Pharmacy vaccinations in Queensland and the slippery slope of health services in community pharmacies

Pharmacy vaccinations

New legislation in Queensland supports pharmacy-based health care services on the basis of pilots of feasibility, embellished as evidence of effectiveness. Family doctors are concerned and disappointed that, despite lack of independent analysis, these pilots have resulted in new legislation with little consideration given to the broader health impacts. This move is paving the way for an expansion into other pharmacy-based health services, which have been successfully delivered in general practice for decades. It is also threatening the medical home model, which the federal government ostensibly supports.

When doctors speak about concerns with pharmacy vaccination programs, they talk about evidence, quality, patient safety and fragmentation of care. However, these messages are heard as ‘self interest’.

Pharmacists on the other hand talk about better access, availability, and gaps in healthcare delivery due to excessive GP waiting times. Pharmacists are not heard as being self-interested, rather as providing a beneficial service for the community. Public health arguments are also intuitively compelling; to a public health advocate it doesn’t matter where vaccinations are delivered.

However, these arguments need to be examined further. We have to look at the bigger picture and take into account adverse effects on our proven Australian general practice model, costs to the consumer, conflicts of interest of the pharmacy industry and issues with the Queensland vaccination trials.

Proven general practice model

Australia’s large network of general practitioners and their teams have been very successful in keeping Australians healthy at a low cost, compared to international standards.

National surveillance data on vaccine-preventable diseases in Australia documents a remarkable success story for vaccinations delivered by general practice, which have caused extraordinary declines in child and adult morbidity, mortality and hospitalisations over the years.

“Vaccinations delivered by general practice have caused extraordinary declines in morbidity, mortality and hospitalisations

Major changes to our primary care model must be based on evidence and not just sound like ‘a good idea’. There is little evidence that delivering vaccinations and other health services via pharmacists will improve efficiency, safety or quality of care for patients. Although there is a convenience factor, people need to ask how commercial interests have been allowed to be placed before health benefits to the Queensland population.

Issues with the trials

In 2014 the Queensland Department of Health approved an application by the Queensland branches of the Pharmacy Guild Australia and the Pharmaceutical Society of Australia, which led to the start of two trials to vaccinate adults over the age of 18 at community pharmacies against influenza, dTPa (diphtheria, tetanus and whooping cough) and MMR (measles, mumps, rubella).

Interestingly, no independent analysis of the trials seems to have been performed. The data that has been reported is superficial, selective and shows elements of observer bias. No analysis was undertaken to establish the clinical need for the vaccinations. No analysis was undertaken to determine what proportion of these vaccinations were high risk.

The trials did not reveal evidence about the impact on vaccine-preventable disease outbreaks. There was no comparison with alternatives such as walk-in vaccination clinics in general practice. General practitioners frequently conduct opportunistic screening and preventive healthcare during consultations for vaccinations, but the impact of missed opportunities for screening and other preventative care in general practice was not looked at, and neither did the trials focus on much-needed better integration of care delivery.

It seems no independent analysis was undertaken to determine whether the standard elements of privacy, documentation or GP notification were met. Further, no mention of commercial add-on practices was monitored, for example, using vaccinations as a means to on-sell other products. As we know the pharmacy business model relies heavily on upselling products to consumers.

The argument seems to be to improve vaccination coverage with claims of managing people ‘who have not been vaccinated’ – these claims are neither verified, nor explained; for example, are these new patients or inappropriate patients? It is a reasonable question as to why these claims have not been subject to closer scrutiny.

The stakeholders’ evaluation contained leading questions, such as: “The results of the trials show that there is increased uptake of influenza vaccination among adults who have never previously been vaccinated or who were not regularly vaccinated. Do you consider this an important public health function?” This raises questions about the objectivity of the process.

Conflicts of interest

There is an inherent conflict of interest in pharmacists delivering general practice services including vaccinations. One of the great strengths of medication prescribing in Australia is the high degree of separation between the prescriber and the medication dispenser. This enables more objective prescribing, free of pecuniary interests and leads to better allocation of resources. This is a strong argument against moving more health services into the pharmacy environment.

“One of the great strengths of medication prescribing in Australia is the separation between prescriber and medication dispenser

The core role of pharmacy is to dispense medication safely and effectively, but the financial viability of pharmacies depends on operating successfully as small retail businesses. Concerns have been raised regarding the environment of pharmacy being more conducive to medication sales than primary care services. The pharmacy sector is seeking new ways to broaden its health services to provide new income streams, sometimes in conjunction with pharmaceutical companies with the prime purpose of profit.

Commercialisation of pharmacy vaccinations has occurred overseas and here in Australia. For example, a pharmaceutical company which produced vaccines involved in the trials, provided financial support to a pharmacy chain for their vaccination training. This illustrates the problem with delivering health services in pharmacies – but this was not reported in the evaluation of the trials.

If it ain’t broke…

There is ample evidence that increasing general practice comprehensiveness of care is associated with decreasing costs and hospitalisations. However, each time a task is given to other providers, the effectiveness and safety of our current proven GP-model is eroded and this will ultimately have consequences for the care delivered to Australian communities.

