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GPs ‘horrified’ at latest pharmacy proposal


Matt Woodley


20/01/2021 5:23:52 PM

The Pharmaceutical Society of Australia has suggested ‘non-urgent’ emergency department presentations be directed to community pharmacy.

Pharmacist talking to a patient.
GPs have expressed concern about conducting potentially complex consultations within a pharmacy setting.

The latest attempt at expanding pharmacy’s scope of practice also lobbies for pharmacists to have a greater role in the COVID and other vaccine programs, as well as the administration of buprenorphine injections for opioid agonist treatment.
 
To facilitate the proposals, made in the 2021–22 New South Wales Budget Submission, the Pharmaceutical Society of Australia (PSA) has requested $14 million in additional funding, along with a further $7.5 million each year in ongoing support.
 
Upon announcing the proposed changes, PSA NSW Branch President Chelsea Felkai backed the ability of community pharmacists to treat emergency department patients seeking care for conditions such as headaches, coughs and colds, earaches and other ‘non-urgent conditions’.
 
‘There is strong evidence that the clinical advice provided by community pharmacists regarding symptoms of minor illness results in the same health outcomes as if the patient went to see their GP or attended the emergency department,’ she said.
 
‘Pharmacists can manage non-urgent conditions or low urgency conditions, provide the right level of care, and mitigate funding and system inefficiencies as patients access professional support for conditions that can be self-managed or require referral.’
 
However, RACGP NSW&ACT Faculty Chair Associate Professor Charlotte Hespe told newsGP she is ‘horrified’ at the thought of emergency department presentations being directed to community pharmacy, and questioned whether the policy suggestion had been properly thought through.
 
‘Why on earth would you take on all the risks of being the GP triaging?’ she said. ‘Do they not understand all the actual clinical risks of that sort of work? That assessment of a basic headache is not just saying, “Go and take a couple of Panadol”?
 
‘Our job is to be able to adequately assess that it is a headache that can be treated with paracetamol, versus one that needs to be more thoroughly investigated. It isn’t just a fun, income generating exercise.’
 
Professor Mark Morgan, Chair of the RACGP Expert Committee – Quality Care, also has reservations about directing emergency department presentations to pharmacy. He told newsGP consultations are more complex than at ‘first glance’, and pointed out the extensive pathway GPs follow in order to properly prepare them to be clinicians.
 
‘It might seem that pattern recognition for frequently occurring minor ailments means that these presentations can be managed through protocols that include safety netting and a low threshold for advising medical review, but I believe the consultation process is much more complicated,’ he said.
 
‘For example, the minor ailment might be a ticket of entry to open opportunities for a patient to discuss underlying mental health issue. Or what appears to be a simple tension headache might be caused by any one of a number of rare conditions that are only likely to be contemplated by a healthcare provider with a great depth and breadth of medical training.
 
‘Medical school is an intensive 5–6 year process that builds foundational scientific knowledge, then integrates that into a deep understanding of pathophysiology and clinical management. This is then backed up by two full years of closely supervised clinical placements.
 
‘All of this is underpinned by assessment of skills and knowledge, and even then, graduates from medical school are only halfway through their training to become independent doctors capable of integrating and filtering complex information from medical records, knowledge of risk factors, patient history, examination and investigations.
 
‘Contrastingly, training for pharmacists is also comprehensive but with a major focus on the effective use of medications only.’
 
The GPs also warned of potential patient privacy issues, fragmentation of care, and record keeping problems as arguments against the PSA’s proposal.
 
‘Where patients see multiple providers, each with their own take on diagnosis and management, there is confusion and lost opportunities for the patient to learn more about the condition they are presenting with; how to self-care, when to seek help, how to avoid wasteful over-the-counter products and how to prevent spread of infections,’ Professor Morgan said.

Charlotte-Hespe-Article.jpg
Associate Professor Charlotte Hespe would rather see GPs and pharmacists work together in a primary care setting.
 
‘GPs have records that cover past history and events, biopsychosocial context of their patients, physical measurements combined with blood test and imaging results, sometimes family history. All of these clues sit there for the astute GP to draw on when the patient presentation rings subtle alarm bells.
 
‘But in this scenario, the patterns of illness that build over time in the GP record are lost, leading to delays in diagnosis of underlying chronic disease and instigation of effective preventive strategies.
 
‘No protocol driven or final year medical student for that matter can be expected to integrate this information and filter the important components, and do so in the timeframe of a typical 15-minute consultation.
 
‘For this reason it is difficult to imagine a suitable pharmacy training program, short of medical school, plus junior doctor years, plus GP vocational training pathways.’
 
To support its position, the PSA proposal points out that the average cost of an emergency department attendance in NSW is $552.19, whereas the average cost per pharmacist consultation is $14.49.
 
‘Under this scenario, if pharmacists were paid through a consultation fee structure of $14.49 per consultation, and if the patient paid for their non-prescription medicines, the NSW Government would save between $131 million and $439 million per annum,’ the submission states.
 
