UTI pharmacy prescribing – doctors reply

Some WA pharmacists have started prescribing for ‘uncomplicated’ UTIs. RACGP WA and AMA (WA) heads – Dr Ramya Raman and Dr Michael Page – respond to questions from Medical Forum. 

MF: How could this program impact on patient safety?

Dr Ramya Raman
Dr Michael Page

Patient safety must come first and hence we are concerned regarding this program. Due to the potential harms, the RACGP and AMA (WA) have not endorsed this trial. However, through our advocacy to date we have endeavoured to improve the safety of the program.

There is no such thing as a simple diagnosis of UTI or any other medical condition. People present to pharmacy with symptoms, not a diagnosis. GPs train for over 10 years before diagnosing patients and do ongoing training over our entire working life for many more years. Medical training cannot be reduced to algorithms and flowcharts when diagnosing medical conditions. 

Pharmacists are valued by GPs, practice teams and their communities and they play a vital role in our primary care system. However, they are not trained to diagnose or prescribe medications.

The best practice for UTI diagnosis involves history taking and patient assessment and then urine dipstick testing as a minimum to determine if what the patient is presenting with is a UTI or something else. That is why the College and the AMA have recommended this process is a part of this trial and any future trials in WA or across Australia.  

The RACGP advocated for the inclusion of referral to a medical practitioner and pharmacists involved in the program are encouraged to advise their patients about the importance of having a GP as part of follow-up care. 

Antimicrobial resistance is a top global health threat and should be top of mind when implementing this pilot. Over-prescribing antibiotics through this initiative could significantly impact the health of our communities. Taking into account WA resistance patterns, nitrofurantoin will be considered as first-line therapy in the program, trimethoprim second line choice and cefalexin has been excluded.

Where neither nitrofurantoin nor trimethoprim is appropriate, the patient should be referred to a medical practitioner for management. Pharmacists will have the challenge of separating their prescribing decisions from the influence of pecuniary interests. Evaluation of patient health outcomes is essential.

MF: How does it impact on privacy issues?

Disclosing confidential medical information in a crowded retail setting is far from ideal. When you visit your GP, you are taken to a separate room away from the waiting room so that you feel comfortable talking candidly about your health and personal circumstances including, where necessary, your sexual history.

However, registered pharmacies providing the service must have an area suitable to maintain confidentiality of the consultation as per the Structured Administration and Supply Arrangement (SASA) which outlines the criteria and conditions for ‘Pharmacist Initiated Treatment of Urinary Tract Infection’.

MF: Is the treating pharmacist obliged to notify a person’s GP/or WA Health about the treatment they have given?

A patient must be provided with a service summary, and this can then be provided to their primary health provider.

The RACGP strongly advocated for the inclusion of “referral to a medical practitioner” as part of the pharmacist supplementary information. Presentations of acute issues provide an opportunity for preventive healthcare and pharmacists are encouraged to highlight to patients the importance of having a GP.  

MF: If a person suffers a reaction to a medication, or it is the wrong medication, what happens next?

This would be an adverse outcome and should be registered in the same way any adverse events for pilots and trials are recorded.

This is an aspect of the trial that we are particularly concerned about. If a person suffers a reaction to the medication, or is given the wrong medication, they will then have to book a GP visit or, if it is after-hours or requires urgent attention, their local emergency department. The left hand won’t know what the right hand is doing. If a patient visits their pharmacy for a suspected UTI and ends up suffering from complications, the GP may be left in the dark. This fragments care and can lead to poor health outcomes.

MF: Is there any evidence to suggest GP access is a problem for women with UTIs?

Depending on where you live, some patients are having difficulties accessing timely general practice care. That is because we are facing a maldistribution of GPs in Western Australia and indeed in communities across Australia. The proper solution is boosting general practice care and ensuring all patients, irrespective of their postcode, can access high-quality general practice care when they need it. 

Reliance upon another workforce who are also currently under strain and experiencing workforce shortages, and introducing multiple providers duplicating the same services adds to health system complexity, duplicates or fragments care, creates patient confusion and directs patients away from the essential coordinated medical care. This compounds the problem of GP access rather than fixing it. 

MF: Does the pharmacist charge the patient for the consult on top of the medication? Is this any more cost effective than a GP consult?

This is not covered by Medicare, so the patient is likely to have to pay. As part of this trial, pharmacists are obligated to make sure patients understand the costs involved when offering the service.