Here’s 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.

At the time of writing Dr Edwin Kruys was Chair of RACGP Queensland.

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.

How should Primary Health Networks support GPs?

It appears the new  Primary Health Networks (PHNs) are here to for the long haul. There is an enormous opportunity for PHNs to add value where they support quality primary healthcare services to the community.

RACGP Queensland has developed a draft position statement identifying 4 concrete targets that should be aimed for in primary healthcare reform at a local level.

The targets are presented below. I believe that PHNs could play an important role in achieving these goals – in collaboration with GPs.

  1. PHNs are in an excellent position to assist healthcare providers and organisations to build effective relationships. PHNs should facilitate a shared health vision for their local area, exceeding disciplinary and organisational boundaries.
  2. PHNs should encourage continuity of care and make sure new models and initiatives do not further fragment our health system and/or adversely affect health outcomes.
  3. PHNs need to play an important role in facilitating better information exchange and communication between healthcare providers.
  4. PHNs should encourage the development of innovative models of care that introduce genuine integration between the various parts of the health system.

Integrated health services, what do you mean?

It has been described as the holy grail of healthcare: the patient at the centre and the care team working seamlessly together, no matter where the team members are located, what tribe they belong to or who the paymaster is.

Integration has been talked about for many years. The fact that it’s high on the current political agenda means that there’s still a lot to wish for. Although we have high quality healthcare services, our patients tell us that their journey through the system is everything but smooth. Most health professionals are painfully aware of the shortcomings in the the system.

What is integration?

So what do we mean when we talk about integration? Co-location of health professionals? Team meetings between doctors, nurses and allied health professionals? Hospital departments talking to each other? Communication between GPs and specialists? Working across sectors? Packaging preventative and curative services? Patient participation? One electronic health record? A shared management and funding system?

Integrating health services means different things to different people. For that reason the WHO proposes the following definition:

“Integrated service delivery is the organisation and management of health services so that people get the care they need, when they need it, in ways that are user-friendly, achieve the desired results and provide value for money.

Integration is a means to an end, not an end in itself. Sharing resources may provide cost savings but, says the WHO, integration is not a cure for inadequate resources. Obviously, integrating services doesn’t automatically result in better quality. It’s also worthwhile noting that co-locating services does not equal integration.

There is a difference between integration from a consumer point of view, which often implies seamless access to services, and professional integration, which is achieved through mixing skills and better collaboration. These two types of integration don’t necessarily go hand in hand.

So it is useful to ask: what problem are we trying to solve? Are we trying to improve the patient journey through the health system? Do we want to support health professionals to deliver better care? Or is the main driver government concerns about costs?

How to achieve it?

One thing is certain: we must fight fragmentation. This is challenging as we are seeing a wave of commercially driven, disruptive services appearing in the healthcare sector. These solutions may be attractive to consumers because they are convenient, but they usually don’t contribute to a better or more integrated health system.

Unfortunately the evidence around integration is limited, but the authors of this MJA article are suggesting a way forward. They have looked at international health reform initiatives improving integration between community and acute care delivery, and they found that the following 10 governance elements are essential to support integration:

  1. Joint planning. Governance arrangements included formal agreements such as memoranda of understanding
  2. Integrated information communication technologies
  3. Effective change management, requiring a shared vision
  4. Shared clinical priorities, including the use of multidisciplinary clinician networks, a team-based approach and pathways across the continuum to optimise care
  5. Aligning incentives to support the clinical integration strategy, includes pooling multiple funding streams and creating equitable incentive structures
  6. Providing care across organisations for a geographical population, required a form of enrolment, maximised patient accessibility and minimised duplication
  7. Use of data as a measurement tool across the continuum for quality improvement and redesign. This requires agreement to share relevant data
  8. Professional development supporting joint working, allowed alignment of differing cultures and agreement on clinical guidelines
  9. An identified need for consumer/patient engagement, achieved by encouraging community participation at multiple governance levels
  10. The need for adequate resources to support innovation to allow adaptation of evidence into care delivery.

Major paradigm shift

The first thing we need is a shared vision. A major paradigm shift towards more integration requires motivated and engaged stakeholders and champions, a shared sense of purpose and a culture of trust. This should be established before embarking on a new journey. We must avoid making the same mistakes that have caused so much havoc in projects like the PCEHR.

It will be a challenge to get health professionals to focus more on coordination instead of daily care delivery. An essential step here is to increase capacity. The last thing we need is an overloaded primary care sector such as in the UK. The RACGP is suggesting an overhaul of primary care funding to faciliate integration and coordination. Similar changes will be required to free up hospital doctors to e.g. discuss patient cases with primary care providers.

