It is my belief that the shared code of conduct used by pharmacy no longer reflects current pharmacy practice.
In my view, this means the existing code needs to be adapted to ensure the public understand what community pharmacists are authorised to do and how the profession currently behaves. That is what a code is for.
Governments have been quick to tell us that pharmacists are “uniquely placed” as “highly trained health professionals” to treat a broad variety of conditions. However, the context of healthcare matters, and community pharmacy has a unique business model.
Unlike other health professions, retail sales constitute a substantial proportion of a pharmacist’s business. Pharmacists and pharmacy owners use a variety of marketing strategies to increase profits, including loyalty programs.
I suspect there are few other health professionals who discuss concepts like basket size in their trade journals. Floor plans can be designed to increase profits, including strategies to keep “consumers” in the retail aisles for a longer period of time to stimulate impulse buying.
No other health profession has such strict anti-competitive ownership laws or such political influence.
The context of community pharmacy is so different from any other health profession that it is my view community pharmacy needs its own code of conduct, recognising that the retail and healthcare goals of the community pharmacy business do not always align.
No other profession sells the products they prescribe, and with that business model, the inherent conflict of interest cannot be removed.
Given governments have agreed to overlook that inherent concern, the following principles in the code of conduct appear to be problematic and, in my view, need to be revised.
Principle 1: Practitioners should practise safely, effectively and in partnership with patients and colleagues, using patient-centred approaches, and informed by the best available evidence to achieve the best possible patient outcomes.
Evidence-based medicine is a triad – decisions should be made using best scientific evidence AND patient preference AND doctor’s opinion. The reason is simple – not all people are the same, and treating to the average is rarely good care, especially for patients in marginalised communities who are unlikely to have been represented in the studies that grounded the trials.
The model in pharmacy prescribing involves determining the best average approach to a condition and applying it to anyone who meets the criteria for the relevant pharmaceutical product. Protocol-driven care may be appropriate for the management of a disorder once a diagnosis is complete, but algorithm-based diagnosis is far less safe.
There is evidence from the pharmacy trials that this approach is suboptimal.
In the NSW “UTI” pharmacy trials, 44% of the women presenting with they thought was a UTI needed to consult a GP within 28 days of treatment, suggesting either the diagnosis or management in pharmacy was inappropriate. Over 200 women in the NSW trials had a serious side effect. In the North Queensland UTI trials only 0.07% were considered “at risk” of a sexually transmitted infection, suggesting history taking may be suboptimal.
In both studies, antibiotic prescriptions were remarkably high, increasing the risk of antibiotic resistance in the community, and the likelihood of untreated chlamydia was very high.
There are plenty of reasons why suboptimal care may well be good enough. However, best-practice UTI guidelines recommend urinalysis and cultures for some patients and contraception guidelines recommend examination for some patients.
Pharmacy may well provide good enough care to the majority, but it is not “informed by the best available evidence” and it will not achieve “the best possible clinical outcomes”.
I would recommend principle 1 be modified to read: “practitioners should practise in accordance with state and territory guidelines” so it more accurately reflects current practice.
Principle 2: Practitioners should consider the specific needs of Aboriginal and Torres Strait Islander peoples and their health and cultural safety, including the need to foster open, honest and culturally safe professional relationships.
I have already commented on this aspect in a previous article. I question how accurately principle 2 reflects current pharmacy practice, because NACCHO has concerns and they are the ones who know.
The fact that NACCHO’s concerns have been ignored is beyond concerning. In my view, this principle either needs modifying to reflect actual practice or there needs to be a greater commitment to partnership with the Aboriginal and Torres Strait Islander community.
Principle 5: Good relationships with colleagues and other practitioners strengthen the practitioner-patient relationship, collaboration and enhance patient care.
In the Pharmacy Code of Conduct, under item 5.1c, pharmacists are expected to “behave professionally and courteously toward colleagues and other practitioners at all times, including when using social media”.
Trent Twomey, the president of the Pharmacy Guild has provided multiple examples of disrespectful behaviour towards colleagues, with, it seems, little regulatory control.