Despite concerns from doctors’ groups, the Queensland government announced in April 2016 that an amendment to the legislation now allows registered pharmacists to administer influenza vaccinations, diphtheria-tetanus-acellular pertussis vaccinations, measles-mumps-rubella vaccinations to adults.

“We should avoid a trade-off between our values and creating monetary value

Pharmacists are ready to roll out more ‘enhanced pharmacy support services’ in the near future. The impact of patients presenting to pharmacies instead of general practice will result in more fragmentation of care, missed opportunities for screening and preventive health care, unnecessary and non-evidence based care, and possibly increased risk and wasted health resources. It also clashes with the innovative national medical home model.

We should avoid a trade-off between our values and creating monetary value; recommendations for treatment and prescribing must only be evidence-based and should not be influenced by commercial factors.

Medical groups should continue to monitor these developments, highlighting the risks to policy makers and reinforce the message that we need evidence-based decision making in healthcare. It is dangerous to rely on short-term financial benefits at the expense of long-term, whole-of-system considerations. In the interest of all Queenslanders, decision makers should focus on strengthening general practice, not dismantling it.

The RACGP remains committed to working collaboratively with both state and federal governments to develop innovative and effective models of care, and strongly advocates for solutions that support integration, not fragmentation.

This article was originally published in AMA QLD’s Doctor Q. Dr Edwin Kruys is Chair of RACGP Queensland and member of the AMA Queensland Council of General Practice.

Follow me on Twitter: @EdwinKruysDisclaimer and disclosure notice.

50 thoughts on “Pharmacy vaccinations in Queensland and the slippery slope of health services in community pharmacies

  1. There was a recent article in the Fairfax media about this issue. The Pharmacy Guild spokesperson made a clear point in recommending that all people who qualify for free immunisations should still attend their GPs for this.

    It would appear that our Pharmacists are only keen on improving people’s healthcare when they can flog the product, in this case a vaccine, to the patient/customer who may, or may not, actually need it..

    The ones that have a clear enough indication to receive the vaccination, to the point where the Government supplies the vaccine for free, are still left for the properly trained professionals. aka GPs, to administer – usually as a bulkbilled visit.

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    • That’s an interesting analysis of the situation.

      The reason that this recommendation is made, is because up until the Victorian Government legislated for the supply of aP vaccines, there have been no publicly funded vaccination by pharmacists in Australia.

      This would mean that any patient who is entitled DUE TO SPECIFIC RISK FACTORS to a publicly funded vaccine, should be notified of the fact they that can access the vaccine for free.

      In the case of influenza vaccine (the only vaccine that was approved for provision under the pharmacy model), there are recommendations for all people to be vaccinated, yet not all people can access it under any government subsidy.

      Are you suggesting from your comment that patients who are not entitled to publicly funded vaccinations are not at risk if they remain unvaccinated?

      Are you also suggesting that a GP is the only health professional who is capable of vaccinating people safely?

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      • Couple of questions Jarrod:

        Can you show me a few pictures of:
        a. Private and confidential area in a Pharmacy where this clinical care can be provided ?
        b. A similar area where customers can be observed post vaccination ?
        c. a well equipped ressus bag for the rare anaphylactic case ?
        d. Evidence of proper documentation in a patient record that is not part of the financial record-keeping system ? The same place where all the repeat antibiotic eye drops that are dispensed are recorded ?

        Not hard questions – just checking if the same facilities are available for your customers that a GP has for his patients.

        Final question – can you show me any hard evidence that there is a clinical need for this service? Evidence that vaccinations were not happening because of a shortcoming of doctors or government vaccination clinics. As opposed to a pure and simple commercial opportunity for Pharmacies.

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          • I have never seen a GP clinic where patients routinely just receive a vaccination in the waiting room or at the reception desk. It is administered in a private room which may or may not be a dedicated practice nurse room. It equally may be a shared room, procedure room or a docor’s room but the point being that it is in a confidential private area behind a closed door.
            That is the routine in GP land and what would be considered a minimum standard. Regardless if a GP or the Nurse he/she employs does the work

            As opposed to a sign and a chair, or perhaps even a curtain or screen of sorts, somewhere inbetween the magnets and perfumes in the shop.

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            • Thinus, why don’t you read the requirements for vaccination in pharmacy before you reveal your ignorance.

              Any pharmacy that provides a vaccination service has a minimum set of facilities that are required as well. It’s not a cowboy operation.

              When you’ve read it, then let me know what you think is lacking in the programme. Look forward to hearing back from you

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            • You wrongly assume I have not read it.

              I quote:
              “Immunisation services should be delivered in a private consultation area to protect the privacy and confidentiality of consumers. There should be adequate seating for consumers in the immunisation service area allowing them to remain in the general vicinity for at least 15 minutes following vaccination.
              The immunisation service area should be equipped appropriately to allow consumers to sit or lie when receiving treatment. Pharmacists should ensure the area is of sufficient size and appropriate layout to accommodate efficient workflow including adequate room for the consumer, their carer and the immuniser, as well as the equipment and documentation required for the service. The immunisation service area should have
              sufficient space and appropriate surfaces for the immuniser to treat potential adverse events, and hand-washing facilities to meet relevant State or Territory health authority requirements. ”
              http://www.psa.org.au/download/practice-guidelines/immunisation-guidelines.pdf

              this clearly states what is required to look after your “consumers”.
              And given your reply I assume you are unable to provide me with the photos.

