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06 Sep 2019

BY AMA VICE PRESIDENT DR CHRIS ZAPPALA

The Community Pharmacy Agreement is currently being re-negotiated between the Guild and the Commonwealth Government. This perhaps explains the re-invigorated effort from the Pharmacy Guild to expand pharmacists’ scope of practice beyond their trained experience into the realm of the general practitioner who has significantly greater training in the correct disciplines and skills to safely and competently diagnose and treat patients. The alternate reasoning here is no more than a beguiling substitution of convenience (and profit generation) for quality and safety.

Some may regard this view as protectionist and old-fashioned, but the statement remains unassailably true and sensible. The measure of the success of an intervention cannot primarily be if the patient found it an agreeable and convivial experience. It clearly needs to be safe, evidence-based, quality care with meaningful outcomes and provided by the most appropriately trained individual.

Retail pharmacy owners i.e. the Guild (who need to be differentiated from the more numerous pharmacists working collaboratively in hospitals, general practice and elsewhere) want two main things:

  1. To dispense/prescribe more of anything they can possibly get their hands on.
  2. To offer medical advice as a ‘professional service’ to patients as a substitute for general practitioners (or anyone else really) with MBS funding to do so.

I suspect the sole reason retail pharmacy owners desire this is to increase foot traffic in their pharmacies so more supplements, foot massagers, perfume and over the counter drugs can be sold. In discussion with non-Guild pharmacists, a significant number realise offering medical advice is out of scope and fraught. It is observed that the profit made from dispensing PBS medications is comparatively small compared to the complementary medicine items (all of which are largely non-evidence based). In addition, the Commonwealth Government’s pharmacy ownership and geography rules create a small, protected group of pharmacists owning businesses at least partially insulated from true market forces. How cosy! 

Let us look at the two main desires of the pharmacy owners/Guild.

Dispensing whatever possible (which means they also shift more stock and have opportunity to up-sell).

The Guild’s own policy regarding safe and effective use of medication states the following:

“The separation of prescribing and dispensing of medicines provides a safety mechanism as it ensures independent review of a prescription occurs prior to the commencement of treatment.” Case closed. Pharmacists are conflicted (prescription for profit) and should never prescribe in accordance with the Guild’s own policies. It is a safety issue as the Guild points out – so let’s accept the only training appropriate to safely prescribe is a medical degree. Anyone can apply to do medicine – unlike pharmacy ownership! If the Guild is happy that prescribing and dispensing can occur simultaneously, then the ultimate convenience is if the general practice dispenses so patients only have one stop for all of their healthcare needs. Perhaps we can do away with retail shopfront pharmacy entirely?

As I’ve mentioned before, usurpers often abandon activities truly in scope that they have been appropriately trained for as they make a blatant grab for extended scope. For example, from the Guild’s own policy document again, the following: “Counselling is an essential element of the dispensing process, ensuring patients or their carers have sufficient information to enable an understanding of their medicines and the intended therapeutic effect, and to minimise the risk of adverse effects.” I know when I go to the pharmacy this never/rarely happens and the account of my patients supports this perception. The next professional service funded in the Community Pharmacy Agreement should perhaps be an examination of the number of times this in-scope counselling occurs and if it occurs, if it is evidence-based/helpful and not just designed to up-sell medicines with no evidence base.

I was recently asked to comment on a PharmacoEconomics article examining the cost savings associated with down regulation of the oral contraceptive pill so pharmacists could doll it out willy-nilly. The study was supported by Consumer Healthcare Products (CHP) Australia who represent the non-prescription medicines market.  Interesting…….

The handsome figure of savings reported in this study was however almost entirely due to a projected reduction in the live birth rate (in the fine print) not due to repeats being given by pharmacists, with a concession made that STI rates would increase. No mention of the lost opportunity in preventative/holistic care conducted by GPs, fragmentation and lack of any sense that re-appraisal of script appropriateness should occur periodically. This is not ‘better self-managed care’ as desired by CHP, but perhaps it is better profits?

