This week saw another low point in the communication and relationships between health groups in Australia. We must find a better way.
It began after the release of a report from the Queensland parliamentary inquiry into pharmacy, which recommends that pharmacists should be able to prescribe and dispense ‘low-risk emergency and repeat prescriptions’ and ‘low risk vaccinations’, subject to consultation with a ‘13HEALTH GP’ or checking ‘the patient’s medical record’ through MyHealthRecord.
Medical groups including the AMA and RACGP indicated they will not support the recommendations. This is hardly surprising as the results of the deliberations by the parliamentary committee led by Chair Aaron Harper MP are not based on mutually agreed principles or a collaborative care model.
Although the report repeatedly mentions a shared prescribing model, the recommendations, if implemented, will not result in effective collaboration. For example, checking the MyHealthRecord (which is not always available or complete) or calling a health-line can hardly be seen as supporting team care and collaboration with treating doctors. Cooperation between pharmacists and medical teams should be more than a box ticking exercise.
I believe we can do better than this.
Community pharmacists feel that their scope of practice is restricted and that they can contribute in a more meaningful way to patient care. Medical groups are concerned that more prescribers can lead to fragmentation of care and poor health outcomes, especially in the absence of meaningful collaboration.
Both arguments are valid and should be explored further. There is always a better way but this requires a willingness to work together and find mutually agreed solutions. Indeed, not an easy task, but we can’t leave this to a group of parliamentarians.
On a positive note, it was good to see that the Pharmaceutical Society of Australia (PSA) recently organised a low-key summit between medical and pharmacy groups to discuss patient safety. PSA president Shane Jackson said that the summit will seek to develop a set of principles to support respectful and collaborative practice between pharmacists and doctors.
Reaffirming these principles is a useful exercise and a good place to start. My colleague Dr Ashlea Broomfield and I spoke with Shane Jackson about collaborative models of care (listen to the BridgeBuilders podcast here). Although doctors and pharmacists may never agree on everything, which is absolutely fine, we must find a better way forward in the interest of our patients.
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.
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.
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 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:
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.
As frequent readers of this blog may know, I am very unimpressed with the recent pharmacy agreement negotiated by the Pharmacy Guild of Australia. We need more teamwork and integration of health services, not fragmentation, and therefore it’s a real shame the Health Minister has signed off on this deal with the pharmacy owners union.
A better proposal has come from the Pharmaceutical Society of Australia (PSA) and the Australian Medical Association. For those who don’t know: The PSA represents Australia’s 28,000 pharmacists working in all sectors and across all locations. The new model encourages close collaboration between pharmacists and GPs.
The PSA and AMA recommend integration of non-dispensing pharmacists in general practice, to improve medication management. The idea is not new. Doctors and pharmacists have argued for this model in the past. There is enough evidence to support collaboration as a way to improve patient care.
Here are the aims of the cooperative model:
Medication management reviews conducted in the practice, an Aboriginal Health Service, the home or a Residential Aged Care Facility
Patient medication advice to facilitate increased medication compliance and medication optimisation
Supporting GP prescribing
Liaising with outreach services and hospitals when patients with complex medication regimes are discharged from hospital
Updating GPs on new drugs
Quality or medication safety audits
Developing and managing drug safety monitoring systems.
Medication reviews by a pharmacists in the hospital do not appear to reduce mortality or hospital readmissions, although they seem to reduce emergency department contacts. Similarly, medication reviews for nursing home residents do not to reduce mortality or hospitalisation – which is disappointing.
However, in these studies pharmacists and doctors are not working closely together as suggested by the PSA and AMA. This matters because studies have shown that doctors are more likely to change their medication management when there is a close collaboration with a pharmacist. This is not surprising as the basic requirements for effective teams are mutual trust, good communication and shared ideas.
A systematic review of pharmacists working in collaboration with GPs showed significant improvements in blood pressure, diabetes control, cholesterol levels and cardiovascular risk. Another review suggested similar benefits as well as a positive impact on drug-related problems.
A recent trial confirmed that pharmacists working in primary health clinics are succesful in identifying and resolving medication related problems and improving medication adherance. The PINCER trial concluded that pharmacist feedback, educational outreach and dedicated support in a general practice setting was cost-effective and reduced medication errors.
Whether the pharmacist-doctor partnership reduces hospital admissions is less clear-cut. An independent analysis by Deloitte Access Economics (commissioned by the AMA) suggests that every $1 invested in the PSA-AMA model would generate $1.56 in savings to the health system, delivering a net saving of $544.8 million over four years.
I spoke to Dr Steve Wilson, Chairman of the AMA (WA) Council of General Practice and senior Lecturer at the School of Medicine, University of Notre Dame.
“We recognised the need for, and the advantage of, having pharmacists within the practice team,” says Wilson. “We have looked at both sides of the coin, the good and the bad, advantages and risks. We have explored the various financial models, for example whether pharmacists should be employed directly, or contracted, and whether to follow the Practice Nurse incentive Payment model or the Mental Health Nurse model.”
Dr Wilson said the strengths of the proposal are:
Quality use of medications as over-arching principle
In-house reviews as opposed to out-of-house
Medication interaction checking
Reviewing the currency of medications, for example deleting old antibiotics still on the list
Screening for adverse medication events or omissions such as whether medications can be reduced or stopped, or whether certain checks have been performed
Checking currency of tests, for example renal function for those on diuretics
Explaining medications to people, for example what side effects to look for
Working with those from culturally and linguistically diverse people or a non-English speaking background, people more than five medications, people with early cognitive impairment etc
Quality Use of Medications meetings within the practice, attracting CPD points
The Pharmacist in General Practice Incentive (PIGPI) system would be structured in the same way as the existing incentive payments provided for nurses working in general practice.
Dr Wilson: “The risk of the program is low, it’s voluntary, doctors and patients don’t have to participate. It’s up to the GP practice to make it work and customise it to their circumstances. There are financial incentives for rural practices. Also practices can share a pharmacist, particularly when closely located to one another.”
“The evidence will build over time. The evaluation component will require input from hospitals and there may be a role for the Primary Health Networks and Local Hospital Networks.”
The proposal has been welcomed by the Consumers Health Forum (they’re requesting feedback here). Although there are clear benefits for patients, evidence-based medicine purists may argue that the evidence for cost-savings through a cooperative model is thin. However, the alternative is that we’re left with the non-cooperative model from the Pharmacy Guild – or no change at all.
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 are some of the questions I have:
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 all community pharmacies happily advise customers to buy their 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.
Sounds great doesn’t it? At first glance this improves access to health services and saves tax payers bucket loads of health dollars. This can’t go wrong!
Maybe not. Here are 5 reasons why role and task substitution by pharmacists will fail:
#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 fail.
It will worsen health outcomes at drive up costs. Is that really what we want?
#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. Take the nurse-practitioner clinics trial in the ACT. They created duplication and resulted in more emergency department presentations. The clinics were also more expensive than a GP service.
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.
One GP said about role substitution by pharmacists:
“If this was a good way to practice a profession, we could all just buy a book on law and represent ourselves in court, organise our own house sales and never need a tradie either. But we all know that there is more to a ‘job’ than it appears.
#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.
Playing doctor may be good for the pharmacist and possibly for the health budget in the short-term, but not for the health of Australians. It will hinder GPs in the effective delivery of care and will eventually increase costs.
There is value in team work, but only if we work together.