Ashley Pade knows only too well the burning sensation and distinctive smell that so many women experience with the arrival of a urinary tract infection.
"It's really painful. You feel like you need to pee all the time," she said.
For the Brisbane woman, it's a four-week wait to see her GP to get much-needed antibiotics.
She's one of more than 10,000 women able to get antibiotics over-the-counter at her local chemist instead, under a two-year pilot in Queensland.
It was designed to reduce the number of women turning up at busy emergency departments out-of-hours with UTIs, who suffer most with these infections.
"To be able to go in on the weekend to get medical attention straight away ... was such a relief," she said.
The pilot was popular with patients and has now been made permanent in Queensland, with other states and territories following suit.
But the peak body for GPs has serious concerns with the program and it has opened a new front in their turf war with pharmacists.
Disagreement over UTI prescribing pilot
GPs say a new report has revealed serious problems with the initial pilot.
The Royal Australian College of General Practitioners (RACGP) president Nicole Higgins said it showed 192 women with recurring UTIs were treated in the pilot when they should have been sent to their GP.
Recurring UTIs can be a sign of other issues and the trial relied on patients self-reporting.
"We know that not all symptoms that people think might be urinary tract infection are," Dr Higgins said.
Dr Higgins said more than 90 per cent of women in the trial received antibiotics, which was too high and could contribute to antibiotic resistance.
"Evidence shows only about half of proven UTIs do need to have antibiotics," she said.
University of Queensland academic Lisa Nissen authored a review into the pilot for Queensland Health and said the data showed the trial was a success.
"What we also found out was that pharmacists were very compliant with the recommended treatment protocols," Professor Nissen said.
"Overall, we were very happy with the outcomes."
Professor Nissen, a pharmacist, said the RACGP cherry-picked statistics out of context.
She also said in a study of 10,270 women, having 192 — or less than 2 per cent — treated outside of guidelines was insignificant.
"Overall, in the proportion of the cases, it was a small number," she said.
Further, the rates of antibiotic prescribing in the study represented those women who'd been assessed as needing treatment, not those already excluded early on.
The 'turf war' between GPs and pharmacists
The clash over the UTI trial is the latest front in an increasingly bitter dispute between the Pharmacy Guild of Australia and RACGP.
The guild has long lobbied for pharmacists to do more over-the-counter dispensing to alleviate pressure on GPs, while GPs believe their expertise makes them best placed to do the work.
Both sides accuse each other of being motivated by money.
They've already been in conflict over the move towards 60-day dispensing for scripts, something the Pharmacy Guild opposes, but GPs support.
GPs have also asked the federal government to look at possible reforms to pharmacy location rules which limit the number of outlets, which would open the door to practice-based outlets.
The feud has become so bitter, Professor Nissen's review of the state government pilot was referred to her university ethics committee twice after complaints.
The college said it had concerns with the design, evaluation and conclusions of the review.
"This had been raised prior to this pilot taking place and it was raised by multiple people from GPs, from Aboriginal Health Services, from other health providers and academics about the design," Dr Higgins said.
"We need to make sure when we're making such big decisions — actually make sure that it's evidence-based."
Professor Nissen said none of the complaints were upheld.
The review has been the subject of two independent inquiries and is currently subject to a peer-review process.
"At a time when health care is under so much pressure, we should be trying to enable our health workforce not disable it," she said.
"We shouldn't be pitting each other against each other in a turf war."
Iain Duggin is a microbiologist from Australian Institute for Microbiology and Infection at the University of Technology Sydney, who specialises in UTIs.
He said offering the opportunity for early treatment of UTIs at the pharmacy was a good thing and could prevent women needing stronger antibiotics down the track, which would be worse for antibiotic resistance.
However, he said, it's a balance against the risk of misdiagnoses.
Dr Duggin said it was a large study that had clear protocols and the prescribing was not a concern if it was with clear controls.
"What I'd like to see is better collaboration between doctors and pharmacists to gain the advantages of both their input for patient care," he said.
"We could potentially use online communication technology to facilitate collaboration better to improve speed and quality of patient care in remote areas."
Calls to 'put the patient first'
Not all GPs back the RACGP's stance.
Sydney GP Robert Marr from the Doctors Reform Society, an organisation that promotes publicly-funded health care, said many GPs supported patients being able to get more services from their pharmacist.
He said there was plenty of work to go around as long as the GP remained the coordinator of care.
"It's appropriate that pharmacists have a role in prescribing some medications under strict protocols," Dr Marr said.
"We've got to stop crying about lost income and start putting the patient first as both doctors and pharmacists."
However, he cautioned pharmacists were also taking on the legal risks associated with potential misdiagnoses.
"There's a lot of things that GP and pharmacists do that seem quite simple and easy until you run into a complication," he said.
Townsville Pharmacist Cate Whalan rejects the RACGP's claims that pharmacists may over-prescribe antibiotics, thereby contributing to the problem of antibiotic resistance.
"As a medicines expert, we are aware of antibiotic stewardship and the best use of antibiotics," she said.
Pilot opens door to wider trial
Ms Whalan said seven of her pharmacists had also signed up to take part in a larger trial that will see 22 other medicines and services become available at the chemist shopfront.
They include the contraceptive pill, extra vaccines, reflux medicines and treatments for school sores and ear infections.
The trial is taking place in Far North Queensland where geography can make seeing a GP harder than it is for most.
Ms Whalan said the scope of practice pilot mostly cleared up current inconsistencies.
For example, at present chemists can vaccinate people for COVID, but can't give them a Vitamin B injection.
The RACGP wants the second pilot abandoned altogether and is concerned about management of asthma and heart disease in the pilot.
"We need to make sure that we have those appropriately-trained people delivering that type of care. It's complex, and sometimes the art is also when knowing not to do anything," Dr Higgins said.
Other peak bodies including Queensland branch of Australian Medical Association College of Rural and Remote Medicine and the Queensland Aboriginal and Islander Health Council have all withdrawn their support for the second trial.
For Ashley, being able to access basic health services at the pharmacy means she's treated sooner and she doesn't understand why the two factions are at war.
"[It] just makes me question whether it's patients' well-being that's being prioritised or not," she said.
"GPs and pharmacists should be working together."
