Should I stay or should I go now? The doctors battling to give expert advice on the risks of pharmacy prescribing
To many of those watching from the outside, the radical expansion of pharmacy scope of practice in NSW has felt like a done deal, one made in smoke-filled rooms behind locked doors.
Earlier this month, Premier Chris Minns stood before the Pharmacy Guild of Australia’s Sydney conference, trying to find the words to capture the depth of his gratitude.
“I really love this relationship between myself, my government and the guild,” he told delegates as he announced a new trial involving pharmacists diagnosing, treating and prescribing for ear infections and wounds, along with having a greater role in managing chronic conditions.
He then added that he would not back down from his pharmacy reforms in the face of opposition from those with “an interest in the status quo”.
The words are best read as a reference to the medical profession as a whole.
But they could also apply to those doctors on the expert committee that, for more than a year now, has been attempting to give advice to his government on the risks and benefits of involving pharmacists in clinical areas that they have previously left untouched.
One of them had already quit — rural generalist Dr David Leaf. He had been part of the group for about a year, but had become increasingly alarmed, claiming that much of the advice was being ignored and that the committee’s existence was merely window dressing for reforms coming irrespective of their potential harms.
Some of the other doctors on the committee — and there have been at least a dozen involved in various capacities — have shared his concerns, most notably RACGP NSW&ACT chair Dr Rebekah Hoffman.
Last week, AusDoc spoke to both about the committee, formally known as the Expert Advisory Group on Expanded Scope Community Pharmacy Services. What does it do, how does it work, what advice has it given and what influence, if any, does the guild exerts on its activities.
“So every other month we’ll have a meeting,” Dr Hoffman said. “Before it happens we’ll get given documents. They depend on what we’re giving advice for but it could be a list of different contraceptive pills where we would discuss the ones we’d be comfortable with pharmacists supplying.
“Or it could be the idea of pharmacist treatment for different diseases and conditions, says impetigo, and advice on the [prescribing] doses or the risk of the different medications involved.”
In terms of who sit on it, members have included those dozen or so doctors but also hospital and community pharmacists (including the NSW Chief Pharmacist). Then there are the various NSW Health officials in attendance to hear and document their views.
The committee does not produce a formal written expert report outlining their collective position following each meeting. Dr Hoffman says there is no requirement at all for the group to express a collective view.
So advice is generally given verbally and, for the most part, individually. This advice is then documented in the meeting’s minutes (although Dr Leaf claims that the minutes have been superficial).
When she is unable to attend, Dr Hoffman says she submits her comments in writing.
NSW Health will also bring in relevant specialists when specific topics are under discussion, Dr Hoffman says.
So, for instance, when pharmacist treatment of atopic dermatitis and psoriasis was considered, a dermatologist attended, and a respiratory physician was brought in to discuss the idea of pharmacists taking on a greater role in respiratory issues.
For Dr Hoffman, the relationship with NSW Health officials has been respectful and collaborative.
“They have done their best to make sure that there is at least a breadth of voices that are at the table,” she says.
And contrary to the idea that all medical advice being given disappears into a bureaucratic void, she can point to instances where doctors changed what was proposed.
With impetigo, she says the initial proposal included both topical and oral antibiotics.
Doctors accepted topical treatment but objected to pharmacists prescribing oral antibiotics, and the proposal was narrowed. The suggestion that pharmacists could start suturing was another example.
Dr Hoffman says it appeared in an initial wound-care proposal but was “very quickly” and “very vocally” opposed by doctors and ditched.
Doctors also pushed back when pharmacists sought to include depot medroxyprogesterone in contraception services, particularly over the suggested age restrictions and the osteoporosis risk.
Modifications followed, although when the government announced reforms allowing pharmacists to initiate the oral contraceptive pill, the drug itself remained, with pharmacists allowed to resupply the injections.
“There definitely was an element that we were being listened to, but at the point where we said what our preference would actually be, they did nothing, it had long sailed past that,” Dr Hoffman said.
Another issue alarming many doctors for some time has been the idea of pharmacists treating ear infections.
This was originally flagged by the government a few years ago — that it wanted to explore pharmacists treating acute otitis media and acute otitis externa.
In his gushing speech to the guild this month, Mr Minns announced the fruits of this exploration — a trial to allow eligible pharmacists to treat ear infections along with wounds, as well as an expanded role managing hypertension and COPD.
He supplied no detail about the types of ear infections, patient ages, medicines pharmacists could prescribe, diagnostic requirements, training, referral criteria or start date. So it is all very vague and unclear in terms of the safety system around it.
But Dr Leaf recalls a brief discussion during an advisory group meeting in which one pharmacist apparently said she had examined some 30 ears and was becoming proficient.
He was asked in the meeting by NSW Chief Health Officer Dr Kerry Chant how many examinations he would expect before certifying a medical trainee as competent. Dr Leaf said he told her “a couple of hundred, maybe 500”.
“There was silence in the group. I remember it distinctly,” he says.
His concern was not simply proficiency with an otoscope.
