What’s behind the recent tensions between pharmacy and general practice?

Day to day, GPs and pharmacists work together very well, according to experts from both sectors.
 
But it’s been hard to avoid the tensions between general practice and pharmacy peak bodies over the last few years.
 
The divide over scope of practice is real, ranging from the GP-backed up-scheduling of codeine over protests from the politically powerful Pharmacy Guild, which represents owner interests, through to the controversial proposed Queensland trial of pharmacy prescribing of the oral contraceptive pill and antibiotics to treat UTIs, and the swift reversal of a government proposal to introduce two-month scripts after Guild pressure.
 
Just this week, the Western Australia government flagged a potential widening of scope of practice to allow pharmacists to be involved in mental health care, chronic disease management and issuing repeat prescriptions for medications like the contraceptive pill.
 
The Queensland expansion of antibiotic prescribers drew strong comments from the Chair of RACGP Quality Care, Associate Professor Mark Morgan, who previously told newsGP the decision was ‘akin to opening up a new thermal coal mine’ given antimicrobial resistance is the ‘global warming of healthcare’.
 
GPs have been working in recent years to bring down rates of antibiotic prescribing, with rates dropping this year for the first time in 20 years, although they do remain too high compared to guidelines. RACGP President Dr Harry Nespolon said the results support efforts not to expand the pool of antibiotic prescribers.
 
The Chair of RACGP Queensland, Dr Bruce Willett, recently took the unprecedented step of writing to all of his state MPs, calling for the pharmacy prescribing trial to be overturned or delayed until a key national committee reports to government on antimicrobial resistance later this year.
 
Pharmacist turned GP, Dr Nick Yim, sounded the alarm on the Queensland plan in MJA Insight, dubbing it ‘fraught with danger’. 
 
‘In my view, allowing pharmacists to prescribe puts convenience ahead of patient safety. There are too many unseen risks and potentially higher costs,’ he wrote.
 
But these are just skirmishes.
 
The big one – pharmacist prescribing – is still up in the air, with the Pharmacy Board of Australia releasing a discussion paper in January suggesting non-medical prescribing may help with the delivery of ‘sustainable, responsive and affordable access to medicine’.
 
Former Pharmaceutical Society of Australia (PSA) national president, Dr Shane Jackson, last year predicted pharmacy prescribing was ‘imminent’ and could be in place by 2020.
 
The current PSA president, Dr Chris Freeman, argues that a collaborative model, where pharmacists prescribe either with checks from a GP or while based in a GP clinic, may benefit both professions. (The PSA is the peak body for practising pharmacists, while the Guild represents pharmacy owners only.)
 
If pharmacist prescribing moves forward, it is certain to be vigorously opposed by peak medical bodies like the RACGP and Australian Medical Association (AMA).  
 
In a complex landscape of powerful pharmacy business lobby groups, disgruntled pharmacist employees, and GP concerns about fragmentation of care and antimicrobial resistance – what is the way forward?

Dr Nespolon believes that change must come from within. 
 
‘Pharmacists, as a profession, are being judged by the public activities of the Pharmacy Guild. These include practicing beyond scope, rejecting any changes that may benefit patients and compliance, [and] promoting a business model that seeks to up sell patients to name a few,’ he told newsGP.
 
‘It becomes clearer every day to the public that pharmacists are using their sheltered position to generate sales, not take care of patients.
 
‘If the PSA and the government do not change this reality, whatever value pharmacists may have will be lost.’

RACGP President Dr Harry Nespolon believes ‘pharmacists, as a profession, are being judged by the public activities of the Pharmacy Guild’.
  
‘Stepping on toes’
‘I am not an anti-pharmacist person. Let’s get pharmacists doing what it is in their scope of practice and get the government to fund that, instead of argy-bargy over what is already done well.’
 
That is Chair of the RACGP Board, Associate Professor Charlotte Hespe, on her concerns about the push for pharmacy prescribing and the proposed state-wide trial in Queensland. 
 
