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