              Surely there are examples you would wish to share – professional services that are offered to consumers ?
              https://1drv.ms/i/s!AqkY_KQRZOsYltl8jfggAK0m1JcZTw

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            • Thinus, you can just as easily use google as you have above to find consultation rooms in pharmacies. You’re being facetious.

              If you’d like to see one in action, feel free to come by my pharmacy. You can find my address online just as easily as photos to bolster or refute your own arguments.

              I would also point out that none of the photos you provided are of a consultation room

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            • How awful for all those kids at school – lining up for immunisations… get a grip. Plus when showing photographs of pharmacy consult areas, hope about not using just the supermarkets. Most pharmacists feel about the supermarket pharmacies like you do about the corporate GP farms.

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            • Dear anonymous

              Only one of the photos came off Google – the other two were taken by GPs, here in Australia.

              I actually did try hard to find photos on Google of Australian pharmacy consulting areas – could not find any. Feel free to send me a good example.

              In regards to photos of a GP consulting room – there is no shortage of those to be found – but of you want to see what mine look like:
              http://tillyarddrivemed.com.au/

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            • Benedict I assume you do understand that GPs very rarely have anything to do with the school based programs? That they are done by State Health based vaccination teams ?
              In teh distant past when I was actually doing those in a remote location the kids all had their shots, one by one, in the privacy of a consulting room.

              Perhaps you need to come and see what a GP room looks like in 2016 and not reply on childhood memories. No lining up at any GP rooms and all vacicnations in privacy of a consulting room

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            • Love your assumptions. Shows your biases. Maybe I am a GP? Maybe, very recently, I was at a local council when there was a reaction to an immunisation, maybe I talked to the nurse about the schools program, or then maybe I don’t know what I am talking about… However, you seem to be reenforcing most pharmacists ideas that doctors are arrogant boof heads who think they know everything.

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            • Maybe you are GP. Maybe your responses are focusing on the issues being discussed and ot making attacks at the posters. Maybe there are very very few GPs still invoilved in any school based program.

              Lots of maybe’s – I try to have less maybe’s in my posts so I am easily identifiable and I still try to play the ball and not the man. Perhaps it is time to come out from behind that pseudonym ?

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            • Your practice is in Charnwood.

              If you cannot find a pharmacy close by that has a consultation room for you to go and view, then you aren’t looking hard enough.

              You might want to give those pharmacies a courtesy call though. You could imagine if someone turned up at your surgery demanding to see the facilities, you may be tempted to politely ask them to leave

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            • The ball mate, the ball, not the man. I am very aware of the services that all three Pharmacies around here offer. As a longstanding local GP I have been inside them all many times over the years and we all actually have very good working relationships.

              Although it does irk me when a patients asks for a flu script (not qualifying for a Gov one), I do a script at no fee of any sort, book the pt for a bulkbilled visit later when they have the script only to hear from patient days later that the chemist offered to give the shot themselves. Was there a fee involved – no idea. I did get a note via the patient with the details which was appreciated although I was not happy with a noshow in the slot that was booked and that I ended up doing a script, losing a consult income and spending unpaid time adding the vaccine details on my system. Was there a medical need for the Pharmacist to dot this? Off course not – it was a commercial decision. And this was not the only time it happened

              Anyway – back to the subject – you dance around the issues and do not answer the questions – here about photos and evidence (by the way you confuse people when you answer my questions posed here elsewhere) and on 6min News about the clear dot pointed flaws identified. Straight answers is all that we ask for instead of repeated comments about bias etc.

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            • Thinus, Ask Dr Kruys for my email address – I’ll happily identify myself…. but while the AHPRA beasties are out there looking for us to slip up (if you are ever up before them, I guarantee your online discussion WILL be perused) I am not prepared to be publicly identified.

              Anyway we have ‘met’ a few years ago in and around a very dusty old town… maybe you have mellowed a bit since then (not long been in Oz at that stage) but the locals still remember you.

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    • The reason the pharmacists have to inform all people who qualify for free vaccinations under the NIP to go to their GP is because nothing’s free… GPs receive renumeration from the government for them, pharmacists don’t, so the patient has to pay. Therefore pharmacists have to tell the patient that they are eligible to receive the vaccine for free if they go to their GP, however the patient can then choose to pay for the vaccination at the pharmacy if they wish to do so, for convenience etc. it has nothing to do with pharmacists not doing something for free, doctors don’t do NIP vaccinations for free either.

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  2. Thanks Edwin for this very useful analysis of the situation in Queensland, and for highlighting the lack of any proper evaluation of the trials.

    Our local professor of pubic health, who is an ethicist, told us that we all have vested interests. I think that this is true. When we are discussing the issues that you have described, it probably helps if we GPs were to admit that yes, we could have a financial interest in immunisations being given within our practices, rather than in pharmacies. I say ‘could’, because as Thinus has said, in many or most cases we actually don’t earn anything extra when we give say an influenza vaccine to a patient while they are seeing us for other reasons, and if we bulk bill for a visit made by a patient only for the purpose of being immunised, we may earn little net of our costs.