‘We want to have a good relationship with [peak pharmacist bodies], particularly the PSA. They want to do the best by pharmacists, and their pharmacists are skilled at medication reviews and want to work with GPs,’ she told newsGP.
 
‘So let’s increase the scope of work doing that, because [medication errors] cause many, many deaths and even more preventable hospitalisations, instead of stepping on [doctors’] toes for things I went to university to learn how to do.
 
‘I’m fully supportive of the role of pharmacy in primary care, and fully acknowledge the vital role they can play in medication management. But we need to strongly understand the need to stay in our scope of practice.
 
‘Prescribing fits in general practice. It does not fit in pharmacy.
 
‘I don’t see how increasing the pharmacy scope of practice is in any way designed to improve patient care. [Pharmacist prescribing trials] are business models, and while they continue to be business models, we will continue to say this is not a model we should be going down.’
 
Associate Professor Hespe, who is also Associate Professor of General Practice and Primary Care Research at Notre Dame, argues that bringing pharmacists and GPs together in a clinic setting represents a better way forward.
 
‘Then we can really make a difference to preventable hospitalisations,’ she said.
 
‘Diabetes is the classic example [overseas]. You get a pharmacist and clinical consultant nurse working in a practice with GPs on diabetes and you get fantastic added value in prescribing advice. But you wouldn’t be able to do that in an Australian setting, as there is nothing that supports that model of care.
 
‘It’s a shame. You become far more aware of what each profession can do in that model – the medication perspective, the nursing dimension.’
 
One prominent GP, who did not want to be named, said that a key issue is the influence of the Pharmacy Guild, whose members have a vested interest in making profits.
 
‘The Guild’s thing is about pharmacy owners rather than the pharmacists who work there,’ the GP said. ‘And those employed in pharmacies are paid very little. They feel like glorified shop assistants.
 
‘[Patient] experiences of big cheap pharmacies are that it’s just a big shop. You’ve got the pharmacist down behind the back counter, doing very little to do with their skill set.
 
‘The money made in a pharmacy these days is all about product. It’s harder and harder for them, because those products are in other places.
 
‘Let me tell you, GPs are struggling for business, too – but we’re certainly not trying to steal [pharmacists’] skill set.
 
‘I’d welcome working with pharmacists more on safety checks and how we manage multimorbidity, rather than having these fights over who should be giving vaccinations.
 
‘It’s time to sit back and do a proper scope of practice for community pharmacists and GPs, to look at where we can better use our skills.’
 
‘We work well together’
‘Certainly, in my experience, GPs and community pharmacists work really well together.’
 
That is Debbie Rigby, an advanced practice pharmacist and highly regarded leader in the profession. Ms Rigby has advocated the uptake of general practice-based pharmacists as a model of care. She often conducts medication reviews in collaboration with GPs in a medical centre.
 
She also calls for better use of HMR and RMMR medication reviews as a way to allow pharmacists to practice at full scope.
 
On the vexed question of pharmacist prescribing, Ms Rigby said there is a divide in how the question is framed.
 
‘Pharmacy associations highlight accessibility [to medication] as a key issue, while GPs and medical organisations highlight fragmentation as a key. But no pharmacist intends it to be an open book,’ she told newsGP.
 
‘We should look to models overseas to see both the benefits and restrictions that should be put in place.
 
‘Pharmacists are well trained in medicines. That’s what we know. That’s our core role. We’re not trained in diagnosis. Proposals around frameworks for pharmacist prescribing have to take that into account.
 
‘We’re having these turf wars without really understanding what we as a profession mean by pharmacist prescribing.
 
‘I strongly support a collaborative prescribing model, where a pharmacist will be working in a GP practice or Aboriginal health service.
 
‘A medical practitioner will do the diagnosis and the pharmacist can provide expert opinion, just as in hospitals pharmacists go on rounds and [doctors] will ask for their input to get the right drug for the right patient and talk about dosing, renal function, age related issues and comorbidity.
 
‘These are the core things pharmacists are trained in and do well. Collaborative prescribing is a good model, and has been shown to be effective overseas.’
 
