As a doctor, I would not feel comfortable working in the role of a pharmacist without having trained as a pharmacist first, and yet the reverse is now being described as delivering on an election commitment made by the Queensland Government.

I am a Qld GP and I am writing to urge you to oppose a Qld Government draft proposal, The North Queensland Pharmacy Scope of Practice Trial, to give Qld pharmacists in certain regions the authority to work outside their scope of practice in an ‘extended prescribing’ trial. Under the proposal, pharmacists who complete a three week (120 hour) course would be able to take a patient history, perform a physical examination, diagnose disease from a set list of 23 conditions, and then initiate prescription-only medication. Furthermore, pharmacists could unilaterally change prescription decisions made by specialist doctors. Pharmacists working in their normal capacities play a crucial role in healthcare teams and are highly valued by doctors. However, diagnosis and management of disease and the necessary prior detailed history taking, physical examination and investigation are not pharmacist skills.

Being able to purchase antibiotics from a pharmacist without a prescription from a doctor used to signify that you were in a developing nation. The sale of these antibiotics by pharmacists in developing countries is known to contribute to antimicrobial resistance. WHO has declared that antimicrobial resistance is one of the top 10 global public health threats facing humanity. Without the need for a prescription from a doctor, the sale of these medications in pharmacies may become unscrupulous and transactional. However, the ship appears to have sailed for discussing Queensland pharmacies profiting directly from prescribing antibiotics, because a trial of pharmacists prescribing antibiotics for possible urinary tract infections (UTIs), where pharmacists are able to charge a higher fee when they do prescribe, is being extended in Queensland to mid 2022. Unfortunately, the success of this pilot has been based on how much patients liked being able to access antibiotics for a possible UTI without seeing a doctor, rather than on appropriate clinical outcome measures like assessing whether any of the treated women actually had a UTI and how many in fact had non-UTI urogenital infections (e.g. genital chlamydia), interstitial cystitis or other serious pelvic pathology.

The extended pharmacy prescribing trial can be reasonably predicted not to be run as a clinical trial as the Qld Government states this ‘trial builds on the community pharmacy UTI medication prescribing trial which commenced in 2020’. The UTI prescribing trial was not a clinically registered trial, it is classed as a ‘service implementation pilot’, with (as the RACGP president has said), “nothing like a control arm or rigorous synthesis of evidence." The UTI prescribing pilot was opposed by The Society of Hospital Pharmacists of Australia, Australia’s National Centre for Antimicrobial Stewardship, the Australian Society for Antimicrobials, the Australian Society for Infectious Disease, the Australian Medical Association and the Royal Australian College of General Practice. The Pharmacy Guild of Australia (the lobby group for pharmacy owners and the sixth most generous donor to Australian political parties in 2020-2021) - supports both the UTI prescribing and extended prescribing trials.

I have heard a number of doctors who previously worked as pharmacists give their opinion on this new pharmacist extended prescribing scheme and they have all said they believe it is dangerous. They attest that pharmacists do not have the breadth of knowledge required to safely handle these clinical responsibilities. Pharmacists given these responsibilities would miss serious conditions as their lack of adequate knowledge and experience would put them in the perilous position where they do not know what they do not know: unconscious incompetence. This knowledge and experience gap could be filled by the equivalent of being accepted to and successfully completing an Australian medical degree, then completing a one-year supervised internship in an accredited hospital, followed by at least one year of work as a supervised resident medical officer in an accredited hospital, followed by at least two years of work as a supervised registrar who has been accepted onto a medical specialty training program and is studying for fellowship exams, exams which need to be successfully completed within a set period of time to attain fellowship. That is what is required to become a GP or other medical specialist, and becoming a GP takes, on average, 12 years. Yet, somehow, this scheme argues that this training could be replaced with a four year degree in an entirely separate discipline followed by a three week course. If I spend four years training to be a plumber and then decide I want to be a carpenter and build your home, but only from a list of 23 types of homes, can I complete a three week course to achieve this?

“If the only tool you have is a hammer, you tend to see every problem as a nail.” Pharmacists are to be given a list of a smattering of 23 conditions (see List 1.) from which they are allowed to diagnose and treat. They are not given latitude to stray beyond this list. Firstly, they would not have the years of experience that are required to develop thorough history and examination skills which guide clinicians to reach a provisional diagnosis and consider important differential diagnoses (for instance the diagnosis of a cancer might be less likely but is crucial not to miss). This clinical acumen takes years to develop and, because of unconscious incompetence, can only develop with high-quality supervision. Secondly, investigations are usually necessary to confirm a diagnosis and/or exclude important differential diagnoses. Pharmacists in this scheme, even if they were to consider differential diagnoses not on the list of 23, would not be able to request investigations such as pathology and imaging or refer to non-GP specialists for further procedural tests (e.g. colonoscopy). Inescapably, there will be confirmation bias to see a provisional diagnosis that is on their list, a diagnosis that does not require utilising investigations that they cannot access.