If anyone had bothered to read the PharmacoEconomics issue in question, they would have also seen two other studies showing very nicely that women do not value the convenience of having a pill re-dispensed to them above a more fulsome discussion and understanding of risks/side effects and the duration of coverage (e.g. Implanon vs daily OCP) and that the cheapest contraceptive method (by far) was the longer-acting versions such as Mirena or Implanon. So, if cost is the governing variable, then down regulating the OCP to allow pharmacists dispensing is indubitably not the best option.

We need patients/consumers and Government to understand that the seductive allure of convenience or affordability is sometimes a deceptive veneer only and should never be allowed to eclipse quality, evidence and plain common sense.

Medical advice provided to patients in place of appropriately trained doctors.

A free discussion with a non-doctor to do a doctor’s job is never appropriate and would not be borne in other industries/professions so should not be accepted in health care. If you cannot examine patients, do not understand pathology or read the medical literature to stay up to date with current thinking, you cannot treat patients. Pharmacists embedded within a general practice team, however, provide an invaluable resource and this very positive and integrated team-based collaborative approach is where the Government should direct funding. This model has a strong evidence base (e.g. Ankie CM et al ScienceDirect 2018).

There is emerging, compelling evidence that OTC re-supply of Ventolin is leading to a dangerous under-treatment of mild asthmatics not on appropriate preventor therapy which could be prescribed by the GP if they saw them. Not only are exacerbations and symptoms greater (Reddel H BMJ 2017), but under-utilisation of inhaled corticosteroid is associated with an increased risk of death (Suissa S, NEJM 2000). When I’ve asked groups of pharmacists how on earth they are going to remain current with diagnostic and treatment guidelines to safely treat asthmatics – a group they think they can manage – I get frostily told this is entirely in scope for them and if any patients are more severe they can be identified and referred on to the GP (where they should have been in the first place).  This is precisely the problem – treating asthma is clearly NOT in the scope of practice for a pharmacist with a dispensing degree, and any attempted assessment regarding disease severity in this context is fraught and leads patients into further harm. How could anyone safely treat an asthmatic without listening to their chest? Insurers/litigators might be interested to get the data on patients repeatedly dispensed with salbutamol inhalers from their pharmacy without seeing a GP, who then succumbed to their disease?

The Queensland University of Technology recently published in JAMA (July 17, 2019) a study using standardised patients requesting emergency hormonal contraception and medication for conjunctivitis. They found that 31.3 per cent of pharmacies involved some form of overtreatment or overselling of medication. In ‘advising’ the standardised patients who had unprotected sex >72h prior (when the morning after pill is not indicated), appropriate management occurred in 16 per cent of cases only, whereas 80 per cent of patients were still provided with drug despite this being contrary to guidelines.  Conjunctivitis treatment was no better with confusion of allergy versus infection.

This report coincides with over-treatment similarly noticed in a Journal of Paediatrics and Child Health study examining pharmacist treatment of infant gastroenteritis which was reported recently in the popular media. Between getting it wrong and over-selling complementary therapies to patients the prospects appear grim for genuine, safe advice to be given. In a blinding glimpse of the obvious, the Australian Commission for Safety and Quality in Healthcare noted that prescribing for a urinary tract infection “requires the expertise of a medical practitioner” due to overarching requirements for antibiotic stewardship and understanding competing medical issues and when NOT to treat. The fact pharmacists think they can prescribe safely for UTIs demonstrates the poor knowledge and expertise underlying their expectations.

If convenience and cost is paramount, let patients get two or three months’ worth of drug at one time – a suggestion the AMA, PBAC and others have thought worthy of serious consideration. Let’s promote online options for patients (e.g. UberPharmacy) or dispensing in GP practices! If patients and the Government want convenience, there are many ways to achieve this that streamlines and shortens the medication supply chain from wholesaler to patients and saves patients from having to trudge to their pharmacy every month for medications, all without compromising the quality of community care that remains the sole purview of the general practitioner and his/her integrated team.


Published: 06 Sep 2019