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

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.

The 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. At the time of writing Dr Edwin Kruys was Chair of RACGP Queensland and member of the AMA Queensland Council of General Practice.

Continuity of care is more than just a catchphrase

The practice I work for recently took over another practice. As is not uncommon in acquisitions, this caused a temporary increase in staff turnover, including GPs.

The response from patients was interesting: just about every other patient asked if I was going to stay. And most patients – not just those with chronic or complex health conditions – expressed their dissatisfaction with the lack of continuity of care.

I’m sure that many colleagues can recall similar anecdotes. This seems to indicate that our patients value personal and longitudinal primary care. Yet, we are seeing many proposals, trials and projects at the moment that threaten this model, and will create fragmented care.

Two examples

For example, Queensland Health is running several trials at the moment that bypass the usual GP, including a hospital-avoidance project where the ambulance service brings patients to selected GP clinics that receive state funding.

However, usual practices do not receive funding or support to increase capacity to manage these extra presentations. Although projects like the one in Queensland may reduce visits to the ED, they don’t support a stable and enduring relationship between GPs and patients.

In another Queensland Health project, pharmacies are being encouraged to administer MMR vaccinations. That vaccinations in general practice are an opportunity for screening and prevention does not seem important to policy-makers.

In primary care literature, ‘continuity’ is often described as the relationship between a practitioner and a patient that extends beyond specific episodes of illness or disease. Unfortunately, other terms are often used synonymously, such as ‘care co-ordination’, ‘integration’, ‘care planning’, ‘case management’ and ‘discharge planning’.

The experience of continuity may be different for the patient and the health practitioner, adding to more misunderstandings.

According to a 2003 BMJ article by Haggerty et al, there are three types of continuity of care: informational continuity, management continuity and relational continuity. Of course, continuity is more than just sending a message to another health practitioner, or uploading a piece of information to an e-health database.

What is continuity of care?

Understanding individual patients’ preferences, values, background and circumstances cannot always be captured in health records. Practitioners who have longstanding relationships with their patients often know this information.

The RACGP describes continuity of care as “the situation where patients experience an episode of care as complete, or consistent, or seamless even if it is provided in a number of different consultations by different providers”.

There is abundant evidence that continuity in primary care results in improved patient health outcomes and satisfaction, and reduced costs. For example, relational continuity reduces both elective and emergency admissions. In other words, the rate of hospital admissions drops when people have their own GP.

Better aligned funding that supports primary care practitioners to provide long-term quality care is much needed at the moment.

Team care

A sustainable health system should free up GP teams and other health practitioners to deliver clinical co-ordination and integration of care across disciplines, especially for people living with complex and chronic health conditions.

Avoiding hospital admissions and increasing immunisation rates are laudable objectives, but it’s not a good idea to do this at the expense of continuity of care by the GP. If patients don’t have a GP they should be encouraged or assisted to find a doctor of their choice.

There is nothing wrong with new models of care as long as they don’t impact on the many benefits general practice has to offer.

This article was originally published in Australian Doctor Magazine.

Disruption in healthcare is happening (whether we like it or not)

Healthcare, and particularly medicine, are slow-moving beasts. This doesn’t mean that innovation isn’t happening. In fact, it’s happening at an alarming speed and doctors are grappling with a quickly expanding knowledge base.

But the highly regulated, traditional industry is vulnerable to external disruption, and we’re seeing more and more examples:

  • DIY tests like skin cancer apps and pap smears
  • Online script services
  • Skin checks at the pharmacy
  • Vaccination services outside medical practices
  • Medical tourism

The flip side of convenience

Disruption is not necessarily the same as innovation. Disruptive services or products are simpler and more convenient to use, but their quality is often poorer.

In healthcare, the risk of disruption is that it affects health outcomes. It may lead to fragmentation and loss of opportunistic screening. I’ll give two examples:

Example 1:  More providers does not equal better care

A busy family doesn’t have the time to visit the doctor and decides to use convenient online health services. As a result they hardly ever visit their family doctor, and if they do, their doctor does not have the complete picture as more health providers are involved in the care.

Example 2: Convenience does not equal safety

Women doing their own pap smears at home may take incorrect samples. Although avoiding the ‘stirrups’ in the doctor’s office is a big plus, the risk of avoiding an expert examination is that things get missed.

The way forward

Disruption in healthcare is happening, whether we like it or not. “Successful entrepreneurs naturally look at opportunities in terms of the jobs they can do for customers,” say the authors of this article. Although it is unlikely that the doctor can be replaced by technology, certain aspects of the healthcare process can.

I believe there are 3 ways the healthcare industry should respond to external disruption:

  1. Continue to listen to health consumers
  2. Develop our own disruption processes
  3. Communicate the strengths and qualities of our services

Marcus Tan, GP and CEO of HealthEngine said in Australian Doctor magazine: “GPs are ideally suited to lead this cultural shift. GPs are highly skilled in managing risk and uncertainty, and are well equipped to make the leaps required to innovate.”

Indeed, if we don’t do it ourselves, others will.

Why we vaccinate: amazing figures from Australia

These graphs show what happens to the number of deaths when we start vaccinating.

The red arrow indicates when vaccines were introduced in Australia. The take-home message: vaccines save lives.

Why we vaccinate
Image (click to enlarge): Number of deaths in Australia from diseases now vaccinated against, by decade (1926–2005). Red arrow indicates when vaccine was introduced. Source: The Science of Immunisation: Questions and Answers, Australian Academy of Science.

For more information have a look at the website from the Australian Academy of Science which provides easy-to-understand information that explains the science of immunisation.