Following the release of Pharmaceutical Society of Australia Report “Pharmacists in 2023: Roles and Remuneration”, we would like to address the findings of last month’s review by the WA government that recommended the scope of professional pharmacist practice should be expanded to include a wider range of health care activities.
An article published by the ABC, Pharmacies could hand out prescriptions for medicines under major WA health care reforms indicated that “pharmacies could be given a dramatically expanded role in the healthcare of WA patients, with their scope widened to include mental health care, chronic disease management and issuing repeat prescriptions for ongoing medications including the contraceptive pill.”
Based on the WA Government’s Review of Community Pharmacy Ownership in Western Australia, the article points out areas to expand pharmacy services to include; hospital discharge, mental health support, monitoring and prescribing for chronic illness, and expanding immunisation services.
The Western Australia branch of the Australian Medical Association described it as “a wish list for pharmacists who want to be doctors” whilst the Pharmacy Guild of WA welcomed the review.
This news from Western Australia generated some varied responses from pharmacists prompting a response from President, Dr Geoff March.
Jared: “We are not doctors, but diagnosis was taught extensively during my degree. I think continual dispensing is within our scope, if we make sure the persons condition is monitored ongoing. If any changes, the patient should be referred immediately.” Omolola: “…with a master’s in clinical pharmacy and a PharmD, there are some things a pharmacist can prescribe pending when the patient has access to a medical doctor.”
Dr Geoff March (GM): Pharmacy should be integrated into the health system and not be treated as a separate entity.
There needs better communication between the prescriber and the patient’s pharmacist. For example, the medication management plan should be shared with the pharmacist who is in a position to systematically monitor the progress and outcomes of medication plans, adjust doses in line with the parameters of the plan, and refer the patient back to the prescriber in a timely when outcomes have not been achieved in the expected timeframe, or the condition is worsening. It seems such an approach would be particularly suitable in the care of people with chronic illnesses.
There are current models for pharmacists to prescribe to a limited extent. Other health professionals can dispense a limited number of specified medications following an approved accreditation course. What is critical is that the prescribing pharmacist is not the dispensing pharmacist except in specific circumstances. In a sense, pharmacists prescribe medicines autonomously in the Over the Counter (OTC) area of practice. There are defined protocols that guide a pharmacist OTC prescriber through this process, along with clearly written professional obligations.
Sky: “…I don’t think the Guild, or any pharmacists think for one second that we are doctors, but we could certainly step in for some minor ailments where Drs are unavailable, especially in rural setting. Pretty sure extensive training would be required anyway… We certainly have the basic textbook knowledge.”
GM: Currently, undergraduate programs provide “basic textbook knowledge”, with limited exposure to clinical practice but it is not comprehensive to the level that several years of clinical experience and ongoing experiential social and administrative learning, so it makes sense to provide extra training. That said, pharmacists administer flu shots, help with common ailments like the flu or gastro, even provide medical certificates. With that in mind, it’s forward thinking from the WA Government to support expanding the role of pharmacists. Especially in rural areas, it may be more practical (logistics and cost) to see your pharmacist than arrange and travel to a doctor’s appointment.
Ric: “The mechanisms behind this echo an overworked system that first of all devalues doctors and pharmacists, then pits them against each other with policies like this masqueraded as better medicine accessibility. It is blatant scope creep on behalf of the pharmacists it is scope invasion to the doctor. Diagnosis and prescribing are their arena, checking and community medicine admin and supply is ours (pharmacists). Someone is trying to save money again convincing pharmacists they can be prescribers, and yes you can – when you complete a medical degree. Doctors underwent the vigorous training to do so, we have no right to devalue that by stepping on their toes for an extra buck! Community pharmacy as a retailer, as it is, is not equipped for prescribing. Neither are overworked, poorly paid working pharmacists.”
GM: Pharmacists aren’t looking to ‘creep’ into medicine, we are calling for pharmacists to be given the opportunity to practice to the full scope of their education and training.
We agree, pharmacists are already working with unacceptable workloads, and at wages well below other health professions. This is slowly changing through our recent work value case and the annual wage case. We believe that broadening of practice settings will result in more employment opportunities, and more importantly, go a long way to improving patient care and professional satisfaction.
Pharmacists aren’t looking to “devalue [doctors] by stepping on their toes for an extra buck,” – we’re looking to add value back to the profession by affording pharmacists the opportunity (should they wish) to practice to their full scope. Many people look at pharmacists as script monkeys or retailers. An expanded role will go a long way to reducing the strain on the health system by encouraging pharmacists, doctors and other health professionals to work collaboratively, for the benefit of the consumer.
Indeed, we support the embedding of pharmacists into GP practices, a move strongly supported by the AMA.
Further, we would like to see pharmacists working alongside the medical practitioner on an appointment basis to provide medications related advice and monitoring feedback (through a pharmacist established monitoring regime) as part of the Home Medication Review service.
Some pharmacists will be more comfortable than others when it comes to diagnosing or prescribing, and that is entirely their choice. Simply, if you or your pharmacy are not trained or equipped, then you should not prescribe.
Why is this important
Late last year, we reported the findings of a pilot trial, ‘What can pharmacists do in general practice? A pilot trial’.
The trial found:
“The co-location of pharmacists with GPs can enhance interprofessional communication and the development of collaborative working relationships. It can also reduce fragmentation of care and facilitate the delivery of patient-centred interdisciplinary chronic disease and medication management services.”
Even though this was pharmacists in a non-dispensing/non-prescribing role, the trial showed their value when practising to their full scope.
What This Means for You
We have a few questions to ask:
- Will prescriber independence be the responsibility to the employer (if not an independent contractor)?
- Will funding go to the pharmacist prescriber or will it go to the employer?
- What is fair and reasonable recompense to the pharmacist prescriber?
The Australian Medical Association (AMA) has come on board with such an approach and has advocated the introduction of a Pharmacist in General Practice Incentive Program, which is structured in the same way as the existing incentive payments for nurses.
Unfortunately, the Pharmacy Guild of Australia resists such a concept because it does not fit with their four walls pharmacy business model. The pilot trial points out; “…the Pharmacy Guild of Australia … prefer their community pharmacy owner members employing sessional ‘outreach community pharmacists’ who could provide support to local general practices on an as-needed contract basis.”
We believe that there is no reason why there can’t be a mixed “business” approach to professional services. Indeed, we have previously advocated the Guild’s above approach for the provision of professional services in pharmacies. But there needs to be greater flexibility in the Guild’s vision for the benefit of the profession and consumers.
Read the pilot trial
‘What can pharmacists do in general practice? A pilot trial’ was undertaken by Louise S Deeks, Mark Naunton, Guan Han Tay, Gregory M Peterson, Gregory Kyle et al and published in the AJGP, Volume 47, No. 8, August 2018.