“Obviously, you have to take a history first, and then you have to put it in the patient’s context, and then you have a look in the ear.”
He says there was no formal process at that point for supervised examinations and quality assurance equivalent to medical training.
Dr Leaf says he originally joined the committee in good faith.
NSW Health had wanted someone who could provide a rural GP perspective, and he thought he was largely going to discuss pharmacist treatment of uncomplicated UTIs.
“I said … ‘I’m going to tell you how it is. I’m not going to be a yes man,’” he recalls.
He says he was told that was exactly the sort of input they wanted.
Having dealt with health bureaucracies before, however, he decided to put his advice in writing.
Over time, he became convinced that the reforms were going to proceed regardless of objections from doctors in the room.
As mentioned, he was also troubled by the meeting records.
“I know that the minutes were pretty flimsy and didn’t necessarily reflect assent,” he alleges.
Asked why he quit, he said his fear was that years later, if problems emerged, merely saying he had been in the room objecting would mean little.
“I think it says more if you’re not part of it, if you’ve been there and you walk away and you’re not part of it.”
Dr Hoffman says the medical members have concentrated heavily on red flags and referral criteria — attempting to define the point at which pharmacists must stop and send the patient to a GP or the ED.
But she says doctors still worry that applying those criteria requires clinical reasoning that cannot necessarily be reduced to a checklist.
She mentions the discussions the committee has had about pharmacy treatment of nausea and vomiting.
Yes, a pharmacist can follow protocols. But a doctor, she says, is trained to start somewhere else: why is this person vomiting?
Could they be pregnant? Having a stroke? Could there be malignancy or some other serious underlying diagnosis?
“Pharmacists [are] not being trained how to think like a doctor,” she says, referring to the skills and knowledge involved in making differential diagnoses.
“Pharmacists are getting trained to identify a symptom and then to give a treatment for that symptom. That symptom isn’t a diagnosis.”
AusDoc asks her why, unlike Dr Leaf, she stayed and did not walk away.
“Look, it has been a significant dilemma,” she says.
“At our last RACGP [NSW&ACT] faculty meeting we discussed whether we were still comfortable to be at the table. The pharmacy trials looked like they were rapidly expanding, looked like they were moving ahead.
“The faculty was split. Some people said, ‘No, it’s time to go. This is something that we can’t continue to put our name to.’
“But the majority said — and where I sit in the camp — is we’re still better off being there, better off being vocal, better off being heard, because then the people, the ministry, health minister can’t say they didn’t know.
“If we’re at the table we have a voice.”
That way, she argues, NSW Health and the minister cannot later say they were not warned.
“If we’ve warned them, if we’ve done the best that we can to make sure that our concerns are heard, then at least they’re being heard even if they’re then being ignored or put aside.”
Was there any sense during the meetings that the guild was setting the agenda?
“I’ve not been privy to where [the agenda] comes from,” Dr Hoffman says. “From my perspective, the working group just gets told the next disease condition we’ll be looking at is this one. And then this is the date. These are your notes. Please attend with any concerns or advice.”
It is important to stress that there does not seem to be any attempt to muffle the voices of committee members. Dr Hoffman says none had been asked to sign non-disclosure agreements, although the documents presented to the committee are confidential.
But both doctors have been explicit in their view that the guild has exerted significant influence on the NSW Government.
As AusDoc reported, Australian Electoral Commission returns show the guild and its state branches disclosed $600,170 in donations to political parties nationally in 2024/25.
This included $59,400 to the Australian Labor Party’s NSW Branch.
As all doctors and lawyers know, association is not causation.
But Dr Hoffman says: “When one of Australia’s biggest political donors keeps securing policies that expand the commercial role of its members, the public has every right to ask what is driving those decisions.”
Dr Leaf echoed her words when speaking to ABC Radio last week.
“I think the pharmacy guild is very powerful.”
You think decisions were made because of the power of the lobby group rather than the medical benefit? Dr Leaf was asked.
“Absolutely. Because there was no medical benefit. When our evidence-based opinions were put forward, they were dismissed. They were not recorded. It felt like the assembled experts in this meeting were there to be ticked off as attended.”
The guild will no doubt dismiss this. It has said the evidence for expanded scope is overwhelming.
As for now, we do not know what will happen next. The details of the looming trial have not been given. But the story is significant and not simply for those in NSW.
It is to do with what in some ways is perhaps the most alarming element of Mr Minns’ speech.
Not his praise for the guild and its supporters. It was his declaration that he would never back down to those concerned about the sudden expansion of pharmacists into prescribing diagnoses; the way the declaration exposed a mindset which seems to see those raising patient safety issues as doing nothing but protecting their vested interests.
Does that trouble Dr Hoffman, that he becomes deaf to what doctors tell him?
“We’re still the experts in the room,” she says. “You can choose whether or not you listen to the expert in the room. The fact they’ve chosen not to listen to them or to listen to us, I think says more about them than us.
“And look, we’ll continue to be loud. We’ll continue to be vocal. But I do hope that this story gains traction beyond the medical media, because it is something that the rest of the community needs to be hearing about as well.”
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