    For me one of the big issues about pharmacists giving immunisations is their failure to inform the patient’s usual GP that they have done so, so that we can add this to our record for the patient.

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    • Dr Oliver, I’d like to thank you for acknowledging that GPs have financial interest as well.

      It should be noted that any person who earns an income based on the weight of their advice has a direct conflict of interest in selling this advice; whether that advice is for a product, a service, etc.

      With regards to the issue of “failure to inform the GP” – can I ask what you currently do when you see a patient who is not your regular patient for an antibiotic. Do you proceed to contact their doctor?

      What about nurse immunisers who visit workplaces and immunise against influenza for an entire workplace – are you not upset that these health care professionals don’t contact you (and every other GP of these workers) to advise you of the vaccine that has been supplies?

      Notification is incumbent on the patient; although it could be facilitated by NEHTA/MyHealthRecord. The Privacy Act allows for communication between health professionals regarding a patient, but can be fraught (ie the Act allows for “emergencies” etc). While we may all like to spend time making and receiving calls from other health professionals with regards to each patient that we respectively see, do you think your time will be well spent in gathering/collating all of this information (and passing it on).

      While we’re on the topic of inter-professional communication, it would also be nice if the GP would communicate with the patients pharmacist such things as dose changes and cessations of medications – these are things that don’t get communicated to pharmacists via current prescription delivery methods (ie via the patient). Do you think that the courtesy of what you are seeking could also be returned to pharmacists, seeing as how pharmacists will on average discuss the patients medication regimen 4-5 times per year more than the doctor?

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      • Jarrod, I think that you have asked some very good questions.

        “With regards to the issue of “failure to inform the GP” – can I ask what you currently do when you see a patient who is not your regular patient for an antibiotic. Do you proceed to contact their doctor?”

        YES. Every single time that I see a patient who is not a usual patient of our practice, I seek and almost always get the patient’s permission to inform their usual GP or general practice about the patient’s visit. I send a copy of my progress note via Argus to GPs who are also so equipped, or if not, I fax my progress note. I do this because if we GPs don’t respect by our actions the centrality of the patient’s usual GP or general practice to the patient’s care, we can’t expect anybody else including pharmacists to do so.

        “What about nurse immunisers who visit workplaces and immunise against influenza for an entire workplace – are you not upset that these health care professionals don’t contact you (and every other GP of these workers) to advise you of the vaccine that has been supplies?”

        Yes, I am upset about this.

        “Notification is incumbent on the patient”

        I disagree. If we accept that the patient’s usual GP or general practice is central to the patient’s care, every other health professional who provides a service to a person should (with the paitent’s permission) inform the patient’s usual GP or general practice.

        “While we may all like to spend time making and receiving calls from other health professionals with regards to each patient that we respectively see, do you think your time will be well spent in gathering/collating all of this information (and passing it on)”

        I don’t want a phone call. I want a message sent by Secure Message Delivery (that is the currently available technology) that makes it easy for me to read the message and to file it into the patent’s electronic clinical record (the one in my practice, not the PCEHR/My Health Recvrd).

        “While we’re on the topic of inter-professional communication, it would also be nice if the GP would communicate with the patients pharmacist such things as dose changes and cessations of medications – these are things that don’t get communicated to pharmacists via current prescription delivery methods (ie via the patient). Do you think that the courtesy of what you are seeking could also be returned to pharmacists, seeing as how pharmacists will on average discuss the patients medication regimen 4-5 times per year more than the doctor?”

        Absolutely. GPs should be communicating more with patients’ pharmacists, including telling pharmacists about all changes to a patient’s current medicines, including whether a new medicine is to replace an existing one, or is in addition to the patient’s existing medicines. In my most recent article in my current series in Medical Observer magazine, about how to improve GPs’ clinical software, published on 22nd June 2016, I proposed:

        “A summary of the patient’s new list of current medicines should be generated automatically every time a GP changes the list in a patient’s electronic clinical record by adding or deleting medicines, or by changing the dosing directions. All changes should be highlighted.

        Medicines for which no prescription is needed should be included. The GP could be prompted to print the new summary or it could print automatically.”

        Space restrictions caused another paragraph that said that the updated list of the patient’s current medicines should be given or sent to the patient’s pharmacist, to be excised from the published article.

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        • Dr Frank, I’d like to show my respect to your response, which was both comprehensive and addressed each of the issues you raised.

          I would be very happy to be a pharmacist working in the area that you practice within.

          A few points.

          1) Pharmacies are not given access to Argus or similar software. The closest I have come to a system like this is cdmNET, and even then, I cannot update a patient’s records without first being invited by the doctor.

          2) Whether the GP should be the centre of a patient’s care is a philosophical debate. Personally, I don’t see this as being the best model, for various reasons. Foremost amongst these is the disempowerment of the patient.

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          • The good news is that pharmacists can use Argus, and indeed our former local pharmacy did that. A version of Argus is available that integrates with Microsoft Word. Please see http://www.argusconnect.com.au .

