Who is the real winner in the latest stoush between pharmacists and doctors?

Last week a state Pharmacy Guild president made a few negative comments about general practice. I thought it was neither here nor there, but what happened next was interesting.

I could not find the original column (admittedly I didn’t look very hard) so I can’t verify his exact words but apparently, he said that increased funding for GPs will only incentivise five-minute ‘turnstile’ medicine.

Most GPs would not have read or been aware of the column until, on the eighth of February, Australian Doctor Magazine, owned by the Australian Doctor Group (ADG), posted an article on their website titled “Pharmacy Guild says GPs working ‘turnstile operations’ filling time-slots with easy patients.”

Then all hell broke loose. There were 170 comments on the article from mostly angry GPs.

A few days later, on the eleventh of February, Pharmacy News published this piece: “Guild takes aim at GPs who favour wealthy, healthy patients”. 

Interestingly, Pharmacy News is also owned by ADG.

Then the response came. On the thirteenth of February a reply penned by the RACGP president was published. And you guessed it, that same day Australian Doctor posted: “Turnstile, cream-skim medicine? RACGP hits back at Pharmacy Guild.”

The ADG publications got hundreds of clicks and views of their website content out of the latest stoush between pharmacists and doctors.

Good on them, one could argue. But hang on, there’s more to it. The ADG website explains how it works:

“We know that GPs are increasingly time-poor and less reliant on [pharmaceutical] sales reps,” says Bryn McGeever, Managing Director of Australian Doctor Group. “They’re looking elsewhere for information.”

“While readership of medical print publications remains strong, digital channels are becoming increasingly popular with almost eight in 10 GPs now reading online medical publications monthly.”

“In recognition of this continuing shift in GP behaviour, Australian Doctor Group last week launched AccessPLUS, a bespoke digital sales channel designed to fill the space left behind as rep engagement continues to fall.”

And the real winner is….

It is sad, but not surprising, that the medical media are fuelling the tensions within primary care. Of course, like other media, ADG is just doing its job. I do wonder how many GPs and pharmacists are aware that they are the product on sale here.

I have had my fair share of altercations with the Pharmacy Guild – but it’s a road to nowhere. I prefer to listen to people like pharmacist Debbie Rigbie, who rightly says, “We must build bridges across our differences to pursue the common good.”

Pharmacists and doctors: Let’s change the script

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.

I’d also like to think we are able to move beyond strongly worded media releases, open letters, lobbying and political donations.

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.

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?

Is community pharmacy on a road to nowhere?

If the community pharmacy sector wants to work better with other healthcare providers, something has to change.

Health Minister Greg Hunt recently announced that the Federal Government rejected many of the proposals in the King review of the community pharmacy sector.

This means for example that pharmacies will not be required to separate alternative remedies, including homeopathic products, from evidence-based medicines.

Community pharmacy owners want to be taken seriously as healthcare providers yet, at the same time, they continue to behave like a commercial interest group.

Recent actions of the sector, such as the pro-codeine lobby, raised many eyebrows. Political donations and backdoor lobbying are still the norm in this industry.

Chemist shop model

“The Guild looks forward to continuing our close dialogue with the Government on all matters to do with the sector and community pharmacy’s role,” said Pharmacy Guild President George Tambassis in response to the announcement by Minister Hunt.

And the Guild’s David Quilty stated: “When it comes to pharmacy, the Federal Government has taken the very reasonable approach that when something works very well, why tinker unnecessarily with it?”

These responses speak for themselves.

The question is, does the chemist shop model work ‘very well’, or is it relying on lotions and potions, anti-competitive regulation and protection, lobbying and political donations to stay afloat?

In the Financial Review Stephen Duckett commented, “Once again, the power of sectoral interest groups in Australian health policy is exposed.” And, “Once again, the public interest has lost out.”

I couldn’t agree more.

I’m looking forward to the day the community pharmacy sector shakes its retail sales focus – we need more team players and collaboration.

About addictive painkillers and dirty backdoor deals

It is concerning that those who have been given responsibility to look after the health of Australians take decisions influenced by commercial interests instead of sound evidence and common sense.

As I have said before we have an opiate problem in Australia and it is the responsibility of doctors, pharmacists, consumers and governments to solve it.

One of the opiates that are harmful is codeine. Codeine is closely related to morphine and can cause dependence, addiction, poisoning and, in high doses or in combination with other drugs, death. That’s why in many countries this painkiller, like other opiates, is only available via a doctor’s prescription.

The independent Therapeutic Goods Administration (TGA) has decided to do the same in Australia after extensive consultations with stakeholders including doctors, pharmacy groups and state health departments.

From 1 February 2018, medicines containing codeine will no longer be available without prescription in pharmacies. There will still be safe and equally effective alternatives available through the pharmacy without a script.

Unfortunately some of the stakeholders are undermining this process, putting patients at risk.

