RACGP opposes pharmacy push for permanent continued dispensing

Doug Hendrie

26/02/2021 4:59:18 PM

The college has said a better and safer way to increase access to medicines under emergency situations would be to increase to the number of drugs included in the doctor’s bag.

Pharmacist dispensing medications.
GPs say there a clinical concerns associated with the new plans for continued dispensing.

Continued dispensing was originally brought in at the beginning of 2020 as a response to Australia’s Black Summer bushfires and the COVID-19 pandemic.
However, the Federal Government has since revealed plans to make the new arrangements permanent, following a sustained campaign from the pharmacy sector.
The proposed changes would increase the list of medications eligible for continued dispensing to include those commonly used to treat chronic diseases like asthma, lung disease, diabetes and heart disease.
In a submission opposing the permanent extension, the RACGP provides multiple examples where continued dispensing and similar state-based arrangements can actually pose harm, such as patients being able to continue with an incorrect dose of their medication without a prescription, or with proton pump inhibitors or strong painkillers without GP involvement – medications that can cause real damage if taken in high doses or over the long term.  
The current and immediate former Chairs of the RACGP Expert Committee – Quality Care (REC– QC), Professor Mark Morgan and Dr Evan Ackermann, have both previously opposed the bid.
Dr Ackermann previously told newsGP that continued monitoring is a core quality issue for any chronic disease.
‘It is a very short-sighted strategy to effectively stop or sidestep reviews by the responsible prescriber,’ he said.
Continued dispensing has traditionally been a tightly restricted arrangement under which pharmacists can dispense certain medications once a year without a valid script, where it is not practical to get a prescription.
The move comes after the Pharmaceutical Benefits Advisory Committee (PBAC) green-lit the expanded list of medications in May last year, and created principles for considering more medications. The Government this month informed the RACGP it intends to press ahead with these changes.
In its submission to PBAC Chair Professor Andrew Wilson, the RACGP laid out its opposition to this permanent shift on the basis that GPs are more accessible than ever with telehealth and e-prescribing. It also reiterated the benefits of often-unseen care provided when patients return for a repeat script, and the well-established safety rationale for the traditional split between prescribing by doctors and dispensing by pharmacists.
‘Separation of dispensing and prescribing medicines improves the quality and safety of patient care, by dividing the roles of GPs and pharmacists based on their specialised field of practice,’ the submission states.
‘Safe clinical governance frameworks must not be compromised unnecessarily for the sake of convenience.
‘While it is appropriate in emergency situations for continued dispensing to be made available to patients, there is no need to introduce the model on a permanent basis.
‘[However], there may be cause for the arrangement to be ongoing in rural and remote areas, provided the pharmacist has a collaborative relationship with the local GP.’
GPs have also told the RACGP that they have questions around the proposed general principles intended to govern the scheme.
For instance, the proposed principles seen by newsGP state that a patient must have a ‘stable condition’ to be eligible, and that the medicine must have been supplied to the patient within the last six months. 
But GPs have questioned how pharmacists would be able to make that clinical judgement, and raised concerns that a prescriber could have ceased that medication for that patient during the six-month period, given many medications are provided based on a month’s supply.
As an alternative, the RACGP has suggested using the same list mooted by the PBAC for continued dispensing to boost the range of oral medications available in the Prescriber’s Bag, an existing arrangement under the Pharmaceutical Benefits Scheme permitting general practices to appropriately supply medications for urgent care needs when a patient needs to begin treatment immediately.
This list of medications is available to GPs practising after hours, when local pharmacies may be closed.
The submission notes that reducing clinical monitoring and support must be balanced against convenience.
‘When a patient visits their GP for a repeat prescription, a GP reviews the patient’s condition and the appropriate treatment and, if still necessary, medication dosage,’ it states.
‘A patient obtaining additional supply of their medication directly from a pharmacy will bypass this necessary medical review by up to seven months or longer. This could have negative consequences for their health and wellbeing.’  
The move has come as GPs worry about the disruption to regular care caused by the impact of COVID-19, with vulnerable and complex patients potentially at higher risk if discouraged from seeking care.
The RACGP submission also points out there is no evidence patients are having difficulty accessing a GP, with almost three quarters who need urgent care able to see their GP within a day, and less than 1% of patients reporting being unable to see their GP when they need to, according to Australian Bureau of Statistics data
However, the submission notes rural and remote areas may be an exception, if they have limited access to GPs.
‘Continued dispensing for these areas may be suitable,’ the submission states. ‘Provided there is support and guidelines for GPs and pharmacists to develop collaborative relationships to ensure patient safety.’
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Dr James Patrick Robinson   27/02/2021 9:28:22 AM

This is an excellent idea which will avoid the risk of harm to patients. I agree that rural and remote collaborations between the local pharmacy and GP could be established to ensure supply of medications while maintaining regular reviews by their GP.

Dr Marc Houghton Heyning   27/02/2021 4:56:38 PM

My practice has recently unilaterally changed its policy in relation to the local pharmacies filling Webster Packs. Up until now, local pharmacies have continued to supply complete Webster packs to patients even when prescriptions have run out and then contacted the practice requesting prescriptions to 'cover' the dispensed medications. Whilst our practice acknowledges that continuation of medication is important in a patient's care, the practice has highlighted several instances where the patient has had their medications changed or deleted but the pharmacies have continued ERRONEOUSLY filling Webster packs based on previous prescriptions.
Our new policy is: local pharmacies have been informed that we will cover a single month's supply for a patient ONCE but no further prescriptions will be written if the patient does not see their doctor in the intervening month and get updated prescriptions. This is for the patient's safety!

Dr Abdul Ahad Khan   28/02/2021 1:07:55 PM

Any Prescriber needs to have the following Information before a Prescription can be issued or Continued :
1. Clinical Examination Skills
2. Knowledge of Co-existing Illnesses
4. Knowledge of Clinical Patho-Physiology
3. Relevant & Recent Pathology Results

Any Person with not even a Basic MBBS Degree is an outright THREAT to the SAFETY OF THE PATIENT.
Pharmacists should never be allowed to either Prescribe or to continue a Prescription issued by the Patient's GP, without a CLINICAL RE-EVALUATION by the GP .

Dr Michael Lucas Bailey   6/03/2021 9:44:21 AM

Nearly every medication error I have ever seen has been a pharmacy dispensing webster pack medications long after they were ceased. Or incorrect doses despite having been sent updated scripts and mediation summaries. Furosemide with worsening renal function sticks in my mind.

The change to active ingredient prescribing is nonsense compared to pharmacy continued dispensing and webster pack errors.