Queensland pharmacists who undergo specific training can now diagnose and manage 17 conditions as part of the Queensland Community Pharmacy Scope of Practice Pilot, but will patient safety suffer as a result?

With the pilot underway, we asked GPs to weigh in.

Overall, GPs felt more comfortable with pharmacists’ prescribing medications for some conditions than others, Healthed’s April 30 survey of 1944 GPs revealed.

For example, 42% of GPs agreed that pharmacists will be able to safely prescribe medications for smoking cessation, 38% for rhinitis, and 36% for acute mild musculoskeletal pain and inflammation.

In contrast, only 10% thought this was true for acute otitis media, 14% for management of overweight and obesity, and 15% for acute diffuse otitis externa.

Lack of training was a key concern, raised by about 30% of respondents who commented.

“How can 12 months’ training equate to full medical training and ongoing clinical experience?” one GP asked.

Other doctors raised concerns about overuse of antibiotics, lack of continuity of care, and conflicts of interest leading to compromised outcomes.

“I’ve seen so many problems already,” another GP said. “For example, someone with shingles who went to three pharmacies, each time being sold something different, with no-one recognising the obvious zoster.”

Tasmanian GP Dr James Freeman feels so strongly that he started a change.org petition against the trial.

Pharmacists shouldn’t try to be doctors, he argues, “because they don’t know what they don’t know.”

“Pharmacists were never trained in the art of medicine. They were trained in the art of pharmacy,” he says.

“And to actually be able to prescribe, there’s a prerequisite component, which is that you can accurately diagnose.”

He argues that the additional training pharmacists will get won’t be enough to catch up with the thousands of hours of training and hands-on practice doctors have in diagnosing people.

“Nobody would suggest that somebody who’s done first year TAFE should build a house, because the house would probably fall down,” he says. He believes that inadequate training and lack of experience will lead to real harm.

For example, Dr Freeman cites the case of a patient who diagnosed themselves with reflux and got Nexium from the pharmacy without seeing a doctor.

“And that continued on ad infinitum. And his underlying problem wasn’t reflux, it was oesophageal cancer – and that’s going to kill him.”

How are participating pharmacists trained?

To participate in the trial, pharmacists need to complete courses with Queensland University of Technology and James Cook University (JCU) which include:

• training in safe prescribing aligned with NPS MedicineWise’s Prescribing Competencies Framework covering clinical therapeutics, safe prescribing and quality use of medicines, plus a practical component under the supervision of an authorised prescriber.
• a clinical training component covering health assessment, clinical examination, and diagnosis and management of specific conditions, integrating safe prescribing practices.

Professor Peta-Ann Teague, a GP who has been training pharmacists doing the JCU component, describes it as “very demanding.”

She says participants gain a deeper understanding of the biopsychosocial model and how to appropriately assess and manage patients in a way that time constraints previously prohibited.

“So instead of having 30 seconds at the front counter where you’re being interrupted by people waiting for prescriptions, they can actually take the time to adequately and appropriately assess the patient,” Professor Teague says.

In the pilot, consultations must be conducted in a private room equipped for confidential, sit-down conversations and patient examinations.

Pharmacists are trained to look for red flags, she adds. So, in Dr Freeman’s example of the patient with reflux, that would mean discontinuing the Nexium and contacting the GP urgently, she explains.

Can potential conflict of interest be overcome?

One of the most common criticisms of pharmacy prescribing is that pharmacists can profit off what they prescribe, creating a clear conflict of interest. About 25% of GPs who commented raised concerns about commercial motives and conflict of interest, which one GP called an “insurmountable problem.”

“There’s that fundamental conflict between doing what’s right for the patient and what’s more profitable,” Dr Freeman says.

Professor Teague acknowledges this is a concern that pharmacists will need to work through, but says the course includes teaching about biases, and notes that many pharmacy consultations will likely not involve prescribing.

“I think there’ll be quite a lot of motivational interviewing, assessment and advice, and co-management with the GP or other allied health professionals.”

Professor Teague says her experience working in regional and rural Australia over the last couple of decades, and seeing the difficulty patients have accessing care and the pressure GPs are under, has motivated her to get involved in training pharmacists, who she says are deeply committed to the communities they’re working in.

“We’re not importing them from the cities, we’re not forcing them,” she says. “These pharmacists are already living and working in these communities. Their kids go to the local school.”

If you do have a pharmacist-prescriber in your area, Professor Teague recommends having a chat to see how you can work together to provide patient-centred care that doesn’t duplicate.

At the end of the day, outcomes of this pilot, like other pharmacy prescribing trials, will be evaluated by an external assessor, she adds.

What your colleagues are saying:

“Clinical acumen does not come from doing a short course and pushing drugs/products you stock. It is insulting to GPs to imply all people need for everything is a pill and a five-minute discussion. ‘Old wives’ tale’ diagnoses and treatments will be further pushed by these inexperienced chemists.”

“Pharmacists have a useful role in the diagnosis and management of acute illness where a GP may not be available.”

“It will be the equivalent of medicine in the third world i.e. it will mostly work but standards will be low.”

“Pharmacists can do all of the above after enrolling into a medical college, do the hard work for years including internship at hospital and get a degree in medicine.”

“Pharmacists complained about threat to their earning with 60-day prescribing, but happy to steal GP profit.”

“I am unsure exactly what their role should be, but they should be able to provide repeat scripts for long-term conditions within certain timeframes, give treatment for common acute illnesses/conditions including antibiotics, creams and drops— particularly with GPs much less accessible in a timely fashion.”

“There has traditionally been a complementary role between the two groups. More fragmentation of services by multiple providers with the expected reduction in effectively communicated information does not bode well for optimising either outcomes or costs.”