The NQ Pharmacy Trial: A Hard Pill to Swallow

By Dr Elise Witter, Committee of Doctors in Training Rural and Remote Special Interest Interest Group Deputy Chair

I remember being a first-year medical student, on placement in a rural GP practice. A distressed child was brought in by his mother, snotty-nosed and tugging at his ears. My supervising GP pulled out his otoscope, imploring me to have a look. Despite rote learning the tips to position a squirming child from my lectures, the practicalities proved much more difficult. It took two people wrangling and several attempts before I finally caught a glimpse of the inflamed tympanic membranes. Or wait, was it actually the external auditory canal? 

My supervising GP waited patiently for me to pronounce a diagnosis as I dithered helplessly, racking my brains for the images from the textbooks, my ruminations interrupted by the high-pitched wailing of a toddler with what turned out to be an otitis media. I studiously listened as the GP patiently explained that most cases of otitis media are viral in origin, that no antibiotics were indicated in this case, but that regular simple analgesia and some topical local anaesthetic drops would help. A few minutes later, patient and parent left the office both smiling, a bravery sticker proudly displaced on the child’s t-shirt. Afterwards, the GP and I reflected together on the challenges of antimicrobial stewardship, managing patient expectations and how to differentiate otitis media and otitis externa.

Seven years of study and three years into my clinical training as a doctor later, I’ve looked in hundreds of ears and confidently diagnosed what I’ve seen, occasionally with a second glance or some advice from a senior doctor when I’ve faced that same uncertainty I encountered in that GP practice. It was this experience that came to mind as I read with a sinking heart about the proposed North Queensland Pharmacy Trial. A trial that proposes that retail pharmacists diagnose and treat 23 conditions autonomously, ranging from otitis media to diabetes, reportedly after just 120 hours of online training. After much more than 120 hours training, I still needed additional practice and supervision to diagnose and confidently manage a simple case of otitis media, to differentiate between cases where antibiotics were indicated and to identify and manage rare but serious complications. How can anyone be expected to safely manage this with such little training, as well as diagnosing and managing much more serious conditions such as heart failure and diabetes? How can safe clinical decisions be made without full access to investigations, specialist referral options and clinical history? 

There are insurmountable problems with this trial. To a person with a hammer all problems look like a nail, and when medications are the only tool in your arsenal, this is what will be offered. This puts patients at risk from inappropriate and unnecessary prescribing, as well as escalating antimicrobial resistance, one of the leading causes of death globally. Medicine is more than writing scripts for medications; it is a collaboration between doctors and their patients to meet their health goals through a variety of interventions, with medications forming just a small part of the toolkit. To care for someone with diabetes requires blood tests, metabolic monitoring, lifestyle modification, diabetes education, dietetics, regular reviews, monitoring for complications and referral to specialists when needed. Entrusting this task to someone without access to these additional services and investigations, with limited resources to document and follow up patients is a clear threat to patient safety and fragments care in the community. This has already been evidenced by the UTI Pharmacy Pilot trial, where one in five GPs have reported seeing complications from pharmacist-initiated prescriptions for UTIs, including missed pregnancies, STIs and cancers. 

Pharmacists have an essential role in the healthcare system. They ensure medication safety, avoidance of interactions and provide additional checks and balances. If pharmacists are allowed to prescribe a range of drugs, an extra safety net in avoiding medication errors and harm to patients is lost. That is not to mention the clear conflict of interest – if you are both prescribing and selling a medication, there is incentive for pharmacy owners to pressure pharmacists to prescribe for profit instead of medical indications. AMA Queensland's survey found almost 97 per cent of women were prescribed antibiotics and one in two pharmacists would have found it difficult to charge the service fee and not also supply antibiotics. The result will be a medication-centric approach to health, driven by profits rather than patient wellbeing. Even more concerning, there is no clear independent regulatory monitoring that will allow evaluation and response to inappropriate prescribing. 

Proponents of this trial claim that it is a solution to a GP shortage and limited accessibility of primary health care services, especially in regional areas. As a doctor-in-training in North Queensland, I fear the opposite is true. Working in Cairns, there is already difficulty in recruiting and retaining GP trainees. Responders to the AMA Queensland survey indicate that the trial would put them off training in the area. With the prospect of managing more complex patients and complications from this ill-thought out trial as a GP trainee, there is limited incentive to work in regional areas. The population my colleagues and I care for in North Queensland is already vulnerable, with a large proportion of Aboriginal and Torres Strait Islander people. Any proposal that disincentivises doctors-in-training and offers up a substandard alternative to healthcare will exacerbate health care inequities and widen the gap for our patients in regional and remote areas. 

These problems have been well recognised. Virtually every professional body initially involved, from the National Aboriginal Community Controlled Health Organisation to AMA Queensland and the RACGP, has withdrawn their participation from the trial. The Professional Services Review has advised that the trial runs contrary to Commonwealth Law, and contradicts the advice of the Therapeutic Goods Administration. Despite this, the trial forges ahead, driven by “election commitments” and political grandstanding. 

This trial is a risk to patient safety. It represents a threat to the sustainability of healthcare in regional areas, rather than a solution. A real solution would be investment in primary care, in a system that appropriately reimburses pharmacists for their expertise, and a shift towards preventative community-based care. We must advocate for the safety of our patients, and continue to fight the implementation of this trial.