            I knew when I wrote about who is or should be at the centre of each person’s care that not everybody believes that it should be the person’s usual GP or general practice. I agree that each person should manage their own care. I should have said that amongst health professionals, the person’s usual GP or general practice should be central to the person’s care. I realise that some or perhaps many pharmacists would argue that the person’s usual pharmacist or pharmacy should fulfil this role.

            I likewise respect your thoughtful contributions to this discussion.

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            • I’ve had a lot of issues with getting access to Argus in the community setting – I’ve had colleagues who work primarily in HMR and RMMR who have had access, but not in community practice. I’ll look in to this now.

              With regards to a patient’s central care coordinator – please note that while the majority of my comments on this article have been reactionary to the unwarranted criticism heaped on pharmacists, this does not mean that I think that pharmacists are the answer to everything.

              My assertion that a GP should not automatically be a patient’s care coordinator is not because I feel that this role should go to pharmacists… it is because it should not be automatic, and the patient should always be the person deciding who they entrust this role to. Perhaps some people may choose their pharmacist to fill this role, but I don’t think this would be very common.

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          • 2) Whether the GP should be the centre of a patient’s care is a philosophical debate. Personally, I don’t see this as being the best model, for various reasons. Foremost amongst these is the disempowerment of the patient.

            As a fellow pharmacist, Jarrod, I feel it necessary to respond to this comment. It is important that one health professional coordinates a patient’s care. It is logical that the GP is the one who does this for many reasons, including (a) the GP is a generalist with a good overview, and (b) in our healthcare system that uses a gate-keeper system means that they manage the referrals to medical specialists and medicare-funded allied health.

            As someone who was a carer for many years, a GP coordinating the care who shares treatment goals and is prepared to advocate for his/her patients is invaluable. A good GP who is prepared to stand up for his patient even when a specialist is not taking a patient-centered view is a god-send.

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            • I agree with your sentiment Amy.

              I’d like to point out that I didn’t suggest an alternative to the GP…. my stance on this is that the patient is autonomous, and they should make the choice as to who the coordinator of their care is.

              For many people, this will be the GP. For most people outside of this, it would be themselves.

              What I have an issue with is the automatic assigning of one health professional as a guardian of the patients care in a manner that implies that the health care system knows what’s best for an individual.

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  3. Dear Edwin

    Thank you for writing this article. The clear theme that is emerging in health care is that of disruption, delegation and deconstruction of the older model.

    This is isn’t a surprise but really the beginning of massive change in primary health care for the future.

    Being a younger GP I definitely see my role as changing and many of the day to day tasks being performed by nurse practitioners, pharmacists and other qualified health professionals.

    Quality must underscore every new direction with evidence based practice being demonstrated but we must also understand, it isn’t all about us (GP) anymore. Our patients have significantly more information, choices and different avenues to access care.

    I do believe a medical home is needed for feedback from various sources. In this case the who performs a Boostrix injection on a patient will send advice of this to their GP or updates their online record.

    The future dominates my thinking in that I’d like to create a workable model of primary care that isn’t heavily reliant on the traditional bricks and mortar practice.

    I know that my views may be contrary to your theme but I absolutely know my expertise, years of study and enthusiasm will be put to work in better ways in the future.

    Thank you for writing this stimulating article.

    Jonathan

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    • The vaccination legislation is a done deal in QLD. What’s next – esp risk of fragmentation and less effective primary care (not just GP) – is a concern.

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      • Dr Edwin Kruys, I find this article extraordinary, for multiple reasons.

        Firstly, the emotive language, with references to “the family doctor” being upset at changes in the way the public can access health care services in Australia. Of course, the fact that this article is highly critical of “the family pharmacist” without having any real substance to it is deplorable and shows that you don’t even have commitment to your own argument – why else would you want to sway your readers with linguistic tricks rather than facts?

        The continual barrage of criticism against pharmacy as an industry in your article is bordering on professional misconduct – You may note that the medical board code of professional conduct has the following entry:
        4.2 Respect for medical colleagues and other healthcare professionals
        3. Behaving professionally and courteously to colleagues and other practitioners including when using social media.

        I’m not convinced that this article (or comments by quite a number of prominent RACGP executive and AMA executive) would pass this point at all – it seems that there is a persistent attitude amongst various RACGP and AMA representatives that it is perfectly acceptable to cast aspersions on the entire profession of pharmacy at every available opportunity.

        Dr Edwin Kruys, you have even managed to get the core role of pharmacist wrong – the role of pharmacists is not “to dispense medication safely and effectively” – it is to ensure that the decisions made by the prescriber are safe and appropriate.

        The general tone of this article seems to be “there is one port of call for health care in Australia – the doctor. If a patient prefers another health professional to provide a service, well, that’s just too bad.” It would seem the idea of patient autonomy is well outside of your consideration, and that patient’s really aught to just let doctors decide what is best for them.

        Another aspect of the criticism in this article that I find extraordinary is that this (and similar comments from other doctors in the media) are providing great fodder for anti vaccination groups. You have to decide what the message you want to deliver is: Are vaccines safe effective interventions capable of being supplied to the majority of the population through various health outlets (including bulk immunisation of workers and students in public settings without privacy); or are they complex, dangerous medical interventions that on a GP can manage in case there is a serious outcome such as permanent disability or death.