One example of the ‘hammer and nail’ problem can be demonstrated if we consider the listed condition gastro-oesophageal reflux disease (GORD) - commonly called ‘reflux’ or sometimes ‘heartburn’. Notably, ischaemic heart disease, peptic ulcer disease, Crohn’s disease, oesophageal and gastric cancers (to name a very few differentials which can present with the same symptoms as GORD), are not on the list. Patients presenting to primary care often want their chest pain to be reflux. Often they have been getting medication from the pharmacy to reduce stomach acid but as they can only access a 7-day supply without a script from a doctor they eventually wind up in the GP office to get a more cost-effective prescription. They look a little sheepish when it transpires the investigations they begged us not to bother referring them for showed they had severe coronary artery disease and needed urgent cardiac surgery. They are never really that surprised as they know GPs go through a decade or more of training to ensure they don’t miss these things. Given that the pharmacist under this scheme would have the ability to diagnose and treat uncomplicated GORD but would not be able to perform or arrange relevant investigations (e.g. an ECG; blood tests, urea breath testing, stool tests, coronary angiogram or upper GI endoscopy) they will often enough only see uncomplicated GORD and patients will die of treatable diseases like cancer and heart disease due to missed and delayed diagnosis. We also have to have our eyes open to the financial conflict of interest inherent in pharmacist prescribing. We know from the recent and necessary overhaul of codeine availability to prescription-only access that some pharmacists can put profits ahead of safe gatekeeping.

This scheme will fragment primary care. Continuity of care is key in good-quality primary healthcare and patients benefit from a consistent doctor-patient relationship. Inserting a pharmacist into a doctor’s role, making their own assessments and plans, will disrupt this relationship. A patient with type 2 diabetes mellitus (T2DM) is extremely likely to have multiple co-morbidities and certainly needs robust management. A GP is best placed to provide the appropriate assessment, patient education and allied health referrals; initiate pharmaceutical and non-pharmaceutical management and continue to monitor the clinical effect of these interventions; and best placed to provide regular screening for microvascular and macrovascular complications of T2DM (including retinopathy, nephropathy, neuropathy, coronary artery disease, cerebrovascular disease and peripheral artery disease) and identify the patient’s accompanying and contributing conditions (e.g. overweight or obesity, hypertension, hyperlipidaemia, chronic kidney disease, and cardiovascular disease), managing these as well. A pharmacist working with the expanded scope under the proposed scheme would not have the ability to manage the majority of the necessary initial stages of care even in the most straightforward of T2DM patients. Why confuse patients by suggesting the pharmacist should play this insufficient interim role?

Research has shown GPs are cost-effective. After all, a large part of their focus is opportunistic preventive medicine, which is proven to reduce costs in healthcare systems. The solution for overburdened hospital systems in rural areas in Australia is better funding and support for both GPs and public hospital outpatient services; not developing world dispensaries.

In summary, the proposed extended prescribing scheme is unsafe due to grossly inadequate training and experience which would lead to unconscious incompetence which may be further exacerbated by confirmation bias and conflict of interest. Furthermore, it would fragment primary care and further burden the hospital system with missed and delayed diagnoses.

List 1.
 Full list of autonomous prescribing conditions under the draft proposal for pharmacist extended prescribing

1. Gastro-oesophageal reflux
2. Acute nausea and vomiting
3. Oral health screening and fluoride application
4. Allergic and non-allergic rhinitis
5. Asthma and exercise-induced bronchoconstriction
6. Chronic obstructive pulmonary disease
7. Impetigo
8. Herpes zoster
9. Atopic dermatitis
10. Psoriasis
11. Mild to moderate acne
12. Acute wound management
13. Uncomplicated UTIs
14. Acute otitis media
15. Acute diffuse otitis externa
16. Dyslipidaemia
17. Hypertension
18. Type 2 diabetes mellitus
19. Musculoskeletal pain and inflammation
20. Weight management for obesity
21. Smoking cessation
22. Oral contraception
23. Travel medicine

Dr Stephanie Dawson-Smith
MBBS, DCH, FRACGP

Please add your signature if you would also like to call on the Qld Government to stop their plan to give pharmacists the role of medical doctors through 'The North Queensland Pharmacy Scope of Practice Trial’, undermining Australia's world-class healthcare system.