Professor Steve Robson
Australia’s largest medical indemnity insurer has entered the debate over pharmacist prescribing, warning proposals to expand prescribing into more complex areas of care have crossed a “critical safety threshold”.
The intervention follows the Pharmacy Guild of Australia’s Rewriting the Script report [link here], which proposes expanding pharmacist prescribing into areas including cardiovascular disease, and comes as the Pharmacy Board of Australia considers national training and qualification standards for pharmacist prescribing.
“Avant would not normally enter these public debates with pharmacists, but we’ve reached the point where medical indemnity insurers need to highlight the very real risk of patient harm,” said Avant Mutual chief medical officer Professor Steve Robson.
An analysis of Avant’s medical indemnity claims found medication-related issues were involved in one in six matters resulting in regulatory action or patient compensation, making them one of the leading drivers of medico-legal claims.
Professor Robson said prescribing authority should expand only where safeguards matched the complexity and potential consequences of error.
“Prescribing sits at the intersection of diagnosis, clinical judgement and treatment decisions, and when it goes wrong the consequences for patients can be tragic,” he said.
“Policymakers need to pause before assuming prescribing responsibilities can continue to expand into increasingly complex areas based primarily on projected efficiency gains or theoretical cost savings, rather than patient safety.
“Affordability should not come at the cost of quality, good patient care and ultimately lives.”
In its submission to the Pharmacy Board consultation [link here], Avant raised concerns about the proposed endorsement for scheduled medicines, arguing it could allow endorsed pharmacists to administer, possess, prescribe, sell, supply and use Schedule 2, 3, 4 and 8 medicines within their scope of practice.
The insurer said it did not support the inclusion of all Schedule 4 medicines and any Schedule 8 medicines, arguing decisions around drugs of dependence required assessment of underlying causes, comorbidities and the need for further investigation or specialist input.
“Pain is only one of many clinical symptoms that must be evaluated, with the causative condition needing to be determined and then managed thoroughly,” the submission stated.
The submission also challenged suggestions that real-time prescription monitoring systems would adequately mitigate the risks of expanded Schedule 8 prescribing, arguing inconsistencies between jurisdictions already created difficulties for existing prescribers.
The insurer’s claims data showed one in 17 claims and complaints involved opioid prescribing practices, with six in 10 of those cases involving either multiple opioids or opioids prescribed alongside other medicines.
Avant also pointed to the 2018 up-scheduling of codeine, arguing that allowing pharmacists to become the sole determinant of access to drugs of dependence risked unwinding safeguards that had reduced codeine use, misuse and opioid use disorder.
Avant argued the endorsement was being developed in isolation from broader prescribing reforms and should proceed only as part of a nationally consistent prescribing framework.
“We believe a nationally consistent prescribing framework is overdue, developed by doctors, pharmacists, regulators, patient representatives and governments, with input from Avant and other indemnity insurers to establish clear, evidence-based principles for prescribing,” Professor Robson said.
Asked to respond to Avant’s concerns, a spokesperson for Ahpra and the Pharmacy Board of Australia told the limbic the Board was “carefully reviewing stakeholder feedback on the training and qualification standards for pharmacist prescribing”.
“This will inform its final recommendation to Health Ministers,” the spokesperson said.
The spokesperson said the consultation, which closed on 15 June, had been undertaken at the request of health ministers and sought feedback on nationally consistent training and qualification standards for pharmacists who prescribe scheduled medicines.
Neither Ahpra nor the Pharmacy Board directly addressed questions about Avant’s concerns regarding Schedule 4 and Schedule 8 medicines, patient safety, medico-legal risk or prescribing boundaries.
Dr Mark Woodrow, a senior emergency physician and general manager of medical advisory services at Avant, said pharmacists played an important role in medication safety, patient education and healthcare access.
“As an emergency physician, I regularly see patients whose presentation is the result of inappropriate prescribing or missed diagnosis rather than the condition that was initially suspected,” Dr Woodrow said.
“I’ve seen patients arrive at emergency departments after blood pressure medications have worsened their kidney disease or heart failure. I’ve also seen patients treated for what appeared to be a urinary tract infection who were in fact suffering an alternative diagnosis requiring urgent emergency care.
“Those examples aren’t an argument against pharmacists. They’re a reminder that prescribing can never be separated from diagnosis and clinical judgement.”