        Lastly, I’d like to comment on the very strong hypocrisy found in this opinion piece. Dr Edwin, you continually accuse pharmacists of a conflict of interest; yet the whole red herring of “fragmentation of care” is predicated on the fear of loss of income.

        Doctors have contributed to fragmentation of care more than any other health professional in this country:

        There is very little communication between GPs when a patient decides to see multiple doctors – never has a GP I’ve visited contacted another GP about my care, either to request information, or to pass it on.
        Doctors in hospitals have had ample opportunity to create a working model for communicating with GPs with regards to patient admissions and discharge – yet the period of time after hospital discharge still remains one of the most dangerous times for patients on multiple medications, due to confusion and medical mishap…. and lack of communication.
        Doctors do not communicate effectively with other health care professionals that a patient utilises. As I’ve commented above, it’s a rare thing for a doctor contact me with regards to a change in a patient’s medication regimen, even when the patient in question is easily confused, and incapable of remembering, understanding, or delivering information about a change in their medication.

        Adding to the hypocrisy of this article is the continual criticism of the evidence for provision of vaccinations in pharmacy. There are so many errors and fallacies in this section that it’s hard to know where to begin:

        Pharmacists are primary health care professionals with expertise in medicines – vaccinations are not outside of our scope of expertise, although up until now, they have been outside of our traditional provision. It could be argued that there was no need for changes in legislation in order to provide vaccination, yet our industry sought it to cement the fact that this is something that pharmacists have always been qualified to provide. For this reason, the feasibility trials that you deride so readily here were only ever intended to be feasibility trials – there is no need to do clinical trials on whether a medical intervention (such as vaccination) is as effective when provided in a primary health care setting by a pharmacist, a doctor, or a nurse – the skills and expertise of each of the health professionals is not the intended measure of the trial.

        Dr Edwin Kruys, your focus on your perceived “failings” of the trial are outside of the scope of the trial – we already know the effect that vaccines have on disease outbreaks; we already know that patients have access to walk-in clinics for vaccination if they so wish to take advantage of it. The purpose of the trial was never to address these issues that you raise – these are only misdirection from yourself to try and ridicule the outcomes.

        While we’re on the topic of “Evidence” I would like to ask you, Dr Edwin Kruys, to provide your own evidence to back up your statements. Where are the studies that show that the pharmacy business model requires “upselling” to stay afloat? Are you implying that pharmacists are selling products to patients that they don’t require in order to improve their profits? You call for evidence without relevance, and then make statements that you can’t back up with your own evidence. Ridiculous.

        With regards to “conflict of interest” – it really blows my mind the hypocrisy that this article is seething with. This entire article screams “conflict of interest” – from the misdirection, to the emotive language, to the criticism of an entire profession for providing a health intervention without your permission.

        It may come as a surprise to you Dr Edwin Kruys, but any person who relies on the professional reputation to earn an income is inherently tied up in conflict of interest every time they utilise their expertise.

        Every time a doctor sees a patient with diabetes according to the cycle of care and PIP funding model, there is a conflict of interest – the patient is being called back so the surgery gains a fee, rather than this particular patient requires the appointment.

        Every time doctors say that they will not participate in the eHealth model and MyHealthRecord until the payments for their time are “adequate”, they reveal their conflict of interest – the payments they receive are more important than the health benefits the patient receive from having all of their records available when clinically relevant…. not to mention, this would destroy any illusions of “fragmentation of care” overnight if an electronic health record were to be effective.

        I’d like to finish with an observation that I hope everyone reads – even if they’ve found the above ridicule of this article too long to read, maybe they’ll read the last comment.

        Dr Edwin Kruys, your final paragraph speaks loudly of your closed mindedness, and is self-defeating in a spectacular way – “The RACGP remains committed to working collaboratively with both state and federal governments to develop innovative and effective models of care, and strongly advocates for solutions that support integration, not fragmentation”

        Dr Edwin Kruys, if you were truly interested in integrative care, the quote above would have mentioned far more than RACGP and government. You would have included pharmacy groups (since this is the target of this article); you would have included other health professionals and stake holders involved with immunisation and primary care. But most importantly, you would have included patients. Patients are, after all, the whole purpose of integrative and collaborative models of care. While you continue to dictate who and what a patient should be able to do, then no one can ever take you seriously about your commitments to working collaboratively with anyone.

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        • Hi Jarrod thanks for your feedback. The patient-centred medical home model as suggested by the RACGP and other groups is all about the patient. Pharmacist are and should be part of the team. Integration happens if we can agree on and work towards common goals. The Queensland pharmacy vaccination trials are based on little or no evidence as outlined in the article; this is a no-go in this day and age and, although a win for the pharmacy sector, it has widened the gap between community pharmacists and doctors.
          I’m interested to hear from you how we can work better together without duplicating services and creating more fragmentation. RACGP Queensland is looking at the pharmacist in general practice model as one way forward.
          And for what it’s worth: I’m using the terms GP and family doctor in many of my blog posts, and I strongly contest that giving an opinion about the amended legislation in Queensland and issues in the pharmacy sector is a breach of the code of conduct.