However, Professor Morgan said economists can take a narrow focus when considering the apparent cost of a minor ailment appointment, which can lead to false assumptions.
 
‘The full costs of minor ailment services need to include opportunity lost for management and monitoring that goes on alongside minor ailment consultations in general practice,’ he said.
 
‘Often the comparator for minor ailment services is emergency department attendance, which is necessarily an expensive service set up to manage severe acute presentations and emergencies.
 
‘But rather than scratching around trying to see which bits of healthcare can be carved off to be done in community pharmacy, it would be better to look at how the health system as a whole could better use the expertise and experience of pharmacists.
 
‘There might be opportunities to invest more in models of care in which a non-dispensing pharmacist is part of the general practice clinic team, with roles in medication governance and patient education.’
 
Associate Professor Hespe is also supportive of GPs and pharmacists working together in a primary care setting.
 
‘I’m more than happy for $7.5 million to come into funding a collaboration between pharmacists and GPs in a primary care setting, where pharmacists assist GPs in better medication management,’ she said.
 
‘Let’s get rid of all of those unnecessary admissions to hospital from medication errors – that would save money and would save lives.
 
‘It would be a worthwhile proposition and that’s where I’d be trying to get your bang for your buck.’
 
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Dr George Al-Horani   21/01/2021 6:42:22 AM

I don’t why should we be surprised with such news , pharmacy Guild are moving slowly but surly to take over our General practice rule , and they are convinced and somehow are able to convince our Government employees that they are able to be ( mini-Doctors ).
We as Doctors should be allowed to prescribe and Dispense medications especially when we work Rural or night shifts where there are no pharmacy open .
Anyone is allowed to open a medical centre but no one is allowed to open a pharmacy!! That proves how weak we are , and how we as doctors don’t have a strong representation.
Unfortunately we are the weakest link and always will be .


Dr Sonia Foley   21/01/2021 7:56:01 AM

Tell me why we are busting our asses? Why are we getting paid peanuts, working our assess off, spending $, sacrificing time with our friends/families and bearing the brunt of responsibility when they are handing off more of our work to pharmacists.

Abx are already being given for "UTI's", chlorsig for eye infections and Canasten for thrush. I've had Pts with no resolution with chlorsig (viral infection that required lubricating eye drops and hygiene), Pts taking canasten when they had a UTI and vice versa because they never had a urinalysis, urine MCS or a vaginal swab. Already doctors are becoming the fall back position rather than the first presentation.

If this goes ahead it will be interesting to see what happens if someone dies of a SAH or an outbreak of pertussis occurs. I'm sure that in the end the responsibility will end up lying on a doctor somewhere! Probably the poor sod who tried to mop up the mess that was created in the first place by incorrect or delayed treatment.


Dr Keith Ian Van Den Heever   21/01/2021 8:00:53 AM

I'm sure we have all stood around in pharmacies waiting for our prescription to be filled,only to have an anxious mother being interviewed by the pharmacy assistant ( seldom the pharmacist hidden behind the desk ). " Now, do they ( your sick toddler who is in the car outside ) have a wet or a dry cough ? " I usually have have to bite my lip to prevent myself laughing out loud.

These charades are further borne out by the proudly displayed merchandise which has absolutely no medicinal or scientific value. My favourite are the plastic bead necklaces to hang around a baby's neck to stop the pain of teething !!! BWAHAHAHAHA ! Also, absolutely no consideration of the inherent strangulation risk, but , hey, anything for a buck !

Pharmacists are NOT doctors, by any stretch of the imagination.If they wish to practice medicine, then they should enter medical school and undergo the training which we have undergone. Forty years later, I'm still learning.


SD   21/01/2021 9:02:20 AM

Pharmacy wants to take all without taking responsibility for it. Recently pharmacy got right to dispense brands of their choice while GP’s will only be allowed to prescribe generic name only in the name of active ingredient prescribing rule. They have cleverly won it by giving justifications. Now pharmacy companies will lure pharmacy owners and pharmacies to dispense their brands with perks or gifts. There is no reason why pharmacies wouldn’t dispense particular brands. How are we not able to see it.


Dr James Courts   21/01/2021 9:43:56 AM

If they want $14.90 for medicolegally high risk work, they can have it. Not sure their indemnity company would be happy though.


Dr Wayne Leonard McDonald   21/01/2021 10:59:05 AM

If the RACGP so much as supports this they do not have a mandate firstly and they don’t support GPS in quality care and in sustaining a practice. There are better ways for GPS and pharmacist to work eg on individual quality use of medicines projects for patients and that will save money. The PSA is totally out of line as Australian Doctors would know. Put them back in their box please RACGP President.


Dr Michael Lucas Bailey   21/01/2021 11:28:05 AM

It always comes down to money. In the proposal pharmacists want to get paid a consultation fee but then promise to also save government money by getting the patient to pay “for their non-prescription medicines”. Isn’t this conflict of interests the exact reason why doctors don’t dispense?