In an address to students, he commented that GP supervision of pharmacist prescribing would be “bloody insulting” and that GPs “stuffed” the health system by letting non-doctors own practices.
Genuine GP concerns have been dismissed as “Chicken Little” arguments.
Anecdotally, GPs are increasingly concerned about the comments made to patients regarding their care, including circumstances where GP scripts are changed without their knowledge.
Theoretically, modifying a script needs the prescriber’s permission. However, pharmacists can now substitute medications without consulting the prescriber at all. Few GPs have received written advice about clinical interventions undertaken by pharmacists, meaning communication is patchy and often inadequate.
GP concerns have been relentlessly ignored and consultations have not taken GP concerns seriously.
Frankly, this is a shame. Most of us have had constructive, highly valued professional relationships with pharmacists throughout our careers. However, it is hard to sustain these relationships when in the face of relentless public disdain from the Guild.
This principle either needs to be clear or needs to be removed.
Principle 6: Practitioners have a responsibility to contribute to the effectiveness and efficiency of the healthcare system and use resources wisely.
Antibiotic stewardship is essential for the health and wellbeing of the community. It is somewhat ironic that the “nudge vs superbugs campaign” attempting to reduce GP prescribing was launched in the same year as the pharmacy prescribing pilot which increased it.
There is also concern that the NSW trials served the population with the least need: urban, privileged, literate women. While these women’s needs are important, we need to think about the community cost of providing more services for this cohort, while rural, less privileged women miss out.
Governments are responsible for getting the best outcome for all Australians, and so they are also responsible for making the difficult decisions balancing the needs of one group with another. The last thing we need is more support for the urban and the privileged.
The code also expects pharmacists to “support colleagues who raise concerns about the safety of patients, and take all reasonable steps to address the issue if there is reason to think that the safety of patients may be compromised”.
Instead, when GPs raised concerns, the Guild went on public record saying the GPs were “lying”. No wonder the relationship between the professions is rapidly deteriorating, further fracturing patient care.
Principle 8: Practitioners must display a standard of professional behaviour that warrants the trust and respect of the community. This includes practising ethically and honestly.
There are several examples of concerning professional conduct that differ from the expectations of the shared code.
Confidentiality in community pharmacy is practiced differently to any other health profession, and although there are often private spaces available, it is common to overhear sensitive conversations.
I have never received a written record of a consultation with a patient I share, so I am unclear whether documentation is appropriate, but given it is almost universal to receive a notification of care from the nurse-led clinic in my area, I’m sure it could be better managed so care can be coordinated.
However, the biggest concern is conflict of interest. In the shared code, the following statement described the responsibilities expected:
Patients rely on the independence and trustworthiness of practitioners for any advice or treatment offered. A conflict of interest in practice arises when a practitioner, entrusted with acting in the interests of a patient, also has financial, professional or personal interests or relationships with third parties which may affect or be perceived to affect their care of the patient.
Multiple interests are common. They require identification, careful consideration, appropriate disclosure and accountability. When these interests compromise or might reasonably be perceived by an independent observer to compromise the practitioner’s primary duty to the patient, practitioners must recognise and resolve this conflict in the best interests of the patient.
I cannot see how this can be met for a prescriber who sells the medication they prescribe, particularly when the pharmacy assistant is encouraged to “companion sell” (or upsell).
If pharmacists choose to continue to work in environments where they benefit from their choice of drug (and there is no reason why they need to) then this statement needs to be substantially modified or removed. To not do so is dishonest.
The second concern relates to advertising. Theoretically, AHPRA polices endorsements, testimonials and inducements. AHPRA also comments on care comparisons, which I would argue includes “GP level care” in pharmacy that really isn’t.
There is no doubt the Guild has a close and mutually beneficial relationship with state and federal governments. This is obvious with the address by Minister Mark Butler given to open the annual Pharmacy conference.