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          • Dr Kruys, there is a big difference between giving an opinion, and framing that opinion in a manner that deliberately calls in to question the motivation of an entire profession.

            If you truly, truly want integration and collaboration, this is the first thing that should be addressed.

            For too long, doctors who comment publicly about the pharmacy profession publish opinions wherein they make statements – presented as fact – that are absurd and mistaken.

            A good example is the comments made here by Dr Thinus – he clearly isn’t even aware of the requirements of any of the various state legislative requirements around the provision of vaccinations in pharmacy, and yet he feels that it is appropriate to imply that pharmacists are providing vaccines in the aisles with other patients looking on, then pushing these vaccinated patients out on the street without observation.

            The sad thing is, that the majority of doctors that I interact with have a strong respect for other health care professionals, including pharmacists; despite this, there is a pervasive tone from representative medical bodies that pharmacists are inept, unqualified quacks looking to profit at the expense of patients.

            One last thing Dr Kruys – don’t you think it’s relevant to mention in an article about vaccination, wherein you call in to question the ethics of an entire profession and accuse them of putting profits ahead of patient welfare, that you actually own a vaccination service, from which you earn an income from charging patients privately for vaccines?

            Don’t you think that this fact in itself is a massive conflict of interest with consideration to this article, and that at the very least, you should have declared this at some point in your article?

            Don’t you think that this conflict of interest should be declared every single time you discuss the matter of the supply of vaccinations when this topic is raised in RACGP meetings?

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            • Jarrod you’re clearly misinformed and making incorrect assumptions. Play the ball, not the man! I would have appreciated your analysis of the, in my opinion poorly designed and reported Queensland vaccination trials. I’d also like to hear your opinion about the risk of duplication of services & fragmentation if pharmacies are doing what general practices teams have been doing successfully for years. How can we work better together?

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          • Jarrod and I often butt heads on issues, but I cannot see how he is making ad hominem attacks, any time he has brought up anything that could be seen as attacking you he uses or refers to excerpts in your writings. Hardly a straw man argument.

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          • “Jarrod you’re clearly misinformed and making incorrect assumptions.”

            Would you mind pointing out specifically where I have been misinformed or making assumptions that are incorrect?

            As Benedict has pointed out below, I have quoted you specifically throughout my responses. If I am misinformed, then perhaps it is because the information you provided in your

            “Play the ball, not the man!”

            Again as pointed out already, I’ve only commented on what you’ve discussed here, apart from you lack of openness about your own conflict of interest.”

            “I would have appreciated your analysis of the, in my opinion poorly designed and reported Queensland vaccination trials.”

            I support the work of QUT and the scope of the research they conducted. I do have an opinion on your analysis of the study, and believe that you have represented it in a way that the study was not designed for, in order to legitimise your opinion that pharmacists should not perform the role of vaccination.

            “I’d also like to hear your opinion about the risk of duplication of services & fragmentation if pharmacies are doing what general practices teams have been doing successfully for years.”

            Well, this is open to interpretation isn’t it.

            Firstly, are clinical services in pharmacy duplicating the role of doctors? Is the role of pharmacist so simlar to that of GP that by expanding our practice to represent a larger portion of our expertise, this is considered “duplicating the role of a doctor”?

            The reality is that this particular issue you have raised did fill a gap, because a significant portion of the people who were vaccinated in the trial against influenza had never had influenza vaccination before. Clearly, there is a portion of the population who are not engaging with the health sector, and by providing services in pharmacy that are safe and effective

            With regards to the wider uptake in services in pharmacy outside of dispensing – these are all areas within which pharmacists have existing expertise. When you look at cholesterol levels, BGL, or HbA1c, for instance – pharmacist have been utilising this information in patient consultations as long as doctors have – the difference is that pharmacists have not had access to pathology. With the advent of POCT, this has opened up the ability of pharmacists to screen these directly.

            Again, is this duplication of services? From my experience, and what I write about, no. These are offered as services that are complementary to existing GP services (ie patients can request a test for their own information). In quite a lot of cases, they are used as screening tools. It may surprise you to know that there is a portion of the population who avoid doctors due to their own fears or beliefs. This proportion of the community still often consume healthcare resources, and often do this within pharmacy…. These patients often access these services, and if/when a potential issue is identified, they are counselled on what this means in a clinical sense, and referred to a GP for confirmation and follow up.

            Now, I’ve had doctors comment online that screening in itself is unethical, due to risks of false positive (unneeded anxiety/fear) or false negative (false sense of security). I’ve had other doctors comment that this is just creating extra responsibility for the GP, who suddenly has patients wanting tests ordered at the behest of some other HCP.

            The problem with these attitudes is that they aren’t looking at the programmes offered, they aren’t looking at the practice of pharmacy, and they aren’t looking at these patients and seeing the impact this can have on the overall healthcare burden of society and government. A patient who has clear risks of diabetes that avoids the doctor out of fear of a diagnosis that they know is possible, is going to be very expensive when the finally end up in hospital due to complications. Identifying them earlier due to access to a service that is considered less intimidating (rightly or wrongly) isn’t duplicating any services of any kind, it is synergising them.

