The success of new health services in community pharmacies should be measured by the way they integrate and communicate with the rest of primary care including general practice.
A trial in WA reported earlier this month that more than 15,000 influenza vaccinations were administered last year with no adverse effects. The Curtin University researchers declared the program a success, saying there was scope to expand pharmacist vaccination services to other vaccines and younger children.
Recently we’ve heard about the ‘success’ of pharmacy trials in several states. However, the question arises: by what measure are the trials a success?
Many of my patients tell me they’ve been vaccinated at a pharmacy but have forgotten where, when and with 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.
Walk-in convenience at pharmacies is often mentioned as a benefit of the scheme, but the preferred model seems to be an appointment during specific pharmacy trading hours.
Narrow vision of health
Public health arguments, such as increased vaccination rates, are intuitively compelling; to a public health advocate, it doesn’t matter where vaccinations are delivered.
Most of these stand-alone models have failed to look at the impact on primary care as a whole
However, most of these stand-alone pharmacy models have failed to look at the impact on primary care as a whole, including general practice teams, at a time when primary care is supposed to be moving towards more integration and collaboration.
Other issues that have often been overlooked are clinical benefit to the public, costs to the patient and health system, and conflicts of interest within the pharmacy industry.
Data reported from Queensland immunisation trials, for example, were superficial, selective and showed elements of observer bias. 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.
The impact of missed opportunities for screening and other preventive care in general practice was not looked at, and neither did the trials focus on much-needed better integration of care delivery.
Yet, there is ample evidence that increasing general practice comprehensiveness of care is associated with decreasing costs and hospitalisations. 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.
Communication, upselling and out-of-pocket costs
The trials also failed to look at whether the standard elements of privacy, documentation or GP notification were met.
Furthermore, there has been no mention of whether commercial practices have been monitored, such as using vaccinations as a means to onsell other products. As we know, the pharmacy business model relies heavily on upselling products to patients. There is a well-known conflict of interest in pharmacists delivering health services including vaccinations.
Australians already pay more out-of-pocket costs than in many other countries
One of the strengths of medication prescribing in Australia is the high degree of separation between the prescriber and the medication dispenser. It enables more objective prescribing, free of pecuniary interests and leads to better allocation of resources. This is another strong argument against moving more health services into the pharmacy environment.
However, it seems that the goal posts are shifting.
Australians already pay more out-of-pocket costs than in many other countries. It is likely that health services delivered in the commercial pharmacy environment will further increase costs to patients. For example, administration of the quadrivalent influenza vaccine by WA pharmacists came at a cost of $30-$40.
Not surprisingly, the recent Review of Pharmacy Remuneration and Regulation posed 140 thought-provoking questions about the current community pharmacy model. It is hoped that some of the issues will be resolved as a result of the review.
It is clear to me that the claimed success of pharmacy vaccinations has to be taken with a pinch of salt.
If community pharmacy is able to better integrate their services with the rest of primary care, including general practice, the resulting model has the potential to become truly successful.
If, on the other hand, the main drivers continue to be profit and sales – leading to more fragmentation and duplication – the model will fail and others may take over medication dispensing soon.
This article was originally published in Australian Doctor magazine (edited).