North Queensland Pharmacy Trial
By an AGPA writer
Some medical trials are so immediately successful that it becomes unethical to continue them. It would be unethical to deny the placebo-takers an obviously efficacious treatment.
Other medical trials are so immediately harmful with dangerous side effects that it also becomes unethical to continue them.
And yet other medical trials are so obviously misconceived that they should never even begin. In this category can be placed the Queensland Government’s proposed trial in the state’s north to give pharmacists the power and wherewithal to both diagnose 23 illnesses and to prescribe treatments (about 150 different drugs) for them.
The trial, called the North Queensland Scope of Practice Pilot, would cover 180 pharmacies and a population of 670,000.
In theory, the scheme would “free up” doctors and enable patients to get to treatment more quickly.
In practice, it is yet another example of Australia’s jurisdictionally entangled health system jeopardising patient welfare.
Why the Federal Government has not done all within its power to stop this folly is mystifying. More of that anon.
The very foundation of the proposal defies logic and good medical practice. Why would you arm a pharmacist with the power to diagnose and prescribe for exactly 23 illnesses and no others?
That is not the way good medicine works. In best medical practice a patient presents with symptoms, usually pain of one sort or another, swelling, or bleeding. The medical practitioner – with a decade or more of training – keeps all the options open, not just of 23 medical conditions, but of all medical conditions, and then by a process of elimination and direction comes to a diagnostic conclusion.
If you say to pharmacists “you may diagnose and treat the following 23 conditions”, there will be an in-built bias to diagnose one of them rather than any of the thousands of conditions known to medical science.
With the best will in the world, a pharmacist whose whole professional training is geared to the treating of conditions already diagnosed by a medical practitioner is in no position to engage in original diagnoses. True, pharmacists come across numerous patients with the 23 fairly common illnesses and would be fairly good at identifying them.
But that is a long way from a medical practitioner taking each individual patient and diagnosing from scratch. The former is an invitation to suggestion bias (it must be one of the 23). The latter ensures patients get the attention of a practitioner who is knowledgeable about all the possibilities.
Diagnosis is difficult enough with vast training and experience. With a tick and flick on a list of 23, misdiagnosis on many occasions will be inevitable. Moreover, there is an obvious conflict of interest because the pharmacist will get the dispensing fee on the drugs dispensed to treat any of the 23 illnesses.
The 23 illnesses include some serious conditions, the misdiagnosis of which could cause serious harm or be life-threatening. They include hypertension, COPD, type 2 diabetes, gastro-oesophageal reflux disease in adults under 50, obesity, asthma, acne and atopic dermatitis. Under the pilot, pharmacists, independently and without medical input, prescribe things like high-strength steroids and pimecrolimus. Yes, there will be extra training, but not the rigour of a medical degree and hospital and general practice experience.
Now to the jurisdictional issues. They hinder best medical practice. The states and federal authorities have a significant overlap. The Feds have a huge say because they control the purse strings. But state law, by and large, governs the practice of medicine: who can deliver what sort of health care; what is malpractice; and negligence and liability law.
Technically, the states could deregulate everything and allow any idiot to engage in medicine. Pharmacists do a great job at what they do: pharmacy. But that does not qualify them to be medical practitioners, no matter how basic the level.
So, it is now incumbent on the Federal Government to end this folly, given that five major health groups have withdrawn support: the Australian Medical Association, the Royal Australian College of General Practitioners, the Australian College of Rural and Remote Medicine, the Queensland Aboriginal and Islander Health Council, and the Northern Queensland Primary Health Network.
Further, the lack of details from the Queensland Government add to concerns about the scheme.
For a start, the Feds should make it clear that no PBS or Medicare payment could be made to patients under the scheme. It seems that that much is obvious.
The Feds have a major interest here. Ultimately, the costs of every misdiagnosis and every unnecessary treatment will be picked up by the Feds. So, if the Feds cannot persuade Queensland of the folly of its proposal, they could get tough and announce that any pharmacist who takes part in the Queensland proposal will be removed from the Pharmaceutical Benefits Scheme.
Yes, remote areas in Queensland have major difficulties with providing medical services. And that is why this proposal is being trialled in Far North Queensland. But the answer is not to allow unqualified people to diagnose and treat illnesses. Rather it is to get more qualified people into those remote areas to do the job properly.
Anything less will cost the health of patients and cost the medical system more because of the resulting inevitable cases of misdiagnosis.