Here’s a challenge for the Pharmacy Guild

A challenge for the Pharmacy Guild

One of the big questions in primary care is: will the community pharmacy sector and general practice be able to work together without fragmenting care or duplicating services? If we don’t solve the issues and start to work as team, patient care will suffer.

For that reason, I’d like to take the Pharmacy Guild up on their suggestion to collaborate.

The relationship between doctors and community pharmacists is an interesting one: the two professions rely heavily on each other. For example, I find the advice and support from pharmacists invaluable when trying to solve difficult medication problems with my patients. Pharmacists also act as a ‘second pair of eyes’ checking my prescriptions.

Both doctors and pharmacists are highly valued by consumers and are, with nurses, in the top three most trusted professions.

On another level doctors and community pharmacists are often at loggerheads. Issues that come up time and time again are differences of opinion about the commercial aspects of healthcare, conflicts of interest with regards to prescribing and dispensing, and who does what.

In the eyes of many doctors, community pharmacy has gone off track with little connection at policy level with other primary care providers. Pharmacist will tell a different story. For example, some pharmacists – not all – seem to think that the main agenda of doctors is to protect their ‘turf’ – but there’s much more to it as I’ll explain below.

Unintended consequences 

A while back I published an article on behalf of RACGP Queensland, drafted with input from a diverse group of academic and non-academic GPs. I outlined various issues with the Queensland immunisation trials, which have led to a change in Queensland’s legislation allowing community pharmacists to administer certain private vaccinations to adults.

The idea behind pharmacy vaccinations is to improve vaccination rates in people who don’t receive care through GP services. This sounds appealing from a public health point of view, but the impact on existing services has not been reviewed or taken into account during the trials.

Unfortunately the change impacts on the care delivered by family doctors and their teams. For example, my patients now regularly tell me that they’ve been vaccinated at a community pharmacy but have forgotten where, when and what exactly – and communication from the pharmacy is usually missing.

One of my frail elderly patients who came to see me for something else declined a government-funded influenza vaccination by our practice nurse because she was booked in to have a private vaccination at the pharmacy the following week, and felt she couldn’t cancel that appointment.

This goes against the argument that pharmacy vaccinations are only targeting people who don’t have a GP or people who fall outside the national immunisation program.

Moving services away from general practice also has an impact on opportunistic screening and prevention of health conditions by GP teams. So far this season I have been able to pick up several health problems in people who came in for vaccinations, including an aortic stenosis, pneumonia and two melanomas.

We are all connected

The Pharmacy Guild’s Strategic Direction for Community Pharmacy. Source: Pharmacy Guild

The Pharmacy Guild’s strategic direction for community pharmacy. Source: Pharmacy Guild

The main message here is that a change in one part of the health sector always affects the other parts. We’re all connected – this has nothing to do with money or turf but is all about providing high value, coordinated care.

It would have been nice if RACGP Queensland had been involved in the recent Queensland immunisation trials; we could have flagged and perhaps solved some of the many issues at an earlier stage.

Will the My Health Record fix these problems? Not entirely, because uploading data to an electronic health record on its own will not replace the need for good communication and collaboration.

In the article we also warned against introducing further changes to care delivery in community pharmacies (see image) that may result in poorly coordinated, duplicated or fragmented health services.

How to move forward?

After voicing our concerns in the article various debates occurred on this blog and in the pharmacy press, for example here and here.

The response from the Pharmacy Guild in Cirrus Media’s Pharmacy News however contained incorrect information:

Response from the Pharmacy Guild

This statement is wrong for several reasons: part of my work as a family doctor involves giving advice to travellers but I am not a proprietor of a travel clinic and I don’t profit from the sale of vaccines or other products.

So how to move forward from here? I thought this response from Tim Logan was more encouraging:

“(…) it profits society more for GPs to work with pharmacists, citing a presentation at the Australian Pharmacy Professional conference earlier this year by US expert Dr Paul Grundy, who demonstrated the benefits provided by a model which encouraged GPs to do so.”

I’d like to take Tim up on his suggestion to work more closely together and invite the Pharmacy Guild to meet with RACGP Queensland. I acknowledge that there are always two sides to every story. Let’s see if there is common ground and room for agreement on how our professions can work better together at policy level, without duplicating services or creating more fragmentation of care.

As said before, the RACGP remains committed to working collaboratively with other primary care providers and government to develop innovative and effective models of care such as the patient-centered medical home, and we strongly advocate for solutions that support genuine integration of care, not more fragmentation.

RACGP Queensland represents over 7000 members in urban, rural & regional areas.

Dr Edwin Kruys is Chair of RACGP Queensland.

Follow me on Twitter: @EdwinKruysDisclaimer and disclosure notice.

4 thoughts on “Here’s a challenge for the Pharmacy Guild

  1. Then maybe the drug rep laws applied to GP’s could be applied to pharmacies? We all know that a GP is not allowed to own a pharmacy, but a pharmacist is allowed to ow a General Practice – perhaps this to could be amended?

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    • Indeed. Let’s for argument sake put aside the issues about profit and corruptability and assume we are all similarly corruptable (or not)

      For a GP to take the dispensing of the vast majority of prescription drugs on is as simple as and assistant to stock the shelves, a good storage control system and the right software.

      From there on it is a matter of picking the box of the shelf, checking the details, popping the label on and dispensing. Off course there are always some drugs that needs more involvement and skills but the vast majority of drugs would be dispensed in this way.

      There is thus a very good argument to allow GPs to dispense and in many ways the argument is very similar to the one being made by Pharmacists when motivating why they should be doing vaccinations and other clinical roles.

      It there begs the question – if these are similar discussions why is there and absolute “never” for one side of the debate and ” it is for the patient’s benefit” for the other side.
      And add to that Max’s points

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  2. This piece is a lot more balanced than others have been in the past, which I appreciate.

    I think it’s worth reiterating that if the RACGP (and AMA for that matter) wish to have a productive relationship with pharmacy bodies, then it is important that the negative rhetoric is reigned in. If you look at the “related” articles attached to this blog, you will note that they are all critical of pharmacy in an unproductive way. This is the general theme of articles written about pharmacy by medical writers (and a lot of commenters on those articles too – although these aren’t representative of doctors at large).

    I would also recommend forming a relationship with The Pharmaceutical Society of Australia, the peak pharmacy body in Australia.

    A few other comments that I have made in the past…. Services in pharmacy aren’t – as a general rule – intended to replace the role of a doctor. I provide multiple services in my pharmacy that are different from what people would consider “traditional pharmacy”. I would note that I do not do vaccinations in my pharmacy, because right above my pharmacy is a medical center with enough doctors on staff to make it a waste of resources. All of these services are about helping patients reingage with the health sector, and all of them involve a referral to their GP or a specialist.

    With regards to fragmentation of care – I will continue to argue that this is a red herring, because the infrastructure required to make true integration is not yet available. To suggest that services in pharmacy are a real threat to ‘fragmentation of care’ in the current environment is hard to swallow… The lack of a functioning communication infrastructure or protocols for when a patient is discharged from hospital is contributing to record numbers of hospital readmissions and medication misadventure. Until this very serious outcome of having ineffectual communication is rectified, the issue of ‘fragmentation of care’ between pharmacy and general practice is irrelevant.

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