It’s about patient safety, selective exemptions from the regulations that govern the medical profession and politics.
When I, and many of my colleagues have raised our concerns about recent changes to pharmacy prescribing rules in Victoria and beyond, the first catch-cry that usually rings out from the Pharmacy Guild is that it views this matter as “the RACGP’s pathetic attempt to create some type of bygone era turf war that’s not in the best interests of patients”.
This is false, clever and deeply concerning.
It is false because GPs don’t covet pharmacy “turf”.
I don’t want to run a shop, sell cosmetics and giftware while practising my profession and I absolutely would never recommend and sell non evidence-based supplements or homeopathic remedies to my patients.
It is false because a turf war implies that we are jockeying about pharmacists providing an equivalent medical service to GPs. That is not the case.
GPs manage undifferentiated and complex multimorbidity, undertake investigations, make diagnoses, coordinate care and provide care over a lifetime. Pharmacy prescribing is about using symptoms to guide the use of pre-determined protocols. Investigation and diagnosis are not a feature.
It is false because pharmacy prescribing is a transaction that links someone seeking symptom relief with medication sales.
That is not the healthcare model of general practice either. We have long recognised the inherent and unacceptable conflict of interest involved in both prescribing and then profiting from the act of prescribing – a concept specifically cited in the Medical Board of Australia’s Code of Conduct.
Moreover, AHPRA states that “it is professional misconduct for a medical practitioner to prescribe medicine that is not evidence-based, safe, or clinically justified”.
“Prescribing must be based on clinical need, with practitioners required to take ‘all reasonable steps’ to ensure the treatment is appropriate.”
One must ask oneself: if pharmacists are to prescribe independently, will this mean an industry-wide determination to remove all non evidence-based remedies and homeopathy from the shelves of Australian pharmacies?
Because to continue to prescribe medicines that are not proven or clinically justified is professional misconduct and will certainly impact the trust of the Australian public.
Another reason that I reject the turf war narrative is because GPs don’t want pharmacies to go out of business.
The reason pharmacists dispense medications separate to doctors prescribing them is because safety in medicine relies on multiple layers of checking and rechecking. Each time a pharmacist calls a doctor with a question, a potential error or harm is averted and mutual learning occurs.
We don’t know who will check the pharmacist when they prescribe and dispense in total isolation.
Turf war statements are clever, because it tosses the valid concern GPs have about safety out of the conversation, and suggests a self-serving preoccupation with stopping patients getting at medicines more easily.
The problem here is that firstly, the narrative of too few doctors is false; 99% of people can see a GP when they need to.
Secondly (and this is where the cleverness morphs into deeply concerning), it insinuates that safety and quality are redundant. It encourages Australian patients to value access and convenience above safety in medicine.
Related
Political leaders are now actively referring to seeing a GP as a hassle. At a time where cancer screening remains low, chronic diseases are under-managed and life expectancy has dropped for the first time in decades, Australian politicians are using taxpayer money to recommend that Australians do what they can to avoid seeing a GP.
That’s a dangerous slippery slope, because we are talking about health here, not a retail product. Harm your health, you can’t just take it back to the shop for a refund.
Concern arises when, as the RACGP advises it is aware of many serious instances of harm occurring in pharmacy prescribing trials, the Guild does not ask what those harms are and what to do about them, it simply states that “allegations aren’t facts”.
But what really disturbs me is the double standard in regulation we are observing as the government delivers on the Pharmacy Guild’s vision that pharmacists “administer, obtain, possess, prescribe, sell, supply, review and/or use Schedule 2, 3, 4, and 8 medicines, within their individual, self-determined, documented and authorised scope of practice”, and the association between these changes and the $600,000 the Pharmacy Guild spent on political donations last year.
These are the regulations that govern medical and pharmaceutical practice which outline why doctors do not own, supply and profit from prescribing drugs, and why we do not self-regulate:
- Medical Board of Australia’s Code of Conduct that prohibits the concomitant prescribing of and profiting from medications;
- Medicines Australia Code of Conduct that prohibits advertising prescription medicines to consumers and prohibits anything offered or provided by a Company in a manner or with conditions that would have an inappropriate influence on the approval, recommendation, prescribing, and/or use of a product;
- AHPRA’s code that “in Australia, strict laws prohibit doctors from profiting from prescribing, including financial kickbacks or owning businesses that incentivise predetermined medicine supply. Prescribers must ensure therapeutic need, abide by state/territory Drugs and Poisons legislation, and avoid conflicts of interest, with breaches leading to criminal prosecution, fines, or loss of registration.”
In 2018, the Therapeutic Goods Administration up-scheduled low-dose codeine to prohibit over-the-counter access in pharmacies due to “high rates of misuse, dependence, and harm (including liver damage, gastrointestinal perforations, and death).”
A 50% reduction in codeine supply subsequently occurred.
This issue outlines the many problems inherent in administering, obtaining, possessing, prescribing, selling, suppling and reviewing drugs, but seems to have been completely forgotten in the rush to enable the very same situation to now occur, but this time with significantly more potent and dangerous opiates and myriad other medicines.
Dr Anita Muñoz is a GP and chair of the Victoria Faculty, Royal Australian College of General Practitioners.
