As the shortage of general practitioners (GPs) increases across Australia, state governments are turning to pharmacists to try to fill the gap in accessible healthcare. A trial of pharmacists to diagnose and treat urinary tract infections (UTIs) has been undertaken in Queensland, with further trials expanding the scope of practice to include oral contraception planned in both north Queensland and New South Wales (NSW) later in 2023. The Queensland pilot for treatment of UTIs had pharmacists limited to treat only women. Despite the serious concerns surrounding these programs, the expansion of trials is being presented as beneficial for access to healthcare for women.1 However, these interventions will have a gendered effect on health, adversely affecting women’s health through potential misdiagnosis, loss of opportunistic screening and fragmented primary care.
Rise in pharmacy prescribing
Despite significant concerns from a number of primary care providers, the Queensland Government plans to introduce the North Queensland Scope of Practice Pilot in late 2023,2 with pharmacists in NSW being able to prescribe for UTIs from April 2023 and the oral contraceptive pill (OCP) from July 2023.1 The Northern Territory and Victorian governments have signalled their intention for similar programs.3,4 It is hoped these initiatives will improve access to some prescription medications.1 Although this article focuses elsewhere, it is worth noting concerns regarding patient privacy, antimicrobial stewardship and the conflict of interest in pharmacists both prescribing and selling a product. These are highlighted in AMA Queensland’s survey of 1307 doctors relating to the Queensland pharmacy trial for UTIs.2
Impacts of misdiagnosis and delayed diagnosis
GPs consider a broad range of diagnoses for dysuria and suprapubic pain. Diagnoses can fall under gynaecology, oncology, infectious disease, dermatology, obstetrics and medication side effects, among others. GPs also consider a range of causative organisms because some, such as Neisseria gonorrhoeae or herpes simplex virus, do not respond to the usual antibiotics used for UTIs. Diagnostic skill and the ability to order pathology are vital to be able to diagnose conditions and treat them appropriately. Concerns for misdiagnosis have been well documented, particularly through AMA Queensland’s survey. Misdiagnoses reported include sexually transmissible infections (STIs), cancer, pregnancy and ectopic pregnancy.2 Misdiagnosis has a direct impact on women’s health through inappropriate treatment and a diagnostic delay of serious conditions. This delay of diagnosis might limit treatment options, such as when an STI leads to infertility.
Loss of opportunistic screening
Although a consultation for contraception can seem straightforward, it is good practice to ‘value add’ with opportunistic screening. The Australian STI guidelines recommend screening asymptomatic sexually active young people for chlamydia, gonorrhoea, HIV and syphilis.5 The Royal Australian College of General Practitioners’s Red book highlights the importance of chlamydia screening, particularly because it is often asymptomatic.6 Women with undiagnosed chlamydia have an infertility rate between 2% and 8%.6 The loss of the opportunity to screen for STIs during a consultation could have very real effects on women’s future health and fertility.
An ideal time to check whether a woman is up to date with cervical screening is during a consultation for contraception. It has been reported that 85% of women with cervical cancer have been under-screened.6 Recent changes have made cervical screening via a self-collect swab more widely available to increase screening rates, with the latest data from the Australian Institute of Health and Welfare estimating participation in the National Cervical Screening program at just 62%.7 Removing the chance during a contraceptive consultation to offer the cervical screening test is counterproductive, and might result in lower screening rates than the current rates.
GPs can also offer more reliable forms of contraception than the OCP, such as long-acting reversible contraception methods (eg an intrauterine device or contraceptive implant).
Loss of opportunity to establish a regular GP due to fragmentation of care
Young, healthy women might only see a GP a couple of times a year for consultations relating to contraception or an occasional UTI. However, this setting up of a long-term relationship with their GP is important for future healthcare. Previous work from NSW demonstrated that young people with a regular GP reported fewer barriers to accessing care.8 They also reported higher rates of knowing which service to present to, potentially reducing unnecessary emergency department presentations. In addition, young people with a regular GP were less likely to report cost as a barrier to access.8 Qualitative analysis in that study showed the value of having at least a regular clinic, if not a GP.
A study from the UK highlighted that for some health problems, such as mental health or breast lumps, patients highly valued seeing their ‘personal GP’ rather than any available GP.9 With reduced consultations by GPs for contraception and UTIs, women have less of a chance to develop this relationship, which can impact their access and care in the future.
Conclusion
Pharmacy prescribing of antibiotics for UTIs and contraception as a quick-fix solution has the potential to negatively impact women’s health for many years to come. Delayed diagnoses or misdiagnoses, as well as loss of opportunity to have a regular GP or clinic, and reduced potential for opportunistic screening will adversely affect women.