But Ms Rigby is clear-eyed about the need to manage the potential financial conflict of interest.
 
‘It is a real issue, that potential conflict of interest,’ she said. ‘That needs to be teased out and controls in place.
 
‘But, the reality is, we have Schedule 2 and Schedule 3 pharmacist-only products where the pharmacist makes the clinical decision based on signs and symptoms, with the caveat that they should see a GP if they don’t see improvement.
 
‘As the safety profile is shown in more drugs, they are down-scheduled to Schedule 3. That’s a degree of diagnosis, and that’s what they do every day. Pharmacy does that well.’
 
Collaborative prescribing
In his doctorate, PSA national president Dr Chris Freeman explored how pharmacists can be integrated into a GP setting.
 
‘It’s clear that the relationship between professional pharmacy and medical groups has been strained of late,’ he told newsGP. ‘In reflecting on that, many GPs and pharmacists I speak to on the ground work well together and will continue to do so.
 
‘It’s clear to me that both GPs and community pharmacists are the pillars of the primary healthcare system … but both sectors are going through growing pains, stimulated by the complexity of care having to be provided, the changing regulatory environment, the constant primary care reform agenda, commercial pressures on both GPs and pharmacists, and remuneration challenges for both. Then we’ve got the digital revolution.’

Pharmaceutical Society of Australia national president Dr Chris Freeman said there is dissatisfaction in pharmacy and general practice about the ability to engage in patient care.

Dr Freeman said there is dissatisfaction in both professions about their ability to engage in patient care.
 
‘For example, how a pharmacist might be limited in their current fulfilment of scope and within general practice, there might be limitations around how a GP might be able to manage more complex patients,’ he said.
 
‘There’s room for scope fulfilment on both sides of [the] fence.’
 
Dr Freeman points to examples where GPs and pharmacists are pulling together, such as the work done to progress real-time prescription monitoring, and the focus on the aged care crisis.
 
But Dr Freeman said that efforts to increase collaboration between healthcare providers often run afoul of the fact funding is done in silos.
 
‘It’s notoriously difficult for clinicians and healthcare practitioners to work together when funding drives it in a siloed way,’ he said.
 
newsGP asked Dr Freeman whether the PSA and the Pharmacy Guild – which the ABC recently dubbed ‘the most powerful lobby group you’ve never heard of’ – speak with the same voice.
 
‘The Guild are a body which represents the interests of pharmacy owners only, and have a role in industrial relations and the interests of proprietors of a business,’ Dr Freeman said.
 
‘The PSA is the recognised peak body for all pharmacists and the custodian of practice standards, training and advocacy groups for individual pharmacists.
 
‘One represents the interests of a business owner, the other is for individual pharmacists.’
 
The Pharmacy Guild has long wielded considerable clout, in part due to its formalised role as the only negotiating partner for the nation’s Community Pharmacy Agreement (CPA), currently worth $18.9 billion over five years.
 
Speaking at the RACGP’s GP18 conference last year, Greens leader Richard Di Natale called for more scrutiny and transparency for these ‘backroom deals’.
 
It was only this year that the PSA has gained access to the negotiations over the CPA.
 
‘Earlier this year, Minister Hunt announced for the first time in the history of the CPA that a body other than the Guild and the government be a signatory. That was welcome, given our members deliver those services,’ Dr Freeman said.
 
Dr Freeman said the PSA and the Guild differ on their preferred approach for pharmacy prescribing.
 
‘We [the PSA] support the move towards pharmacist prescribing, but we see that the most likely model is one occurring in collaboration. [The Guild’s view] is that it should be autonomous prescribing,’ he said.
 
Dr Freeman pointed out that many other allied health groups already have limited prescribing rights, ranging from optometrists to podiatrists.
 
‘One would argue that the [pharmaceutical] expertise of pharmacists would exceed those other groups,’ he said.
 
