RACGP pulls out of pharmacy prescribing trial role over ‘fundamental flaws’

Doug Hendrie

3/02/2020 3:26:05 PM

The RACGP will not take part in Queensland’s controversial pharmacy prescribing trial advisory group, citing issues with monitoring and the risk of misdiagnosis.

Pharmacist giving prescription
Flaws with monitoring the ‘most serious potential complications’, such as misdiagnosis and the potential for increased antibiotic resistance, are cited as reasons for the RACGP’s withdrawal.

RACGP representatives attended the first meeting of a steering group for Queensland’s Urinary Tract Infection Pharmacy Pilot in late 2019.
But the meeting did not address all of the college’s concerns, leading to its decision to pull out of the trial.
Flaws with monitoring the ‘most serious potential complications’, such as misdiagnosis or delayed diagnosis and the potential for increased antibiotic resistance, are cited as reasons for the withdrawal in a letter sent to the head of the trial by RACGP Queensland Chair Dr Bruce Willett and council member Dr Paul Bryan.
‘As overseas experience has demonstrated, pharmacist-initiated antibiotics reduce neither health system costs nor GP workloads,’ they write.
‘We believe [the trial] represents an unacceptable departure from current medication scheduling arrangements conducted by the Therapeutic Goods Administration (TGA), and carries risks in the form of fragmentation of care, misdiagnosis and delayed diagnosis, antibiotic resistance, financial costs to patients, and opportunity costs in the form of missed preventive care.’
The GPs fear pharmacist prescribing for urinary tract infections could see potential misdiagnosis of patients with more serious conditions such as pelvic inflammatory disease, appendicitis, pregnancy (including ectopic pregnancy), and bladder tumours.
‘The trial must employ a comprehensive and reliable means of screening for these conditions, given that examination and referral for investigations will not be possible. For example, the current plan to exclude pregnancy on the word of the patient is unacceptably unreliable and potentially unsafe,’ they write.
‘With proposed follow up during the trial likely to be limited to a phone call to the patient one to two weeks after the pharmacist–patient encounter, there is the possibility that rates of misdiagnosis and delayed diagnosis will be significantly underestimated.’

RACGP Queensland Chair Dr Bruce Willett says concerns around the trial remain.

The medical community has been stridently opposed to the trial since its beginning, with the RACGP, Australian Medical Association (AMA) and Australian College of Rural and Remote Medicine (ACCRM) criticising the move.
Concerns have intensified after a warning by the UK’s largest pharmacist organisation and indemnity provider, the Pharmacists’ Defence Association (PDA), over a number of serious medical incidents – including deaths – linked to independent pharmacist prescribers.
Dr Willett and Dr Bryan state in the letter that the PDA warning lists four high-risk situations, two of which apply to this trial – undertaking prescribing for walk-in patients where a diagnosis may be required, and without reference to their clinical records.
While most pharmacists have access to My Health Record, these records are not guaranteed to be up to date or complete, Dr Willett and Dr Bryan state.
The RACGP’s withdrawal comes as the pilot nears launch. It will see consultations be undertaken by registered pharmacists in a private consultation room, though other details have not been released.
But the RACGP remains concerned over the dangers of increased antibiotic prescribing at a time when antimicrobial resistance is one of the major global threats to health, according to the World Health Organization.
The trial has no funding or means to monitor the impact of the trial on local rates of antibiotic resistance.
‘This is a significant limitation given that more prescribers will increase the absolute number of antibiotics dispensed to the community (as has been the case in the UK), amidst rising rates of antibiotic resistance,’ Dr Willett and Dr Bryan write.
They are pushing for the trial to include only one antibiotic, trimethoprim, rather than trimethoprim, nitrofurantoin, and cephalexin.
This option ‘carries the lower risk of short- and long-term harms,’ they write.

A Queensland Department of Health spokesperson told newsGP that patient safety is a ‘priority’ for the trial.
‘The scope, protocol and model of care for the pharmacy prescribing trial is under development in consultation with stakeholders,' they said.

'The trial protocol, education, training requirements and model of care – including the choice of antibiotics for urinary tract infections by community pharmacists – is under development. This is being done in consultation with experts and a range of industry stakeholders.
‘This trial will include thorough evaluation activities and strict governance and reporting.’
The RACGP last year wrote to all Queensland MPs, sounding the alarm over the potential dangers of the trial.
The trial comes amid a broader push by the Pharmacy Guild of Australia – which represents pharmacy owners – to expand the scope of practice for pharmacists, which has been met with alarm from peak medical bodies.  
The Queensland Government last year accepted all recommendations made by a parliamentary committee inquiry into pharmacist scope of practice. The Guild welcomed the findings as a way for ‘pharmacists to operate to the full extent of their training’.
The Guild wants to expand the scope of practice for pharmacists by becoming ‘pharmacist prescribers’ in collaboration with doctors.
The Pharmacy Board of Australia last year cleared the way for two models of pharmacist prescribing – collaborating alongside doctors, and structured prescribing with limited authorisation – but backed away from autonomous prescribing.
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Dr Matthew James Harvey   4/02/2020 9:14:46 AM

Queensland Health's top priority for this trial is safety? Then the trial should not proceed. The Pharmacy Guild wants to create Pharmacist Prescribers, but fails to understand there is a fundamental difference between diagnosing and prescribing, and fails to understand that diagnosis must always precede prescription. Safe prescribing requires not only a knowledge of the appropriate medication choices for a given condition, and a knowledge of potential interactions with other medications, but also of implications of that medication upon other health conditions, and it requires a diagnosis to be made. Making a diagnosis is not a skill one can acquire by doing a learning module, one can't even acquire it by graduating from a medical school! Safe and independent diagnosing and prescribing takes years of postgraduate training and experience, which our pharmacist colleagues, as learned as they may be in their area of expertise, simply do not possess. It's never #justascript.