It is time to leave the Machiavellian era of Australian healthcare behind

Community pharmacy groups are lobbying for pharmacy prescribing, a topic that has been on the wish list for a long time. Medical groups are concerned about patient safety and fragmentation and are pushing back. Is this Australian conflict model what we want or is there a better way forward?

Some pharmacists want to be able to write prescriptions as they believe it is in the scope of practice of a pharmacist and more convenient for patients.

Examples from abroad are used as an argument why Australia must follow suit. A ‘collaborative prescribing pilot’ is underway and the pharmacy sector is looking forward to the soon-to-be released results.

Pharmacists expect that their proposal will be cost-saving as people will not need to see the family doctor for prescriptions.

Pushback

Not surprisingly, medical groups are upset and believe the proposal is not helpful and not in the best interest of patients.

Doctors are concerned that soon the head doesn’t know what the tail is doing or, in other words, that more prescribers will lead to more fragmentation and adverse health outcomes.

Concerns have been raised that warning signs or significant (mental) health conditions will be missed and screening opportunities lost. Some have also argued that pharmacists prescribing and selling medications at the same time creates commercial conflicts of interest.

As a result there will likely be pushback from medical groups. It is to be expected that when the debate heats up some unpleasant words will be said in the media before the Health Minister of the day makes a decision based on evidence, opinion or political expedience.

Then there will be a loser (usually not the Health Minister) and a winner, and the relationship between pharmacists and doctors remains sour at the expense of patient care.

A better way

This series of events has become a familiar scenario in Australian healthcare. What’s missing is of course a joint strategy or a solution that would benefit both parties as well as our patients (a win-win-win solution).

Community pharmacists play an essential role within primary care teams. The pharmacy sector is under pressure and is attempting to implement strategies to remain viable into the future, such as introducing services currently provided by doctors, nurses and others.

An obvious way forward would be for pharmacists and doctors to explore models that are not competitive but complement each other. This is a joint process that requires broad support from both parties.

We desperately need genuine collaborative models of care, such as pharmacists working in general practice, but there may be other models too.

This is of course easier said than done. It is, however, time to leave the Machiavellian era of Australian healthcare behind. Who’s going to take the first step?

Disruption by the after-hours industry and why you should care

Disruption by the after hours industry and why you should care

After-hours medical home visiting services are important for patients and their doctors but we need an ethical and sustainable model that integrates with day-time services.

Doctors and professional medical bodies including the RACGP and AMA regularly express concerns about healthcare models that compromise on quality, fragment and duplicate care or fail to use scarce health dollars efficiently.

The Medicare Benefits Schedule (MBS) Review Taskforce has voiced similar concerns in relation to some of the home visiting services. In its recently published interim report the taskforce notes that the growth in claiming of urgent attendances by after-hours medical services is showing an increase far in excess of population growth.

The taskforce believes the services often interfere with continuity of care by the patient’s regular GP and represent low value care. It is not convinced that the rise of urgent after-hours home visits has had a significant impact on hospital emergency department services.

Inappropriate use of funding?

Indeed, there are indications that funding for after-hours medical services in the community may be used inappropriately. For example, I have received reports from some of these services delivering repeat prescriptions after-hours to patients’ homes. The care is often not provided by GPs but by less qualified practitioners.

An after-hours visit classified as ‘urgent’ attracts a Medicare rebate which can be $100 more compared with the same service provided at a GP practice. This has created a lucrative standalone after-hours industry which doesn’t always represent value for money for the taxpayer.

No reduction of emergency department presentations
The assumption that increased provision of urgent, after-hours consultations (MBS item 597) would reduce demand for emergency departments has not been confirmed. Source: AFP

Let’s look at the ACT: since the arrival of the bulk-billing National Home Doctor Service in the capital, home visits rose from 1588 in 2013–14 to 20,556 in the previous financial year.

According to the Medicare Benefits Schedule Review Taskforce, Medicare benefits paid for urgent after-hours services have increased by 170 per cent, from $90.8m in 2010–11 to $245.9m in 2015–16, whilst benefits paid for normal GP services increased by 27 per cent.

There is no reasonable explanation for the exponential growth. The taskforce is of the opinion that MBS funding should continue to be available for home visits in the after-hours period but has made some sensible recommendations to improve the model.

After-hours lobby 

The response from the after-hours lobby speaks for itself: The National Association for Medical Deputising Services started an aggressive lobbying campaign to ‘protect home visits’.

Although several after-hours services left the corporate lobby group – including the Canberra After-Hours Locum Medical Service, the Melbourne-based DoctorDoctor service and the Western Australian Deputising Medical Service – the campaign continues to target consumers and politicians.

The actions of the lobby group and some after-hours services have raised eyebrows. Mass media advertising and marketing campaigns via television, newspapers, and billboards will drive unnecessary use and should be avoided. Similarly bookings for after-hours deputising services during daytime hours should stop.

A sensible solution

It’s not rocket science: As after-hours home deputising services do not offer comprehensive GP care, they should only be used when a patient’s usual GP or general practice is not available and the patient has a health concern that cannot wait until the following day.

It is time to use these Medicare-funded services wisely – when genuinely needed, not wanted or promoted.

Blood tests at the chemist is like getting your car serviced at the lawn mower shop

Pharmacies are the right place to get your medicines and receive medication advice, but they are the wrong place to get a blood test.

AMCAL chemists are offering customers pathology tests at a cost of up to $220.

Ordering a test through a pharmacy chain rather than your local GP creates risks for patients including fragmentation of care, unnecessary duplication of tests, confusion about the interpretation of the results and increased out-of-pocket costs.

It may lead to incorrect, incomplete and unnecessary tests as well as wrong conclusions and false reassurance.

A pathology test should be recommended based on a medical assessment which may include your personal medical history, symptoms and a physical examination. Pharmacists do not have the diagnostic skills required to provide this kind of care safely.

AMCAL customers will be paying out-of pocket and are not eligible for a Medicare rebate. For example, a vitamin D blood test will cost $89.50, a ‘fatigue screening’ $149.50 and a ‘general health screening’ $219.50.

Our Australian Medicare system reimburses patients for a range of pathology tests after an appropriate assessment by a doctor.

The standard packages sold by AMCAL may not include the tests that are required for your unique circumstances or health problems.

We really need better integration of health services in Australia. We need pharmacies to work together with GP teams, not introduce more commercially driven duplication and fragmentation of services.

Ordering a pathology test through the chemist is like getting your car checked at the lawn mower shop. Nothing wrong with the lawn mower shop but it just isn’t the right place.

Pharmacy vax claims need a pinch of salt

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. There is a well-known potential 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.

This article was originally published in Australian Doctor magazine (edited).