‘So if we were able to prescribe in a collaborative framework, it would improve not only access but [help] the patients get the care when and where they need it, rather than being shipped around the health system to an individual with a defined scope of practice.’
 
newsGP asked Dr Freeman about the financial conflict of interest that could occur if a pharmacist could prescribe and also dispense a medication.
 
‘Wherever there’s a pecuniary interest in the business of health – in general practice or pharmacy – there’s always the risk of bias in how someone might practice,’ he said.
 
‘What I would say is, pharmacists, like GPs, operate under a code of ethics, and while there are examples of people who do practise unethically, on the whole both professions do adhere to it. 
 
‘Our view is that the process for prescribing and dispensing should be absolutely separated. Not from commercial reason, but from safety – you need a second person to review that prescription before supplying it to a patient.’ 
 
Dr Freeman said delivery of the flu vaccine by pharmacists is now seen as commonplace, and that many would deem it a success.
 
‘The initial fears and concerns [about pharmacy flu vaccines] haven’t been realised,’ he said.
 
‘When something new is proposed, people often look at it through a negative lens, without balancing it with what mechanisms for safe practice are already established.’
 
Dr Freeman said it is hard to comment on the proposed Queensland-wide trial allowing pharmacists to prescribe certain antibiotics, as the details have not yet been made public.  
 
Trouble in pharmacy-land
The ongoing ructions come as the pharmacy sector struggles with issues of financial viability, concerns over low wages and pharmacists leaving the profession.
 
Pharmacists are among Australia’s lowest paid health professionals, according to ABS employee earnings figures. A 2016 Australian Journal of Pharmacy poll of more than 1300 pharmacists found a majority wanted to leave the profession.
 
A 2018 report by Professional Pharmacists Australia (PPA), a union for employee pharmacists, states there are two models of pharmacy – one relying on government funding for allied health such as medication reviews, and another that ‘focuses on retail sales of health products at heavily discounted prices’.
 
‘2018 has seen the intensification of the shift away from professionalism towards commercialism. Approximately 60% of the My Chemist group’s revenue comes from retail product sales,’ the report states. 
 
The PPA last year made a claim to the Fair Work Commission for a rise in pharmacist award rates, which was opposed by the Pharmacy Guild, among other organisations. 
 
‘This is where we are’
Dr Evan Ackermann, former Chair of the RACGP Expert Committee – Quality Care, is a long-time critic of Pharmacy Guild influence and efforts to increase the scope of practice for pharmacists.
 
‘The Pharmacy Guild, by dint of old legislation, is the legislated body the government negotiates with to negotiate each CPA,’ he told newsGP.
 
These are five-year agreements that detail funding of pharmacy – who gets paid what. The outcome of the CPAs has been great profits for pharmacy, while decreasing conditions for frontline pharmacists. 
 
‘The RACGP has proposed a new model for the Pharmaceutical Benefits Scheme which gets the pharmacist in a professional role, but it really would impact on Guild profits,’ Dr Ackermann said.
 
‘The Productivity Commission has advised the government to stop funding the existing pharmacy model, but the Guild has been active politically to get support for existing pharmacy model from all sides of politics.
 
‘So this is where we are. Pharmacy-protected boundaries, protected ownership, and now business models underwritten by the government.’  
 
Dr Ackermann said the debate around codeine up-scheduling was telling.
 
‘From all standards it was clear codeine needed to be up-scheduled, but the pharmacy groups tried everything to undermine this process,’ he said.
 
‘Even now we are still seeing misinformation promulgated by Guild representatives saying codeine prescriptions have increased – whereas the truth is total codeine consumption has dramatically fallen by 50%.
 
‘The historic differential between prescriber and dispenser – you cannot be both – has been gradually broken down by pharmacy. Pharmacy wants an increasing role in selling prescription drugs. I see this as a major threat to patient safety.
 
‘This has gone under the mantra of “increasing access to medications” for patients, along a self-care model. However, there is no evidence that patients are suffering, or that there is a problem in Australia from lack of access to medication – the opposite, in fact.’
 
Pharmacy Guild President George Tambassis declined to be interviewed for this story.

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