Adverse outcomes related to pharmacist prescribing have been reported widely – with around half of GPs noting they had encountered at least one in the last 12 months, and 30% stating they had an unsatisfactory experience related to pharmacist prescribing of antibiotics for UTIs, according to a March Healthed poll with more than 1850 respondents.
The findings add weight to a dossier of more than 60 examples of pharmacist prescribing related harms that the RACGP collated from GPs around the country – which RACGP Victoria chair Dr Anita Muñoz presented to Safer Care Victoria last month.
“We have people with dysuria being treated for UTIs when in fact they have STIs, genital herpes, we’ve had a vulval cancer treated as a UTI, abnormal uterine bleeding treated as a UTI, there was a vulval abscess treated as a UTI and so this essential premise that if a woman complains of discomfort when they pee, that must be a UTI is so unbelievably one-dimensional and is proving to be very often incorrect,” Dr Muñoz said.
“In addition, we’ve had people with pyelonephritis treated for simple cystitis and days later have ended up in hospital and in one instance in ICU. We’ve also had people who are not meant to be treated on the protocol being treated – for example a man was treated for UTI in a pharmacy.”
GPs in Healthed’s survey recounted that pharmacists prescribing for what they thought were UTIs had missed bladder cancer, leukaemia and other malignancies, renal calculus, thrush, herpes, chlamydia and other unspecified STIs.
“There’s been a decoupling of prescribing from appropriate investigation and diagnosis,” Dr Muñoz said.
“The pharmacy prescribing protocols are making the assumption that the pharmacist will be beginning with the correct diagnosis, and we are seeing over and over again that that is totally fallacious.”
“The fact that the Pharmacy Guild and governments continue to posit that there’s been no harm from any of these trials is disingenuous,” she said, citing examples such as those above.
The pushback comes as the government forges ahead with plans to fund a national pilot for pharmacist prescribing of antibiotics for uncomplicated urinary tract infections and initiation and resupply of hormonal contraception (in accordance with state and territory regulations) for women with a concession card at the rate of $7.70.
The 12-month trial will begin in January 2027. Pharmacy Guild of Australia President Professor Trent Twomey has assured the public that this will provide affordable access with shorter wait times, without compromising safety.
“Importantly, pharmacists will only deliver these additional services with the appropriate clinical training and within clinical protocols. Safety is, and always will be, central to pharmacy care,” Professor Twomey said.
The Guild took an edgier tone when its spokesperson responded to the concerns raised by the RACGP. “The RACGP’s pathetic attempt to create some type of bygone era turf war is not in the best interests of patients,” she told the Age. “Allegations are not facts.”
Dr Muñoz categorically rejects the turf war narrative, noting that she believes pharmacists provide a valuable but separate service to GPs, helping to create a system of checks and balances.
However, the conflict of interest for those who both prescribe and dispense is a concern.
Dr Muñoz said that while the Medical Board of Australia, Medicines Australia and AHPRA all have codes of conduct prohibiting other prescribers from profiting off the act of prescribing, these regulations are not being applied to pharmacists, creating a double standard.
“In addition, the reason we have always separated prescribing from dispensing is because it has been recognised as an essential safety mechanism so that there are multiple layers of checking and rechecking and thinking and rethinking when it comes to safe and rational uses of medications.”
Moreover, she said it’s “very concerning” that many pharmacists continue to offer, recommend and sell non-evidence-based remedies and homeopathic products to patients.
“There is an inherent tension there with indicating to the public that you are able to safely prescribe and dispense in isolation, yet at the same time continue to profit from recommending medicines and products that are either known not to work or have no evidence behind the claims that they work,” she added.
Dr Muñoz said the College and AMA provided the Queensland government with a list of instances of harm during its pharmacist prescribing trial, but it had no impact on the decision to continue and then expand the trial. Likewise, when the RACGP presented their dossier of instances of harm to Safer Care Victoria in March, there did not appear to be much appetite for change.
“They were thankful that I had shared that with them, but they said that there is an ongoing directive from government to continue to roll out the pharmacy prescribing initiative,” she said.
Another issue is that safety protocols for pharmacist prescribing differ markedly between states and territories.
The Pharmaceutical Society of Australia (PSA), which supports the upcoming trial, said it would work to standardise differences in pharmaceutical prescribing protocols between states and territories to ensure consistent delivery.
“We currently have eight different protocols for pharmacist prescribing for uncomplicated UTIs in place across the country, as well as several different protocols for prescribing of hormonal contraception,” PSA president Professor Mark Naunton said.
“This pilot will provide an opportunity to remove this duplication and inefficiency through adopting a nationwide approach.”
But details are still being hashed out.
A spokesperson for the Department of Health, Disability and Ageing said “the terms and scope of the trial are being developed and will be finalised in consultation with pharmacy groups, clinical experts and states and territories.”
“The trial is intended to test whether access to affordable and timely treatment for uncomplicated UTIs and certain hormonal contraception can be improved and done safely and effectively through a time-limited, independently evaluated pharmacy model.”
Safety shouldn’t be sacrificed for the sake of convenience
Associate Professor Gino Pecoraro, an obstetrician and gynaecologist based in Queensland, is among those raising concerns.
“You can’t offer up safety on the altar of convenience,” Dr Pecoraro said.
A contraceptive consultation is so much more than just writing a script, he added, noting screening for sexually transmitted infections, taking a proper history and making sure they are up to date with other screen tests are all important – as is ensuring that the patient is on the best contraceptive for them, which may be a reversible long-acting contraceptive, for example.
“A proper medical consultation that gives an opportunity for a whole heap of preventative health care measures. And just because you’ve been on a pill for a certain number of years does not mean that that’s still the right method of contraception for you,” Dr Pecoraro said.
“Unfortunately, it’s all a political fix for a political problem of trying to make the government appear as though they’re doing something to salvage Medicare, when really it should be a medical fix for a medical problem.”
The National Association of Specialist Obstetricians and Gynaecologists also criticised the push for “convenience medicine.”
“When prescribing and dispensing occur in the same commercial environment, incentives inevitably shift,” NASCOG stated. “Consultations become transactions. Preventive care becomes optional. And women’s health risks drifting from comprehensive medical care toward something closer to retail medicine.”
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