Pharmacies will be handed $1.26 billion for delivering healthcare services. Good for them. But meanwhile the government is not prepared to increase the Medicare rebates patients receive when they see a doctor.
As a result of the new health policies, visits to the doctor will become more expensive in the years to come, whereas pharmacies will be paid more to deal with health problems. With this move Health Minister Susan Ley seems to make a clear statement: Don’t go to your doctor, see the pharmacist instead.
A vague agreement
It could be me but I’m not entirely sure what the Health Minister will sign off on – it’s all still a bit vague:
The Pharmacy Guild says on its website: “The Government has committed to $50 million over the Agreement for a Pharmacy Trial Program to trial new and expanded community pharmacy programs which seek to improve clinical outcomes for consumers and extend the role of pharmacists in the delivery of healthcare services through community pharmacy.”
National President of the Pharmaceutical Society of Australia Grant Kardachi says: “PSA particularly welcomes the doubling in this agreement to $1.26 billion of funding for the provision of patient-focussed professional services.”
According to Australian Doctor magazine, “some $600 million will be spent on ‘new and expanded’ services, but there is no detail on what services this will cover.”
One thing is certain: Pharmacies are going to deliver more healthcare services – and at the same time the freeze on indexation of the Medicare rebates comes at a cost for patients.
Here re my questions:
Is Minister Ley’s decision helping to improve teamwork within primary care, or is it creating more confusion and frustration for patients and their doctors?
Can pharmacists and their assistants offer the same quality healthcare as doctors and practice nurses?
Can the person who is selling the drugs give independent health advice?
Why not spend part of the money on increasing the rebate patients get back from Medicare after visiting their doctor?
Why not spend part of the money on improving access to practice nurses and GPs?
Does this mean that doctors will miss opportunities to pick up on health problems, because patients will see the pharmacy assistant instead?
When the Pharmacy Guild talks about ‘evidence-based’ services, what do they mean? (given the fact that many community pharmacies also sell unproven remedies and products).
The war (…) was an unnecessary condition of affairs, and might have been avoided if forbearance and wisdom had been practised on both sides ~ Robert E. Lee
Separating the medication prescribers from the dispensers has merit. One of the advantages is that doctors and pharmacists don’t get tempted to diagnose problems to sell more drugs.
The Australian Pharmacy Guild wants to change this. They prefer pharmacists to do health checks, give advice and perform interventions such as vaccinations – while at the same time selling the solution to the problems they identify.
The Guild’s strategy is marketed as providing better access to patient care, and is apparently based on overwhelming international evidence. Indeed, in some countries pharmacists offer a wider range of services.
I’m not sure it’s always better overseas. One New Zealand doctor seemed very unhappy about pharmacists managing medical problems (and I have heard similar stories from other countries):
“I practise in New Zealand where pharmacists are allowed to treat ‘easy’ diagnoses like urinary tract infection [UTI]. Last week I consulted with a young lady who had had two diagnoses of UTI and two courses of trimethoprim [an antibiotic]. When I examined her she had a significant UTI, thrush and the possibility of a chlamydia infection, results awaited. Nothing is ‘easy’ in medicine!
The Pharmacy Guild may be a politically clever bunch, but they should have suggested a multidisciplinary solution here. Their strategy will create a backlash. In the end nobody will be better off.
Where to from here?
The signs are on the wall. Dispensing medications is not sustainable for pharmacies. Just like video rental shops had to change their business model because people started downloading movies and using automated DVD rental kiosks, this particular part of the pharmacist’s job may soon be history. The authors of an article in the British Pharmaceutical Journal ‘Dispensing: it’s time to let it go’ said: “If the aspirations of pharmacy fulfilling a clinical role integral to public healthcare is ever to be realised, community pharmacists must shift their focus away from dispensing and towards NHS service provision.”
The key here is integration. According to the authors medications could be provided in-house by health care organisations or delivered by mail, and the focus of pharmacists should be on providing integrated services like medication reviews and drug utilisation reviews. This would indeed employ the skills of pharmacists and at the same time ad value to patient care provided by other health professionals.
Or maybe pharmacists should be made responsible for quality control of over-the-counter medicines and help to stamp out misleading claims made by the domestic complementary medicines industry.
