‘Very real risk’ in prescribing scope proposals, warns Avant

Australia’s largest medical indemnity provider has warned policymakers to put patient safety first as they weigh up proposals that would significantly expand pharmacy prescribing rights.
 
In a rare public intervention, Avant said the changes currently under consideration, which could pave the way for pharmacists to prescribe Schedule 8 medications, raised the prospect of a ‘corresponding increase in patient harm arising from misdiagnosis or inappropriate prescribing’.
 
The insurer’s Chief Medical Officer, former AMA President Professor Steve Robson, warned against basing reasons to expand scope of practice on access and efficiency concerns.
 
‘Avant would not normally enter these public debates with pharmacists, but we’ve reached the point where medical indemnity insurers need to highlight the very real risk of patient harm,’ he said. 
 
‘Prescribing sits at the intersection of diagnosis, clinical judgement and treatment decisions, and when it goes wrong the consequences for patients can be tragic.
 
‘Policymakers need to pause before assuming prescribing responsibilities can continue to expand into increasingly complex areas based primarily on projected efficiency gains or theoretical cost savings, rather than patient safety.’
 
Avant revealed around one in six of its indemnity claims involved medication-related issues, making them ‘one of the leading drivers of medical negligence claims’.
 
It also referenced the release of the Pharmacy Guild of Australia’s ‘Changing the Script’ report last week, which suggests pharmacists’ autonomous prescribing could directly save the Australian health system more than $1 billion annually and reiterated an argument for pharmacists’ prescribing scope to expand into areas such as cardiovascular risk assessment.
 
The Guild, along with Advanced Pharmacy Australia and the Pharmaceutical Society of Australia, also set out the case for pharmacists to prescribe Schedule 8 medications in a joint submission to the Pharmacy Board of Australia last year.
 
RACGP President Dr Michael Wright, who previously worked as Avant’s Chief Medical Officer, welcomed the indemnity provider’s stance.
 
‘It’s really helpful to see other people in the health system recognising the dangers and calling them out,’ he told newsGP.
 
‘The issue here is we don’t have the evidence to show that expanded prescribing is safe – and the data from Avant suggests we should have some real concerns here.’
 
However, the pharmacist indemnity insurer Pharmaceutical Defence Limited (PDL) has queried Avant’s intervention and said it does not share the same view.
 
‘Avant insures medical practitioners, not pharmacists, and is therefore not likely to be in an informed position to comment on pharmacist prescribing,’ it told The Australian.
 
‘PDL has been intimately involved with all the changes to pharmacists’ scope of practice and is of the view that suitably trained and authorised pharmacists are needed nationally to improve timely healthcare delivery, assist in addressing existing healthcare workforce needs, and improve patient outcomes.’
 
For Dr Wright, however, the concerns remain.
 
‘Given the size of the medical indemnity providers, they’re well placed to understand the broader risk, and we definitely should look at their information,’ he said. 
 
Dr Mark Woodrow, an emergency physician who works as Avant’s General Manager Medical Advisory Services, also highlighted the complexity of prescribing, and the importance of reaching an accurate diagnosis.
 
‘As an emergency physician, I regularly see patients whose presentation is the result of inappropriate prescribing or missed diagnosis rather than the condition that was initially suspected,’ he said.
 
‘I’ve seen patients arrive at emergency departments after blood pressure medications have worsened their kidney disease or heart failure. I’ve also seen patients treated for what appeared to be a urinary tract infection who were in fact suffering an alternative diagnosis requiring urgent emergency care.
 
‘Those examples aren’t an argument against pharmacists.
 
‘They’re a reminder that prescribing can never be separated from diagnosis and clinical judgement.’
 
Professor Robson believes the debate should now be about the diagnostic capability, clinical training and oversight needed for safe prescribing.
 
‘From our perspective as an insurer, the greater the complexity, uncertainty and potential consequences of error, the higher the threshold should be for expanding prescribing,’ he said. 
 
A consultation for a national prescribing framework under consideration by the Pharmacy Board of Australia ends this week.
 
It set out two options: firstly to allow endorsed pharmacists to prescribe Schedule 2, 3 and 4 medications, and a second option – preferred by the Board – which would allow pharmacists to be endorsed to prescribe Schedule 8 medicines.
 
When contacted about Avant’s concerns, the Pharmacy Guild pointed towards the work underway to establish that prescribing framework.
 
‘National health ministers will finalise a decision in the next few months,’ a spokesperson told newsGP.
 
‘Submissions, from competent and relevant organisations, are currently being considered by the [Pharmacy] Board.’
 
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medication-related harm pharmacy prescribing scope of practice