pointed out that many pharmacies are also closed after hours so may not address this access issue.
Pharmacist prescribing in rural areas was the most strongly supported of all the scenarios discussed in the webinar with almost three-quarters of participants casting a ‘yes’ vote. (72% yes 21% no 7% not sure).
Antibiotics
The panel raised many of the concerns expressed by consumers about pharmacists prescribing antibiotics.
Naidu felt it could work if this was done in conjunction with a GP and it might have some advantages for patients if it meant they could avoid sitting for long wait times in the general practice.
Nolan highlighted the complexities involved in prescribing antibiotics and the vital need for stewardship in this area to avoid running out of effective antibiotics and creating superbugs.
In his experience, at least 70 percent of respiratory infections in children are caused by viruses (where antibiotics are ineffective) and he questioned whether pharmacists would be able to distinguish between bacterial and viral infections in patients.
Sim suggested that pharmacists should be given authority to exercise their judgement on specific conditions and stressed the advantages of providing timely access to antibiotics in some cases, such as urinary tract infections.
She said that pharmacies now provide more than 50 percent of COVID-19 vaccinations, which she believes is evidence of a consumer preference for receiving some services from pharmacists.
She also said there could be some advantages to pharmacy prescribing, such as providing an opportunity for them to educate consumers and also for altering dosages or de-prescribing.
In the online poll a majority of respondents (59%) voted ‘yes’ to antibiotic prescribing by pharmacists with 30% voting ‘no’ and 10% ‘not sure’.
Governance matters
The issue of funding for pharmacy prescribing was raised by consumers in the discussion with attendees expressing a preference for pharmacy prescribing services to be bulkbilled or incur no out-of-pocket costs to consumers.
Sim acknowledged concerns around cost and also suggested that it was important that pharmacists are fairly remunerated to ensure prescribing services are sustainable.
Clinical governance was highlighted as an important issue, in particular as pharmacy prescribing may reduce the scrutiny on medicine use which currently occurs when both the GP and pharmacist are involved.
All panel members agreed on the importance of developing robust governance processes, including clarifying medico-legal responsibility for adverse events.
Naidu stressed the need for culturally appropriate services and panel members also discussed the need for improved communication between GPs and pharmacists.
Sim said that these have improved since pharmacists took on a role in COVID vaccination but stressed the importance of ‘real time’ sharing of information between providers so that consumers experience seamless care.
Next steps
CHF undertook to monitor the pharmacy prescribing trials being undertaken around Australia and encouraged participants to continue the conversation with CHF on this issue via social media.
Dr Elizabeth Deveny also suggested that consumers engage with the Pharmacy Board of Australia, which is responsible for developing accreditation standards for pharmacist prescriber training programs, which will involve consumer input and public consultation.
Other perspectives
Pharmacy Board of Australia position statement
Pharmacy Guild statement: Autonomous pharmacist prescribing standards to be developed
Royal Australian College of General Practitioners statement: Queensland pharmacy trial risks poor health outcomes and higher costs for patients
Australian Medical Association statement: Pharmacist prescribing a dangerous proposition which won’t fix workforce issue
National Aboriginal Community Controlled Health Organisation (NACCHO) statement: Pharmacy led pushes for extended, independent scope of practice threaten to erode the quality of primary health care provided to Aboriginal and Torres Strait Islander people
See Croakey’s extensive archive of articles on safety and quality of healthcare
