GPs question prescribing scope
The Royal NZ College of GPs will work with the Pharmacy Council to further develop the proposed pharmacist prescriber scope of practice.
Submissions on the proposal closed last month and the council is currently in the process of compiling them into a composite document for detailed analysis and discussion by stakeholders.
While the New Zealand Medical Association has, in its submission, strongly opposed the proposal and reiterated its objections to it dating back to August 2007 when the proposal was originally mooted, the college response has been more measured and conciliatory.
“General practitioners and patients greatly value the important contribution pharmacists make to patient care,” RNZCGP chief executive Karen Thomas says in the submission.
“The college strongly supports collaboration between health professionals.”
The college says it is pleased to see pharmacist prescribers will be expected to understand rather than make a diagnosis.
“Doctors’ particular training teaches them diagnostic skills. Even for doctors who have received this lengthy training, reaching an accurate diagnosis is frequently not straightforward.”
Most GPs who individually contributed to the college submission have reportedly been opposed to pharmacists gaining prescribing rights.
To this, the college says, GPs interact frequently with community pharmacists, but seldom with hospital pharmacists.
“Not surprisingly, the majority of the feedback which we received from members reflected the assumption community pharmacists would become prescribers. ”
The college thinks an explicit and unambiguous statement early in the document or in a covering letter would have enabled GPs to identify the majority of pharmacist prescribers will be working in secondary care environments and community pharmacists wishing to become prescribers will not be in a dispensing role and would not be able to own a pharmacy.
“Had a similar explicit statement featured in the consultation document, this would have enabled feedback from GPs to be more focused on the types of scenarios which the Pharmacy Council presented at the November meeting [to discuss the proposal] and less on the issues resulting from prescribing by community pharmacists,” the college says.
While the proposal says prescribing by community pharmacists may happen under exceptional circumstances, such as in isolated rural communities, and talks of clear separation of prescribing and dispensing roles, the college does not support community pharmacist prescribing.
Many GPs also expressed concern around who would be held responsible in various situations where medication was stopped, altered or initiated by a pharmacist prescriber, particularly if this was without the GP’s knowledge.
The RNZCGP thinks the description of a collaborative environment in the proposal is not sufficiently robust.
“This is a very significant issue because the ‘collaborative environment’ is relied on to address major safety, quality and efficiency issues. The definition of a collaborative environment [in the proposal] focuses on the pharmacist having access to patient notes. This is essential for the purposes of communication, but not sufficient to produce safe, efficient and effective patient care.”
The Pharmacy Council proposes to work through these issues with the college.
Meanwhile, NZMA in its submission to the proposal points out, while pharmacists might undertake cardiovascular risk assessment or prescribe for minor ailments such as thrush, the treatment of the “minor ailment” is based entirely on the patient’s description of it.
Detailed submissions from the RNZCGP and NZMA are available at www.pharmacytoday.co.nz RK
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No surprises at GPs’ hesitancy
Is it naive to expect doctors to easily agree to the pharmacist prescriber proposal? Would pharmacists be willing to consider allowing GPs to dispense medicines?
Wairoa pharmacist Robin Norvill says he wouldn’t have a problem with doctors dispensing medicines, provided they were required to meet the same exacting standards pharmacists have to meet with regard to various acts, regulations and schedules, and also had the background pharmaceutical knowledge that goes with pharmacist training.
“If you think about it, many GPs, particularly those in rural practices, are dishing out medication now after hours, rather than dispensing properly. Pharmacist prescribing requires considerable training to achieve.”
Wairoa in Northern Hawke’s Bay is a typical example for adding weight to pharmacy’s argument in favour of the proposal. The isolated town has, until now, had a fairly good number of GPs who also cover the small, local hospital.
However, Mr Norvill says the town will be in crisis in the next five to 10 years as four of the regular GPs are in the 50 plus age bracket and most are looking to cut back their workload. The other three positions are covered by locums, which in itself creates stress on the system.
He says to make the most of the workforce available, Wairoa is currently looking towards an integrated healthcare system, where the doctors will all practise in one set of rooms attached to the hospital.
“We are in discussion about the pharmacies having access to clinical notes in order to be able to assess prescriptions properly, without interrupting the practice by phone with such regularity as we do now,” Mr Norvill says.
“I have been asked if I would consider being a pharmacist prescriber. I already do a fair bit of clinical work with patient reviews under our Medicine Management contract, and also attend the GP monthly peer review/continuing education evening and contribute to this.”
Such interaction between GPs and pharmacists, Mr Norvill says, has broken down barriers and helped both sides to understand the problems each are dealing with.
Meanwhile, NZMA’s refusal to budge from its 2007 stance, strongly opposing the proposal, is seen by some as patch protection.
Veteran pharmacist Harvey Lockie says patch protection is the “elephant in the room” that never gets discussed. Mr Lockie thinks whether or not pharmacists get prescribing rights was always going to be a political problem, rather than clinical.
On the suggestion of greater awareness among prescribers and a closer relationship with them to explain the limited circumstances in which pharmacists could potentially be prescribing, he says no amount of relationship building and explanation will make the doctors yield any of their power and income.
“They just don’t want it to happen and never will. If the supermarkets explained to us why they want more pharmacy only drugs released to them for the public good, would we then support them? Don’t think so.” RK
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