Dr Suresh is a GP and skin cancer doctor in Brisbane, and patients can book with him at this link

First of all, apologies for my unintended break over the holiday period. I was just too busy with family. You know how it goes.

Well anyway let’s get back in to the swing of things. Today I’m talking about contraception. More specifically the need to see a doctor to obtain it here in Australia.

We aren’t talking about emergency contraception, or condoms. No today we are talking about mainly the oral contraceptive pill.

The pharmacy guild has been hard at it again recently. It seems to be a never ending barrage from them against brand GP. They appear ever increasingly desperate to get pharmacists the ability to prescribe medications that at present require a doctor’s signature. But why? Do individual pharmacists want this? Or is it the companies driving this? One wonders what the motive could be. The pharmacy guild would certainly like you to believe it’s about convenience for patients. That it’s about financial pressure and cost saving. But is it?

Let’s talk about the convenience factor first. Most patients when coming in to discuss contraception will come maybe once a year (less if on a long acting reversible contraception (LARC). ONCE a year. Is that too often? Is once a year too inconvenient? Is a 15-20 minute appointment once a year too much? If it is then there’s probably bigger fish to fry quite honestly. How long would you be waiting in the queue at the till with all those other patients not at their doctors wanting contraception anyway? Probably would work out the same.

So let’s talk about what you usually get at the doctor for that time.

  • A health review with your doctor
  • A review of your mental health
  • A review of your medication
  • A review of your other medications
  • A review of any blood tests or other investigations you have had or are outstanding
  • A review of your screening – breast and cervical
  • Discussion about sex
  • Discussion about other forms of contraception
  • A safety check regarding domestic violence and or coercive sex
  • Review and discussion about the safety of the pill you are taking, checking against medical eligibility criteria (MEC) to ensure it is safe for you to take
  • Discussion around future conception planning or menopausal treatment if needed
  • Combine this with an annual skin check if needed for maybe another 15-20 minutes and make it even more convenient
  • A chance to discuss anything else you want or need to

All of this will take place in a room with a closed door, in confidence. Not in front of a till, in an open shop for all to hear.

Now let’s talk cost. Many GPs in Australia bulk bill. So this means no out of pocket for patients. Even if they don’t, like me (I bulk bill patients with concession cards and kids), the out of pocket is likely to be between $30-50 at most. Once a year. For all the above. With no upselling. No incentives. No quotas. No bonuses for the doctor.

Is the pharmacist likely to offer you the same as the doctor, but for free? They will do all the above? In a closed confidential room. For free? Not any pharmacy I’ve ever been to.

Let’s go back to convenience. So you visit a doctor once a year, but how many times do you need to visit the pharmacy for those repeats? Usually 4 times a year. Why doesn’t the pharmacy guild lobby to reduce this to once a year? After all that would be much more convenient for the patients. But then that would cut the profit for pharmacies.

Now don’t get me wrong. This isn’t a pharmacy bashing post. My local pharmacists are great, and they have my full respect. They have stepped in and alerted me to errors in my prescribing plenty of times, or rang me to confirm I meant to prescribe what I did. They do a fantastic job. They are essential. They are qualified professionals in their own right. But they are not doctors, and don’t provide the same service. And no pharmacist I know wants this.

I’d like to finish by showing a letter by one of my colleagues. She has given me permission to post it verbatim, including her name. It was a reply to an OP-ed on this subject and I think it sums it up perfectly.

The advent of the combined oral contraceptive pill was a boon to women all over the world: fertility control and menstrual regulation in the form of a daily tablet. These days some women take it to prevent pregnancy; some use it to treat acne, endometriosis or polycystic ovarian syndrome. Some women take it as part of their gender-affirming transition. And since it has been available, the oral contraceptive pill has been the subject of various political debates.

Absolutely, safe and effective contraception is something to which women should have ready access. And according to Simon Blacker, ACT guild president, the Pharmacy Guild wants to make accessing contraceptive scripts more ‘convenient’. He proposes that pharmacists be allowed to continue supply of oral contraceptives, for women who are ‘stable’ on the pill. But is convenient contraception the safest and best choice for women? Or are we missing the wood for the trees and seeking simplistic solutions?

Women do have ready access to the combined contraceptive pill: one visit to a GP and they have a year’s worth of prescription. They have a script – provided it’s the most appropriate choice for them, at this stage in their life. Provided they’re remembering to take it. Provided they haven’t started smoking, gained a lot of weight, started suffering from migraines, or are only using it because of coercion from a partner who refuses to use a condom. Provided there’s no family history of a clotting disorder. Why is this important? Because women’s health isn’t just about whether or not they become pregnant. It’s also about whether they are being unnecessarily exposed to the risk of physical or mental harm.

What do I talk about when I see a woman about contraception? I ask whether she’s having sex, and with whom. If there is consent. Whether she needs STI screening. If she’s having trouble remembering to take the pill. Whether there are side-effects. Whether she has genetic or lifestyle predisposition to having a fatal blood clot or a disabling stroke. Whether she has plans to start a family. Whether her cervical screening is up to date. Whether an alternative contraceptive would be safer, cheaper or more effective.

Are we as women likely to have some tricky conversations with a pharmacist? Even in the privacy of their consulting room, are we likely to disclose the number or gender of our sexual partners? Or will it just be assumed (it is, after all, ‘convenient’ to assume) that women who are ‘stable’ on the pill are monogamous, sexually active cis-hetero women with a consensual male partner? And if we’re not all monogamous in our activities, who will arrange the STI screening? Who will perform the overdue cervical screening test? Who will provide the advice on family planning? Is it still convenient to see a pharmacist for the pill if you’re referred back to your GP? And who ultimately takes responsibility if things go pear shaped?

Annual follow up with a GP isn’t necessarily free, but it is good value. A GP is the person who co-ordinates and takes responsibility for longitudinal care in all aspects of reproductive, physical and mental health. That is hard to do well from a distance – how do I ask gently about weight gain, or mood side effects, if all I get is a written summary of an annual pharmacist visit? This sort of care fragmentation is already a regular frustration to hospital patients and GPs – the left hand hasn’t been told what the right hand is doing. And the Medicare system recognises this: Why else would non-GP specialists require a GP referral, other that to ensure appropriate clinical handover and continuity of care?

Some will call this a turf war between GPs and pharmacists. It’s not about that: it’s about care vs convenience. True reproductive liberation requires more than a quick-fix script. It means placing value on the health of a whole person. GPs might be busy, but whole-person care is our raison d’être. We’re not too busy for that. Pressuring women to see a pharmacist because it’s quicker and cheaper sends the patronising and familiar message that we are worth less.

Why do women still need to see a GP to get the pill?
Because our reproductive health is too important to be fragmented in the name of convenience and government cost-cutting.

Dr Penny Gosling
BSc MBBS FRACGP

*Dr Penny Gosling was not involved with creation of this content other than her letter above.

So next time you wonder why you need to visit a GP for that script, please remember with a #justaGP it’s never #justascript.

Dr Suresh is a GP and skin cancer doctor in Brisbane, and patients can book with him at this link

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