            “How can we work better together?”

            You can start with an attitude change.

            Personally, I’m sick of seeing opinion pieces from medical professionals about pharmacy, because I know every single time that they will be negative, misinformed, and poorly researched.

            If the medical profession truly values the idea of collaboration (and please look to Olive Frank’s comments above for someone who is seemingly taking this seriously), then cut out the negative rhetoric. Start looking at your own representatives, and how they talk about pharmacy (and optometry, and physiotherapy, and nursing, etc) and start to realise that collaboration can’t exist in an environment with this kind of entrenched disrespect.

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            • Thanks for sharing your POV.
              You mention a ‘conflict of interest’ with regards to my presumed ownership of a travel vaccination service. Not sure where you got this from. I am an independent contractor and don’t own a vaccination service.
              I don’t earn an income from ‘charging for vaccines’.
              Most importantly: I don’t profit from what I prescribe.
              Happy to discuss further offline.

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  4. The reason the pharmacists have to inform all people who qualify for free vaccinations under the NIP to go to their GP is because nothing’s free… GPs receive renumeration from the government for them, pharmacists don’t, so the patient has to pay. Therefore pharmacists have to tell the patient that they are eligible to receive the vaccine for free if they go to their GP, however the patient can then choose to pay for the vaccination at the pharmacy if they wish to do so, for convenience etc. it has nothing to do with pharmacists not doing something for free, doctors don’t do NIP vaccinations for free either.

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    • Not really. I think GPs are very aware of what they don’t know. We are more scared of the damage Pharmacists who are not aware of what they don’t know might do to patients.

      And let’s face it – Both sides have a commercial interest in this debate but at least the GPs have a really good argument re. The protection of patients’ healt and privacy issues.
      The Pharmacist argument is a pure commercial one. You simply cannot put lipstick on a pig no matter how hard you try

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      • Dr Thinus, your own comments in this posting, and in others on this article, clearly show that you aren’t able to judge what you don’t know!

        You state in this comment that “at least the GPs have a really good argument re. The protection of patients’ healt and privacy issues” – as if pharmacists aren’t also subject to the Privacy Act, as if pharmacists aren’t concerned for the health of their patients with every single clinical decision they make.

        The fact that you think that pharmacists only have a “pure commercial” reason to provide any health service proves that you aren’t, in fact, aware of what you don’t know.

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        • Jarrod you and I have danced this dance many times over the years – and as usual you play the man & not the ball.

          You only need to answer a few simple questions – as stated above. Nothing personal – just some hard cold facts showing the medical need for pharmacies to take this task on as opposed to the commercial want. And show some examples of pharmacies that give their “consumers” the same privacy and due diligence that they would get at a GP clinic.

          Really very straightforward. No need for personal attacks by any commentators

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          • as previous – Jarrod and I often butt heads on issues, but I cannot see how he is making ad hominem attacks, any time he has brought up anything that could be seen as attacking you he uses or refers to excerpts in your writings. Hardly a straw man argument.

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          • Pharmacists that have been renovated in the last five to ten years often include a seperate room with solid walls and a solid door that can be closed to ensure a private consultation. The biggest barrier to these being adequately utilised is the question of – do you use these for every single person picking up medication, or do you flag to everyone that someone has a reason for increased privacy by using it in only selected instances?

            Liked by 1 person

            • One of the local pharmacies – actually asked me to check out their premises when it was first fitted out. Another (a few years ago) wanted to do in pharmacy immunisations and received an injunction from a nearby GP practice, based on potential loss of earnings.

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    • Thanks for this link. The article quotes Dr Lisa Nissen, head of QUT’s School of Clinical Sciences.

      I wrote a comment:

      ” all health professionals should be working with each other”. I agree with this. I hope that it means that every time that a pharmacist administers an immunisation, she or he seeks the patient’s permission to inform the patient’s usual or general practice, and once the patient has agreed to this, sends the information preferably via a Secure Message Delivery system such as Argus that makes it easy for the GP to file that information into the practice’s electronic clinical record for the patient.

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    • Yes, thank you Benedict. Good to read ‘the other side’ (many more examples above), but not always correct either.

      The Pharmacy Guild’s Tim Logan was originally quoted as saying that I have a ‘vested interest as proprietor of a commercial travel clinic’. This was echoed several times in the comments above. This information is incorrect.

      So, to set the record straight:

      I am an independent contractor and don’t own a vaccination service.
      I don’t earn an income from ‘charging for vaccines’.
      I don’t profit from what I prescribe.

      I have contacted the editor of PN and the word proprietor has been removed from Tim Logan’s original quote – a small improvement at least.

      This post is now closed for further comments. All participants have had had a chance to give their feedback on the article. As always, the truth lies probably somewhere in the middle. It’s obvious that the challenge will be to bring GPs and pharmacists closer together. I am happy to take the discussion offline with interested parties.

      Liked by 1 person

  5. Pingback: Here’s a challenge for the Pharmacy Guild | Doctor's bag

  6. Pingback: Here's a challenge for the Pharmacy Guild - The Medical Republic

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