Starting next January, pharmacists in Ontario will be able to prescribe medications to treat patients for certain minor ailments. This expanding scope of work is a natural evolution of the wider services pharmacists across the province have been performing since COVID-19 began to stretch the health-care system. They have taken on COVID-19 testing, vaccinations, and the distribution of antiviral medications like Paxlovid.
The immense pressures COVID-19 puts on health services across Canada could be long-lasting, and Ontario health authorities are wise to make better use of pharmacists to reduce visits to emergency departments and help develop a more sustainable health-care system. This is also the time to examine and address important concerns about potential fragmentation of care and potential for conflicts of interest as the scope of pharmacists’ work expands.
Reducing emergency department visits
The average wait time in Ontario emergency departments in 2019 climbed to a record high of 16.3 hours, the CBC reported. Avoidable visits are a contributing factor. A report published by the Canadian Institute for Health Information in 2014 found that 1.4 million visits may have been unnecessary, often the result of treatment sought for minor ailments such as a sore throat. A simple urinary tract infection, for example, can necessitate a visit to the emergency department if it strikes outside of clinics’ or doctors’ hours when all that is needed are antibiotics.
Nearly 35 per cent of avoidable emergency room visits could be managed by pharmacists prescribing for minor ailments.
However, the scope of practice for pharmacists across Canada varies dramatically. Up until now, Ontario has been a laggard in advancing pharmacist prescribing for minor ailments. British Columbia still is. But in Alberta, for example, pharmacists can prescribe any non-narcotic or controlled prescription medication independently and order lab tests for patients.
With an estimated price tag of $304 per emergency room visit, expanding pharmacists’ scope could bring significant savings for the government and reduce the workload of emergency staff. Furthermore, a recent study evaluated a scenario in which Ontario pharmacists prescribed for minor ailments, and found significant potential savings per year: $38,985,402 for treatment of upper respiratory tract infections, $3,782,753 for contact dermatitis, and $4,890 for conjunctivitis.
In 8 out of 10 provinces, pharmacists already prescribe medications to treat minor ailments. Alberta pharmacists have been doing it since 2007. Ontario, however, has lagged, with critical expansions in scope such as administration of COVID-19 vaccinations and PCR testing born out of necessity rather than foresight.
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But earlier in May, notable amendments to Ontario’s Pharmacy Act were formally approved. The section under “Controlled Acts” has expanded to include prescribing of medications for 13 minor ailments in a newly created Schedule 4 of the legislation. These minor ailments are:
- Allergic rhinitis
- Candidal stomatitis
- Conjunctivitis (bacterial, allergic or viral)
- Dermatitis (atopic/eczema, allergic or contact)
- Gastroesophageal reflux disease
- Herpes labialis
- Insect bites and urticaria
- Tick bites, post-exposure prophylaxis to prevent Lyme disease
- Musculoskeletal sprains and strains
- Urinary tract infection (uncomplicated)
Fragmentation and other concerns
Patient care is never done in isolation. A key aspect of pharmacist intervention is understanding when to make referrals to physicians. Minor ailment prescribing can ease the workload of family physicians and emergency rooms, but many conditions are best addressed at the doctor’s office.
The potential for further fragmentation of care must be addressed. The Association of Family Health Teams of Ontario and the Ontario College of Family Physicians have both strongly emphasized continuity of care in letters submitted to the Ontario College of Pharmacists.
Pharmacists must be integrated within Ontario’s electronic health records system and communicate any prescribing actions to the patient’s physician. Communicating care to physicians is already a standard of care. For example, patients visiting their pharmacist for a medication review will have a notice sent to their family physician describing any discrepancies identified or interventions made. It is expected that with prescribing for minor ailments, any interventions will be similarly shared with the family physician.
Conflicts of interest are another major concern, as highlighted in a letter from the Ontario Medical Association. Conflicts can arise when pharmacies are incentivized to prescribe in order to receive compensation for medication dispensing. There should be compensation for this service regardless of whether the drug is dispensed. This places the act of prescribing at the centre of the patient interaction. With compensation separated from dispensing, such a framework reduces the risk of potential overuse of medication by cutting the incentive for pharmacists to prescribe solely to increase the volume of drugs dispensed in pursuit of making the service profitable.
Nonetheless, pharmacist prescribing needs to be monitored for its quality of service and the process should be evaluated on an ongoing basis. The solution to conflicts of interest is greater transparency, as it is with the health-care system as a whole.
Lastly, there are also concerns of misdiagnosis or insufficient education and training. However, the minor ailments selected are amongst the many therapeutic areas pharmacists are equipped to address. Students graduating from Canadian pharmacy schools undergo four years of training and matriculate with a professional doctorate. Some even complete a one-to-two-year residency where they often receive specialized training within a hospital setting. Furthermore, to support this expansion in scope, there will be additional training and courses specific to the prescribing for minor ailments.
The successful mobilization of pharmacists during this crisis has demonstrated that they can do more to alleviate pressures on the health-care system. However, pharmacist services continue to differ across the country, and all provincial governments need to evaluate whether their current health-care strategy best captures this untapped opportunity. Minor ailments may prove to be a great opportunity to relieve pressure from a strained system.