The Royal Australian College of General Practitioners (RACGP) has urgently warned the Queensland Government to abandon the planned North Queensland Pharmacy Scope of Practice Pilot in a retail setting due to concerns that it will fragment care and lead to poorer patient health outcomes.
It comes following harrowing details emerging of the Urinary Tract Infection Pharmacy Pilot - Queensland, which has seen pharmacists allowed to prescribe antibiotics for UTIs. GPs have reported many concerning incidents including:
a patient in their 20s being interviewed about symptoms at the counter within earshot of multiple customers. It turned out that the patient had chlamydia (i.e., later diagnosed by a GP) but was prescribed antibiotics for a UTI and upsold products including cranberry tablets by the pharmacist
a patient in their 50s prescribed antibiotics for a presumed UTI who turned out to have a 15-centimetre pelvic mass causing serious urinary symptoms
a patient in their 60s with a recurrent UTI, who therefore should not have even been eligible to access antibiotics, being prescribed the antibiotic trimethoprim despite known resistance to the drug.
The RACGP and other medical bodies have resigned from the scope of practice pilot steering committee amidst serious concerns regarding patient safety. The controversial pilot will allow pharmacists to diagnose 23 conditions, including asthma and type 2 diabetes, without any consultations with a GP.
RACGP President Dr Karen Price said that the Government must change course on the pilot and launch an independent inquiry into the UTI pilot.
“I am urging the Queensland Government in the strongest possible terms to immediately change course on the planned North Queensland Pharmacy Scope of Practice Pilot,” she said.
“If the Government is to proceed with the pilot, we should be looking at pharmacists working as part of a team in the hospital or medical practice setting, rather than in an unsupervised retail space. The Royal Australian College of GPs has previously pushed for team-based models of care, including general practice-based pharmacists.
“Conducting the pilot in retail spaces means that there will be insufficient training and supervision for the pharmacists. The pilot needs to be focussed on the needs of the community, rather than generating profits for pharmacy owners at the expense of their customers and pharmacists.
“Patient health and wellbeing must come first. Our communities deserve safe and quality healthcare from appropriately qualified health professionals. The incidents emerging from the UTI pilot highlight just how dangerous it is to authorise non-medical health professionals to provide services they simply are not trained to provide in an unsupervised retail setting.
“Additionally, the Government should halt the UTI pilot and launch an independent inquiry because I suspect that the incidents uncovered so far are just the tip of the iceberg.
“We simply do not know how many patients have suffered negative health outcomes resulting from this pilot because the details are not being made public and we need to get to the bottom of it right away. The fact this pilot has been extended without any evidence being released regarding patient health outcomes is deeply concerning.”
RACGP Queensland Chair Dr Bruce Willett said that the pharmacy scope of practice pilot is riddled with risks.
“When it comes to this pilot, one of the main concerns we have with how it’s currently configured is training,” he said.
“Ultimately, we want pharmacists working within our practice and there may be times when they can prescribe under the supervision of the GP. However, under this pilot pharmacists will be operating without supervision in a retail space separate from other healthcare professions, including GPs.
“Pharmacists simply don’t have the proper training to diagnose or manage complex health problems, including asthma and type 2 diabetes, on their own in a retail setting. All GPs undertake a minimum of 10-years training to diagnose and treat patients without any supervision.
“Pharmacists will be diagnosing, treating, and prescribing for serious conditions, completely unsupervised, after just the equivalent of three weeks of training. Patients will be telling pharmacists their personal medical information at the pharmacy counter with other customers standing just metres away.”
RACGP Rural Chair and Townsville-based GP Dr Michael Clements warned that the pilot could fragment care.
“If the pilot proceeds in its current form, continuity of care, which is particularly important for patients with complex health conditions, will be disrupted and the GP won’t be aware of what the pharmacist is doing and vice versa,” he said.
“This is unimaginably dangerous when you consider what has happened already during the UTI pilot.
“There is also the conflict of interest that exists. It’s important to keep in mind that pharmacists will not only be diagnosing conditions, but then also selling patients medications based on that very diagnosis. If the pharmacists are operating independently in a retail space, this may lead to prescription choices being influenced by profit margins and we may see an increase in prescriptions because there is evidence of this occurring overseas. In Britain for example, when pharmacists were allowed to prescribe antibiotic eye drops, the number of prescriptions increased dramatically.
“So, the RACGP is urging the Queensland Government to put patient safety first and change course on this pilot because the long-term health outcomes of many patients are at stake.
“Some communities in north Queensland have a shortage of GPs and this is a problem occurring in many parts of Australia, particularly in rural and remote areas. It’s something the Royal Australian College of GPs is all too aware of, and we are working with national and state and territory governments to ensure a better distribution of specialist GPs across the country. However, this pilot is not a solution to GP workforce challenges; we need more than band aid solutions for rural and remote healthcare.”
Cairns-based GP Dr Aileen Traves said that she had spoken to numerous patients whose health and wellbeing had been put at risk during the UTI pilot.
“The incidents that have come to my attention during the UTI pilot will send a shiver down the spine of all health professionals, including GPs,” she said.
“A patient in their 20s with chlamydia was misdiagnosed with a UTI and prescribed the incorrect antibiotic as a result. She had a history of recent unprotected sex, but the pharmacist did not consider the possibility of pregnancy or recommend a GP referral to discuss contraception or testing for STIs”.
“It turns out the woman did have an undiagnosed pregnancy and yet was given trimethoprim, a category B3 medication which is not recommended for use in the first trimester of pregnancy. She came to see me when the symptoms did not resolve after taking the antibiotics and I had to take it from there. I shudder to think how many others like her have been misdiagnosed.
“A patient in her 50s was incorrectly diagnosed with a UTI, when she actually had a 15-centrimetre pelvic mass. This is particularly concerning because it would have been found if a physical examination had been performed by a GP at first instance. This is why patients should consult with a GP rather than a pharmacist because the symptoms of a UTI are similar to many other serious conditions and can be easily misdiagnosed.
“The case of a woman in her 60s is also incredibly troubling. She had a recurrent UTI, which GPs know is a risk sign that the patient may have an infection resistant to antibiotics. This patient should never have been prescribed the antibiotic trimethoprim. GPs do urine tests to determine antibiotic resistance and this patient had been shown to have antibiotic resistance to trimethoprim on multiple previous urine specimens. Her condition deteriorated so severely she ended up in a hospital emergency department with urosepsis, which is severe sepsis caused by a urinary tract infection.
“These incidents were brought to the attention of GPs; however, we are not part of the management pathway, so there is no way of feeding this information into the pilot. How safe and effective can the pilot really be if there is no way to notify the pilot organisers of adverse outcomes?
“Every day I think to myself – how many more cases like this are out there? These are just the patients that have come to the RACGP’s attention, but there must be so many other people whose health and safety have been compromised by this dangerous UTI pilot.”