A national review of primary care workforce regulations is investigating ways to increase Australians’ access to quality health care.
The review is considering how health-care workers can use more of their skills and training, to work to their full scope of practice. This includes exploring who should be allowed to prescribe medications.
Independent pharmacist prescribing is increasing around the world, and now trials are starting in most Australian states.
The review should focus on expanding pharmacists prescribing for stable conditions and long-term medications, under the direction of a GP.
What’s the problem?
It often seems like health workers are at odds, but there’s one thing the professional bodies for doctors, nurses, and allied health workers all seem to agree on: we need more team-based care. Governments agree too.
As rates of complex chronic disease rise, it’s no longer possible for one clinician to provide all the care, advice and support many patients need.
There is good evidence that a team of different kinds of health professionals working together can improve access to and quality of care, and reduce costs.
But Australia lags other countries when it comes to letting primary care professionals use all their skills. Partly as a result, Australia ranks behind most wealthy nations in the share of GPs who say they delegate aspects of care to other workers.
That’s one reason for rushed appointments and long wait times, with nearly one-quarter of Australians saying they wait too long to see a GP, and almost one-third not getting to see their preferred GP.
There are lots of things holding teamwork back. They include workforce shortages in some parts of Australia, cultural barriers, inadequate IT systems, a fee-for-service funding model, and clinics getting too little support to change how they work.
But the rules about who can do what, and who gets paid for doing what, are a big part of the problem. That will be the focus of this review.
Scope to share prescribing
The Pharmaceutical Benefits Scheme funds 215 million prescriptions each year. In the five years to 2021–22, that number rose by an average of 3.3 million prescriptions each year.
Those prescriptions can be written by authorized practitioners, such as doctors, dentists and optometrists, as well as nurse practitioners and midwife practitioners, who have post-graduate degrees.
Trials are underway to share this growing workload with pharmacists. This recognizes pharmacists’ expertise in medicines, and their availability on a walk-in basis in most communities around Australia, including those with long waits for GP care.
It also reflects support from pharmacists and patients for a prescribing role.
Victoria’s 12-month pilot is set to begin in October, and will allow pharmacists to prescribe repeat scripts for oral contraceptive pills, as well as treatments for some mild skin conditions and urinary tract infections (UTIs).
A similar trial is under way in New South Wales.
Queensland, which already allows pharmacists to prescribe medications for UTIs, will begin a new trial later this year, allowing pharmacists to prescribe for a broader range of common health conditions.
Just a few weeks ago, Western Australia introduced pharmacy prescribing for UTIs.
It’s new here, but in many other countries pharmacist prescribing is well established. Models vary, but pharmacists can write prescriptions in countries including Canada, New Zealand, the United States and the United Kingdom.
In a growing number of countries, pharmacists can prescribe independently. For example, in England all newly qualified pharmacists will soon be able to do so.
An approach that has been around for longer overseas but that isn’t part of trials here, is pharmacists prescribing under a clinical management plan agreed with a patient’s GP.
Under this model, people with stable, long-term conditions that are being successfully managed with medication can get prescriptions renewed by their pharmacist, rather than having to return to the GP.
The evidence shows this type of prescribing can be just as effective as prescribing by doctors.
What approach should Australia take?
The Australian review is an opportunity to follow the evidence and catch up with other countries. If expanding prescribing rights is done carefully, it will improve access to care and reduce costs, without compromising the quality and safety of care.
But if there are too many prescribers working independently, it could increase fragmentation of care in a system that is already disjointed and hard to navigate. This has been one criticism of recent Australian pharmacy prescribing trials, all of which have some component of independent prescribing.
By working in partnership with GPs, pharmacist prescribing could go beyond the narrow range of medicines and conditions covered in independent prescribing schemes. It would complement effective pharmacy services that review medications and advise patients about them.
That’s why the review should focus on collaborative prescribing for stable, chronic conditions. This will help more patients, while keeping GPs at the heart of the primary care team, making sure that the pieces fit together.
As in other countries, additional training will be needed for pharmacist prescribers, and a range of implementation issues need to be considered. This includes ensuring:
- pharmacists have sufficient training and skills
- efficient systems are in place for sharing clinical information and working with GPs
- both the pharmacists and the GPs they work with are paid appropriately.
Getting to the future of team-based care that all the major health professional groups espouse will require compromise. Pharmacy prescribing is already here, and it’s likely to go further. To get the best results for patients, community pharmacists should welcome leadership from GPs, while GPs should support pharmacist prescribing.
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