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Message of caution from a GP who dispensed for years

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Message of caution from a GP who dispensed for years

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Dr Justin Coleman takes a closer look at a controversial suggestion from the RACGP.

The RACGP has just sprinkled a little fertiliser on the turf war between GPs and pharmacists.

In their submission to a governmental pharmacy review, the RACGP raised the concept of GPs dispensing “the most prescribed medicines by volume” from their own practices, which would “greatly improve patient convenience and reduce exposure to non-evidence based products”.

The concept was buried on the final page of the submission, and did not even warrant a summary dot-point, so it was far from a full frontal attack — more a warning shot across the bow.

If pharmacy interests are justifying their expansion into vaccinations and blood tests by touting a one-stop-shop model, this RACGP submission reminds them two can play at that game. After all, a stop doesn’t necessarily have to involve a shop.

If patient convenience, rather than business profit, is truly the goal, the submission argues that bypassing the pharmacist is just as feasible as bypassing the GP.

Plenty of GPs like the idea. Responses (on the Medical Observer Website) to the breaking news on Monday included some who seemed to enjoy “taking the fight to enemy territory” and others with more nuanced approaches.

In particular, some rural GPs who already dispense medications saw it as a mixed blessing. They enjoyed the control over dispensing, and the patient convenience, but dispensing takes time and makes it hard for GP locums.

I spent years dispensing in remote NT communities, and I must say the gloss wears off pretty quickly. While I’m sure I learned a few things, and quite liked being able to immediately alter warfarin doses and give the first antibiotic tablet, it was inefficient.

Superficially it may seem quick and cost-effective, but my time cost for multiple patients was so high that I delegated most of the daily routine to Aboriginal health workers, whose medication knowledge is nothing compared to a pharmacist’s.

Arguments for GPs dispensing are stronger where access is difficult — remote areas and after-hours services, for example. But if it were to become more mainstream, the flow of money increasingly becomes an issue.

In remote Aboriginal health, I was paid a wage regardless of how I spent my time, and the PBS supplied free medicines. I almost always chose generic, cheap, ‘good old-fashioned’ drugs, and often no drug at all. There was no incentive for me to do otherwise.

Never underestimate the benefits of a strict separation between the decision to prescribe and personal profit for the prescriber.

This is the reason I rail against conflicts of interest, alternative practitioners recommending their own expensive treatments and, indeed, community pharmacists upsizing a PBS script with a complementary medicine or vitamin sale.

Reading between the lines, I suspect the last of these was one of the underlying drivers for the cheeky GP-dispensing suggestion in the RACGP submission. After all, some recent pushes by pharmacists seem to be about financial viability in the face of dropping PBS income, rather than about health outcomes.

Judged purely on the basis of health benefits for patients, my turf-war scorecard would read as follows:

Complementary and alternative medicines in pharmacies? No.

GP dispensing? Mainly no. Limited to unusual circumstances where pharmacy access is the issue.

Pathology tests promoted and sold by community pharmacists? No. We have enough trouble educating highly trained GPs about the potential harms of overtesting. Pharmacist advocates don’t seem to have even considered the possibility.

Vaccination by pharmacists? Yes. I don’t see the big problem. GPs do indeed provide add-on services during vaccine consultations, but we can just as easily provide these at some other visit.

Pharmacists working from within general practice? Yes. A true team approach is a great idea.

*This article first appeared in Medical Observer


 

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