It’s a privilege and a pleasure to be here once again to address the Pharmacy Guild of Australia’s flagship conference … The relationship we have with your sector and your representatives whether that’s the Guild or PSA, it’s just so essential to our deep, deep ambition to ensure that Medicare and PBS are not just there but are shaped in a way that leads to a change in patient needs of the 21st century. Your contribution is enormous. I value this relationship as testing as it can be at times enormously ... I know that you feel there is no more important work for you as trained pharmacists. So thank you for everything that you do, thank you for your relationship with government and all the best in your conference.
Minister Butler’s opening address to GP25 was … less enthusiastic. It is not available online, but I certainly recall the phrase that if we didn’t respond to the political carrots “I’m not against using a stick”. The most positive statement was:
My focus is on ensuring there’s two things – first of all, it’s on patients to ensure they have affordable, accessible support from primary care through GP-led teams, that’s our most important lodestone. Connected to that, inextricably, is support for a thriving general practice sector. And although we might not agree on every single aspect of what we’ve done over the last three and a half years, I think it’s pretty hard to argue that this government has not done more to support the general practice sector than any I could certainly remember.”
Frankly, this is rather lukewarm.
The commonest description of pharmacists, when I analyse Hansard and government media releases from state and federal government, are that pharmacy is “accessible” and “affordable” (which of course it should be given the government’s investments).
General practice is “a cornerstone” and the “backbone” of the health system, responsible for “keeping patients out of hospital”.
Where it gets uncomfortable is the moral loading of commentary about health professionals themselves. Pharmacists are “highly skilled”, “trusted” or “professional”.
I could not find an endorsement of GPs as “highly trained”, “trusted” or “professional”, just persistent suggestions that they are failing to meet the needs of financially challenged families.
The implication is clear: GPs are morally corrupt, charging struggling families despite government support, and need to be “bullied” into bulk billing. What they actually do is apparently an enigma.
Should this be the concern of the Pharmacy Board?
This political bias has strayed into territory that, in my view, comes uncomfortably close to endorsement.
In NSW, the Premier is giving away contraceptive scripts for the first 5000 women to present to a pharmacy.
Given the political power the Guild yields, and the political donations it provides, it is concerning to see so many testimonials from politicians. Is this a conflict? Governments would say they are simply either performing a public service, promoting a new government sponsored program.
Is a community pharmacist, who is prescribing what they sell in conjunction with what they upsell, the same as a hospital pharmacist prescribing chemotherapy in the context of a highly experienced team? How will community pharmacy be regulated and governed?
And importantly, now that governments control the three parts of a product – the cheap (through fees, the pharmacy agreement and dispensing fees), the fast (through pushing accessibility) and the good (through oversight of AHPRA) when does government endorsement of clinical skills become inappropriate advertising?
Why do I care? Why does it matter to an ageing GP who, frankly, is doing little acute care anyway?
I care because I am an ageing Australian with daughters and parents and friends who want general practice to survive long enough to look after me in my dotage.
Because going into a pharmacy and hearing my GP described as “senile” for prescribing an appropriate antibiotic is distressing.
Because I have seen far too many potential disasters with overconfident and undertrained registrars to watch the management of red eyes by a health professional with half the training as anything but dangerous.
Frankly, it raises my blood pressure every time I have to overhear this sort of thing when I’m picking up a script. And I never consented to picking up the pieces when my patients are harmed.
Primary care is an ecosystem. There is good evidence we are losing a lot of GPs like me, as mixed billing has become emotionally as well as financially unsustainable. We are kidding ourselves if we think the vast investments in pharmacy aren’t “freeing up” GPs to, well, do something else.
And the relentless undervaluing is followed by increasing disrespect and worsening occupational violence.
And the patients with highest need? The multimorbid, poor, culturally and linguistically diverse, rural patients who don’t fit the standard bulk billing model? Where do they go?
Thinking pharmacy can expand endlessly, taking more and more pieces of care, without gutting general practice is naive. If we are to keep an eye on what the community needs, rather than just the individual who values convenience, this shift is a shift away from equity and public health.
Which is the last thing we need.
Professor Louise Stone is a GP in Canberra and an academic at Adelaide University. A collection of her research, policy and teaching materials can be found at drlouisestone.com.
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