Would you rather….

Everyone wants a quick fix, so would you rather have a doctor examine you then prescribe appropriate antibiotics or just pop into the pharmacy and pick a box of whatever a potted history may suggest may be suitable for you?

Personally, I am much more comfortable with the financial disconnect between prescriber and dispenser, that is the current situation in Australia. And I say that having worked as both community retail pharmacist and as a general practitioner

script pad

Prescribing is influenced by the marketing of drug companies. This makes absolute logical sense as why would drug companies spend billions of dollars for the flash brochure, pens, personal visits and other inducements. In fact, it has been suggested that more money is spent on marketing drugs than actually gets spent on research and development. Any physician who suggests they are not influences is deluding themselves. That is why I don”t see drugs reps. When you add in the profit from the  direct sale of medications from the prescriber to the patient, the situation surely becomes even more conflicted.

This Swiss paper by Kaiser and Schmid published in Health Economic concludes that the above scenario leads to an increase drug cost of some 34%.

Park et al. showed that after the the introduction of a physician dispensing ban in 2000 in South Korea, there was a significant reduction in antibiotics prescribing. The economic incentive to both prescribe and dispense was removed.

Following the reclassification of chloramphenicol eye drops to be available over the counter, there have been significant increases in the supply in the UK. Surely, there hadn’t been a coincidental epidemic of conjunctivitis? As an aside, as highlighted by Dr Casey Parker from BroomeDoc, most children presenting with acute infective conjunctivitis will get better by themselves and do not need treatment with an antibiotic.

In Australia, codeine was rescheduled to prescription only in 2018 This has lead to a massive decline in codeine use in Australia. And more importantly, a drop in harm from over use of codeine as described in this paper by Cairns et al.

Dr Mark Taylor, eloquently argues for maintaining the status quo for oral contraceptive prescribing, that is, the disconnect between prescriber and dispenser to ensure women receive safe contraceptive advise. There may be savings, but who will pay the price of under-screening for sexual transmitted infection, cervical cancer, hypertension, early pregnancy, depression etc.

When the prescriber becomes the dispenser, where are the checks for errors. I have to put my hand up here and admit to making a prescribing error or two over the last 20 years. A call from an alert pharmacist has saved our patient from harm. It is well known that medication errors contribute to patient harm. The authors, showed that 2-4% of hospital admissions were medication related and deemed three quarters potentially avoidable. In both community and hospital practice pharmacists and physicians work better collaboratively, and need to improve that collaboration.

Of course, the biggest evidence for not increasing the scope of pharmacist practice is to wander up and down the shelves of homeopathic remedies, multivitamins and herbal concoctions all for sale with most having absolutely no evidence of benefit. Oh except to the proprietor’s profit margins. Webpages such as these make helpful, profit rising strategies to upsell products. I like this counterfactual from JAMA.

supplementsSo why then is the Australian Government listening to lobbying from the Pharmacy Guild to permit pharmacists to increase their scope to prescribing antibiotics for example. Of course, in the ideal world, the lobbyists would argue, that with proper training and accountability, a pharmacist would be suited to hand out antibiotics for infections. But as we all know, the ideal world doesn’t exist. Pharmacist are pushed by proprietors to upsell, delegate sales to less trained pharmacy assistants, GP pressed to fit a 20 minutes consultation into ten minutes. Politicians are elected on the platform of honesty and integrity end up handing out grants to sporting clubs in marginal seats to bolster elections outcomes. It is far from an ideal world.

Currently, I consult my patient in the privacy of a closed room. When I hark back to my pharmacy days it was in an open shop, across a counter of next to shelf full of shiny tablets and potions. Where would you like me ask some really personal questions?

It just seems logical and sensible to maintain the status quo!

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