Hospital pharmacists side with GPs on community pharmacy prescribing powers

Pharma News: GPs are calling for patient safety to be prioritised. It comes following Royal Australian College of General Practitioners (RACGP) President, Dr Nicole Higgins, and RACGP South Australian Chair, Dr Sian Goodson, speaking at the Parliamentary Select Committee on Access to Urinary Tract Infection Treatment.

The College’s submission outlines why expanding pharmacy powers to treat urinary tract infections (UTIs) is not the right call.

RACGP President Dr Nicole urged the state’s leaders to heed GP warnings.

“Ask any GP and they will tell you – there is no such thing as an ‘uncomplicated’ UTI. GPs and practice teams value the vital role that pharmacists perform, and we are right behind pharmacy and general practice working hand in glove. However, GPs complete over a decade of training and undertake years of supervised training to manage patients and treat conditions such as UTIs. Whilst pharmacists are expertly trained to perform their functions, they are not trained to make a diagnosis.

“We must be very careful not to fragment care and risk the long-term well-being of any patient. If the left hand doesn’t know what the right hand is doing it can put people in jeopardy, and that is exactly what can happen if pharmacists and GPs are both performing jobs such as prescribing antibiotics. I note too that a crowded retail setting is not a suitable environment to have sensitive conversations about a condition such as a UTI. There is no consult room, and we know from the Queensland experience that patients had to discuss their sexual history in earshot of other customers.”

Interestingly, the Society of Hospital Pharmacists of Australia (SHPA) has also expressed concerns about community pharmacy prescribing powers to treat UTIs, stating that community pharmacists do not have access to previous patient pathology results required to make informed clinical decisions around treatment.

“For example, in the absence of urine sensitivities or kidney function, pharmacists may find it challenging to ascertain suitability for antibiotic treatments such as nitrofurantoin, which requires dose adjustment in kidney disease, or where an alternative treatment may be indicated.

“Community pharmacists also do not have access to Medicare to enable urine samples to be analysed for culture and sensitivities. While treatment for simple UTIs is empiric (where treatment is started before knowing whether the pathogen is susceptible to the antibiotic or not), in the case of treatment failure on the first antibiotic, results will not be available to guide treatment if the consumer is then referred to the GP. In addition, if sensitivity data is not collected, the true resistance rate in the community cannot be ascertained,” noted the SHPA in its submission to the Parliamentary Select Committee.

However, The Pharmacy Guild of Australia pointed to the success of Queensland’s Urinary Tract Infection Pharmacy Pilot (UTIPP-Q) noting that it “was subject to a robust evaluation which found that the service was of significant value because of improved accessibility to primary health care services, was convenient, and the treatment provided resolved women’s symptoms in 87% of cases.”

The Guild highlighted the fact that community pharmacists are already providing services for the treatment of uncomplicated UTIs in Canada, Scotland and New Zealand where the cost of the service is paid by the patient.

Dr Goodson backed the President’s calls and warned of the risk of poor health outcomes if pharmacy prescribing powers are expanded.

“We know of several very concerning instances including a patient who had chlamydia being prescribed antibiotics for a UTI and then also upsold products including cranberry tablets. Another patient who was handed antibiotics for a presumed UTI turned out to have a 15-centimetre pelvic mass and there was also someone with a recurrent UTI given the antibiotic trimethoprim despite known resistance to the drug.

“Keep in mind – these are just the cases we know about. The Queensland pilot was not a proper clinical research trial conducted by an independent expert evaluating public health outcomes. Rather, patients were surveyed by the pharmacist who provided the service and there was no recording of whether there was a reduction in hospital presentations for UTI complications. Only 32% of women who received a service were followed up by pharmacists, so we don’t really know how many of them fared after their visit to the pharmacy.”

Alarmingly, the report also highlighted that 50% of pharmacist respondents found charging a $19.95 service fee difficult when they did not supply the antibiotic to treat the UTI. So, it’s clear that there is a very real risk of overprescribing, noted the RACGP.

“The reason we have always separated prescribing and dispensing is to avoid any potential conflict of interest. So, we certainly don’t want any model where pharmacists diagnose and prescribe for a condition, such a UTI, and then sell the very drugs required to treat that health issue. Let’s stick with what we know works best – GPs diagnosing and prescribing and pharmacists dispensing,” stated Dr Goodson.

The RACGP SA Chair also warned of other unintended consequences of expanding the remit of pharmacy.

“At a time when we must do everything possible to combat antimicrobial resistance, there has never been a worse time to expand the number of antibiotic prescribers. Evidence abounds, including a 2021 Australian study which showed a significant increase in topical chloramphenicol prescribing after it was rescheduled to pharmacist only in 2010. This is just another reason why expanding antibiotic prescribing is such a bad idea, we should be limiting such prescribing to instances where it is absolutely necessary and only under the supervision of a GP who has the requisite training and expertise.”

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