As to the cost of an emergency department consult, a general practice consult has always been far more cost effective. Unfortunately the defunding of general practice through inadequate MBS indexation has left the country with not enough GPs. Medical students no longer want to be GPs when they can get paid more in any other specialty. GP clinics are booked out because there aren’t enough GPs. Clinics can’t afford to not be booked put because rebates only just cover expenses that keep going up with increasing practice requirements.

How can we convince a government that they will save money by increasing MBS rebates for GPs so that there will be enough GPs and GPs won’t have to be 100% booked.


Dr Veronika Marie Kirchner   21/01/2021 12:52:23 PM

Imagine my horror at seeing a sign in my local pharmacy after a recent refurbishment, declaring it as “Your Health Clinic”. Silly me! And I thought it was a pharmacy


Dr GP   21/01/2021 1:25:17 PM

Articles like this encourage me that I’m making the right choice to retrain in a different specialty


Dr Primo Phillip Bentivegna   21/01/2021 1:30:37 PM

This is the biggest crap I've read yet, horrified is an appropriate description.
Time for the college to grow a pair, and start fighting for it's members.
Enough is enough.


Dr Gary Robert Wilson   21/01/2021 3:37:11 PM

The College and the AMA need to reign in the tentacular reach of the PSA. They are massively erosive of general practice, and GP's are either too disinterested or too busy to stand up. Moreover, I'm not sure many pharmacists want the responsibility, and surely won't when the lawyers come swooping around a major error of judgement. The government would be stupid to allow this to occur and it would be purely from a short-sighted bean-counting POV if they were to rubberstamp it. It could erode health care standards and cost lives.


Dr Robert Stewart Richardson   21/01/2021 10:15:56 PM

diagnosing and dispensing by the same person leads to fraud and criminality, except in remote or emergency settings.
If you want to be known as crooks, pharmacists go for it
Its like the rules of separation of powers in a democracy.


David   22/01/2021 8:46:30 AM

Working in a country hospital emergency department , I see many patients walk that could have been treated successfully by their GP if they had a face to face consult instead of over the phone or simply having enough same day appointments. No wonder patients are angry and the pharmacies are stepping in. Not saying this is right but there is a void that needs to be fixed.


Dr Penny Lisa Wood   22/01/2021 12:17:15 PM

David: so what are country GPs supposed to to then? Magically have extra time in the day, or magically somehow create extra doctors prepared to work rurally?


Dr Jean Margaret Sparling   22/01/2021 1:31:40 PM

Would be interested to see the “Strong Evidence ” of Pharmacy Guild. If general practice is allowed to die, Australia will have lost one of its most valuable resources. Doctors are becoming too tired, too disheartened by an over burdened over involved government. Medicine was an honourable profession now being degraded by those lacking a medical degree, with general practice the very backbone of this profession. A well known and respected family doctor should continue to be the first port of call when medical help is needed. They are the gatekeeper for the best health outcomes of each individual. Conditions which to the untrained may appear minor, have so often a more sinister and urgent side.


Dr Abbas Hussein   22/01/2021 1:59:28 PM

Pharmacists are already dispensing OTC medications but now they want to be paid for the same thing that they have been doing all along., PSA has twisted that a little to show governments that they will be saving money. Governments will listen to $$$ talks but not to fragmentation of care, risks to patients, etc unless AMA/Colleges can show the benefits in monetary form.


Dr Raymond Yeow   23/01/2021 9:46:44 PM

When will the medical profession learn that political donations ie real $$$$$ talk loudly ?
As a profession, we have way more Drs than pharmacists....Drs should easily be able to outspend the pharmacists in donations .......There is the world as we wish it to be , then there is a the world as it really is .....


Dr Sonia Foley   23/01/2021 10:37:34 PM

Tell me why we are busting our asses? Why are we getting paid peanuts, working our assess off, spending $, sacrificing time with our friends/families and bearing the brunt of responsibility when they are handing off more of our work to pharmacists.

Abx are already being given for "UTI's", chlorsig for eye infections and Canasten for thrush. I've had Pts with no resolution with chlorsig (viral infection that required lubricating eye drops and hygiene), Pts taking canasten when they had a UTI and vice versa because they never had a urinalysis, urine MCS or a vaginal swab. Already doctors are becoming the fall back position rather than the first presentation.

If this goes ahead it will be interesting to see what happens if someone dies of a SAH or an outbreak of pertussis occurs. I'm sure that in the end the responsibility will end up lying on a doctor somewhere! Probably the poor sod who tried to mop up the mess that was created in the first place by incorrect or delayed treatment.


Dr Tatiana Cimpoesu   29/01/2021 5:45:51 PM

Why invest time and money studying for a medical degree?


Dr Gursel Alpay   1/02/2021 10:35:09 PM

I feel this represents a continuation of Abott's attacks on primary health care. Unfortunately, the RACGP and AMA are failing us despite increasing membership fees We need a strong body to represent GP's to help prevent further decay of our primary healthcare system. The future of general practice is under great threat from large pharmacy corporates. Now, they can provide medical certificate,Covid immunisations and can advertise virtual consultations at chemist. This is a shame on this government.