The big question is: who will take the lead? It is likely that a lot of  work will happen at a local level and primary health networks could play a crucial role here. A shared agenda, clear goals and genuine stakeholder involvement are keys to success.

The baby, the bathwater and a better health system

So we have a healthcare funding problem. Although there seems to be an appetite for change, it’s essential not to throw the baby out with the bathwater.

Our fee-for-system hasn’t done a bad job. Australians are healthier and live longer compared to many other countries, and our primary care sector is delivering cost-effective care.

On the other hand, as a result of population ageing, advanced technologies and new treatments, care becomes more expensive. Care needs are increasingly complex and require more interventions by a larger number of health professionals.

Our current fee-for-service may not be the best funding model for people with chronic and complex health problems, as it does not reward certain aspects of care – such as coordination.

The Federal Government is aiming for a ‘healthier’ Medicare and intends to find better ways to look after people with complex and chronic diseases, and keep people out of hospital longer. As part of this strategy the Primary Health Care Advisory Group (PHCAG) has been established to advise the government on reforming primary health care.

The PHCAG recently released a discussion paper and individuals, peak bodies and consumer organisations have responded with submissions. The advisory group’s recommendations for government are expected by the end of the year.

The future vision

The Royal Australian College of General Practitioners has, after consultation with members and external organisations, developed the ‘Vision for general practice and a sustainable health system’. If implemented, it will keep the benefits of fee-for-service for acute care, while improving care for people living with chronic and complex health problems.

The current Medicare Benefits Schedule discourages GPs from spending the time required with patients who have chronic and complex health issues. The system is based on face-to-face contact with patients – while care coordination and teamwork does not always involve the physical presence of the patient.

Consumers would like to see a healthcare model that empowers patients; they want less fragmentation and better integration and coordination of care.

To solve these issues, the RACGP made a range of recommendations in its submission to the PHCAG, based on the freshly developed vision. Essential components of the submission are voluntary patient enrolment and, in addition to the fee-for-service model, the provision of supplementary funding to support a range of patient services not currently or appropriately recognised.

Benefits of the medical home

Voluntary patient enrolment for all patients – not just for those with chronic and complex health conditions – ensures enduring relationships between patients, their personal GP and extended healthcare team, allowing for better targeted and effective coordination of clinical resources to meet patient needs.

There are four main benefits of voluntary patient enrolment:

  1. Practices will have a better understanding of their patient population and can better tailor services to the needs of their community.
  2. A stable and enduring relationship between a patient and a GP has a positive impact on health outcomes.
  3. It will benefit prevention and management of chronic diseases.
  4. Linking chronic disease management Medicare item numbers to a patient’s medical home will make sure funding for chronic disease management is directed efficiently and effectively.

Patients may choose whether or not to enrol in a medical home. Likewise, GPs and practices may choose to participate in the program.

Patients will be able to access standard consultations through any general practice, but chronic disease management, integration of care and preventive health will be limited to their medical home.

Implementing the medical home will need both initial and ongoing investment. However, any investment will result in cost savings, as efficiencies in the system are achieved.

New funding models

The introduction of support for GPs and their teams to undertake coordination work on behalf of their patients is essential and will stimulate multidisciplinary teamwork. This includes direct and efficient (electronic) communication between providers, and GPs need to be able to delegate care coordination responsibilities within a team.

A comprehensiveness payment made to a practice would recognise the practices and practitioners that offer a broad range of services to the community. The payment would be based on a defined breadth of item numbers used within a defined time.

The current incentives (PIP and SIP) need to be replaced by practitioner support and practice support payments as outlined in detail in the RACGP vision.

Reporting of de-identified patient data can be useful for the purposes of informing health system planning, but the college does not support the reporting of individual patient’s health outcomes or a pay-for-performance system. There is no evidence to suggest that reporting health outcomes improves the quality or safety of care, and there are no successful overseas models that can be adopted.

The cost of delivering quality care within the general practice setting is significant and increases annually in line with wages, consumables and infrastructure costs. It is imperative that Medicare patient rebates keep pace with the increasing costs of delivering quality care, so the freeze on Medicare rebates must be lifted.

General practice in Australia delivers efficient and cost-effective care. It is clear that health systems focusing on primary care have better health outcomes and lower use of hospitals. Now is the time to strengthen primary care – but let’s not throw the baby out.

This article was originally published in The Medical Republic.