We need honest medication advice. “(…) It comes as a shock to walk into some pharmacies to see them urging products on customers where there is no evidence base of effectiveness,” said NHMRC boss Professor Warwick Anderson recently. “If you’re providing advice and care to patients, you should be clear about the evidence for the treatment.”
The pharmacy industry is comfortably protected by their community pharmacy agreement with the Federal Government, and state laws stipulate only pharmacists can own a pharmacy. A new pharmacy cannot set up shop close to an existing pharmacy. Other professions, like doctors and lawyers, don’t have this competition protection.
The service expansion drift of pharmacy-owners will eventually provoke a response from the AMA and RACGP and other medical organisations. The idea of the pharmacist in general practice has been floating around for a while. Doctors may demand dispensing rights and lobby for an end to the pharmacy cartel.
A study in the Medical Journal of Australia showed that dispensing doctors issued fewer PBS scripts than non-dispensing doctors. This is one argument for dispensaries in GP surgeries; other arguments are evidence-based medication advice and consumer convenience. Think about it: What’s easier than, after having seen the doctor, walking to the dispensing machine in the hallway, scanning your script and receiving your medications? Robotic dispensing reduces medication errors (see video below) and nobody is suggesting multivitamins, supplements or probiotics at the same time.
But just because a service is more convenient, doesn’t mean that it is a good solution. Doctors should not do the pharmacist’s job, just like pharmacists would do well to stay away from medical services.
There is still time
Pharmacy-owners face reduced profits because the Government has set lower prices for generic medications under the price disclosure arrangements. Although it is understandable they are looking for other income streams, this is a dead-end. The last thing we need is a war between pharmacists and doctors.
Needless to say it’s not in the interest of health consumers. It will create confusion, duplication, false reassurance, frustration, missed screening opportunities, fragmentation of care and higher costs.
Doctors have to accept change too. If people feel they cannot access a GP when they need to, we should improve this. One solution would be to fund nurse-lead walk-in vaccination services within the safe, clinical environment of the GP surgery. The pharmacist can play a role as part of the multidisciplinary team.
The current community pharmacy agreement expires in June 2015. There is still time.
So there is a budget crisis. There’s also a new federal Health Minister. And, here it comes, community pharmacies are negotiating over a billion-dollar deal with the Government: The Community Pharmacy Agreement sets out the Government funding pharmacists receive for dispensing PBS medicines.
If it’s up to the Pharmacy Guild, pharmacists will be:
Filling repeat prescriptions to ‘free up doctors time’
Treating ‘easy’ minor ailments
Giving more vaccinations (e.g. a flu-shot for $25 with no Medicare rebate)
Doing ‘easy’ health checks, screening and preventive health services
Giving mental health support.
At first glance this improves access to health services and saves tax payers bucket loads of health dollars. Here are 5 reasons why role and task substitution by pharmacists needs more thought:
#1: Avoiding the doctor is probably not going to help
A repeat prescription or a vaccination is a valuable opportunity for a family doctor to screen for, and treat health issues before they escalate. This is one of the strengths of general practice. If people don’t come in because they get their cholesterol or blood pressure scripts from the pharmacist every 6 months, this system will come at a cost.
#2: We are treating people (not ailments)
People are more than the sum of their ailments. Over the years there have been many attempts to replace the doctor with algorithms, machines and computers, and they have all failed.
The human body and mind are complicated. As they say, if you think a professional is expensive, wait until you hire an amateur.
#3: Don’t put the cart before the horse
If it’s improved access or multi-disciplinary care we’re after, then strengthen general practice. Unfortunately the opposite is happening: Practice nurse support has been cancelled, and I won’t mention the Medicare rebate cuts and freeze.
#4: Disruption is not innovation
A common mistake is to assume that disruption is the same as innovation. Disruptive services – like those suggested by community pharmacists – may be simple or convenient, but the quality will be poorer.
A recent study showed that only 3 out of 32 fish oil supplements contain what the label says; I believe pharmacies should focus on evidence-based medication advice and quality control of over-the-counter drugs.
#5: Conflicts of interest
A question we should ask is: Can the person who is selling the drugs give independent health advice? Pharmacies face reduced profits because the Government has set lower prices for generic medications under the price disclosure arrangements.
Although it is understandable pharmacies are looking for other income streams, it is unlikely that the proposal by the Pharmacist Guild is a win-win solution. There is value in team work, but only if we work genuinly together.