Wheeling and dealing

Publicly the Pharmacy Guild of Australia states that it is not seeking to overturn the decision by the TGA. It has, in fact cashed in a large sum of money from the federal government to develop and deliver education, information and communications for community pharmacies and patients to enable a smooth transition to the upscheduling of codeine.

However, behind the scenes it seems other things are happening.

Pharmacy Guild lobby
Shortly after Pharmacy Guild representatives spoke to NSW Deputy Premier John Barilaro he called for a reversal of the TGA decision. Image: Pharmacy Guild

For example, shortly after Pharmacy Guild representatives spoke to NSW Deputy Premier John Barilaro, he made the following statement: “(…) the Nationals are calling on the Federal Government to reverse their decision in relation to the way customers can access codeine products over the counter.”

The Guild’s approach was clever: They picked a pharmacy in a town with no doctor, invited Barilaro, took a picture with him and issued a press release thanking the Deputy Premier for his support of the Guild’s ‘common sense’ proposal to allow pharmacists to continue to supply codeine, stating: “What are patients with headache, toothache or period pain meant to do in Harden when there is no doctor within a hundred kilometres for a week at a time? The AMA has no answer.”

The AMA reiterated the concerns around codeine, including that 75 per cent of recent painkiller or opioid misusers reported misusing an over the counter codeine product in the previous 12 months and that these products were even more likely to be misused by teenagers.

The AMA also expressed concern about the Guild’s lobbying of State and Territory Governments to undermine the independent TGA ruling.

The Guild immediately responded on social media saying this was ‘overblown self-serving nonsense from the AMA’.

President of the Royal Australian College of General Practitioners (RACGP) Dr Bastian Seidel reminded Guild representatives that opiate painkillers including codeine are not normally recommended for tension-type headaches.

A good explanation of some of the problems with codeine can be found in this article written by a pain specialist from Deakan University: Over the counter codeine gives as many headaches as it fixes.

Substandard rural solutions 

Sales of codeine-containing medications without script represent a revenue of $150 million per year for pharmacies.

The Guild has been busy lobbying State Health Ministers – successfully, it seems.

This weekend the Australian newspaper reported that all State Health Ministers, except for South Australia, have written to Federal Health Minister Greg Hunt “relaying unnamed stakeholder concerns about the unintended consequences of requiring a script” for codeine. NSW Health Minister Brad Hazzard was one of the signatories on the letter according to the Australian.

Here’s a screenshot of (part of) the letter to Minister Hunt in which the State Health Ministers explain why they are worried about the upscheduling of codeine:

Letter from state health ministers

If it is true that people in regional areas are indeed “managing chronic conditions with codeine medications” bought from a pharmacy than that is of course a concern as codeine should not be used for this purpose.

Pharmacy Guild lobby
Pharmacy Guild lobbies NSW Health Minister Brad Hazard about codeine. Image: Pharmacy Daily

The State Health Ministers seem to implicate in the letter that it is preferable to treat chronic conditions by self medicating with over the counter codeine purchased from pharmacies instead of going to a doctor to get appropriate treatment.

This would indicate a lower standard of care for people in rural and regional areas. The upscheduling decision by the TGA could actually help regional patients receive more appropriate treatment via a doctor and cut out-of-pocket medicine costs.

Cash for access unethical

The Australian also revealed that Queensland Health Minister Cameron Dick, who also signed the letter, failed to disclose seven cash-for-access meetings with Labor donors. One of the donors was the Pharmacy Guild of Australia.

Queensland’s Premier Ms Annastacia Palaszczuk had earlier announced she had a moral responsibility to ban certain donations.

The Guild gets high level access to politicians in all states via significant donations. Their political donations are on the rise (see graph). Concerns have been raised for a while now that the Pharmacy Guild is able to influence healthcare decisions based on commercial principles instead of sound evidence.

The Guild regularly negotiates a massive agreement with the Australian Government to the value of $19 billion for dispensing PBS medicines. This begs the question how ethical it is that the Guild, at the same time, transfers money into the bank accounts of the political parties it is negotiating with.

Pharmacy Guild donations
Political donations (Australian dollars) by the Pharmacy Guild Australia 2012-2016. Source: AEC.

The Guild’s solution is weak

The Pharmacy Guild said on their website: “When we put our solution to the politicians they think it makes sense, particularly when we explain how up-scheduling alone will mean a loss of convenience and higher costs for patients, as well as the clogging up of GP practices.”

Although the medical profession and health consumer organisations can see through this rhetoric, it appears some politicians have more difficulties and I don’t blame them – at first glance the arguments by the Guild sound convincing.

The recent Health of the Nation report showed that most Australians can see their GP when they need to and are able to get an appointment for urgent medical care within four hours. The argument of ‘clogging up GP practices’ as a reason for over the counter opiates is deceptive and it is probably not the Guild’s place to comment on this.

So let’s look at the Pharmacy Guild’s preferred solution. They believe that pharmacists should continue to sell codeine without a script for acute pain and state pharmacies would monitor misuse via their real-time monitoring software called ‘MedsASSIST’. The Guild continues to remind everyone that they are the only one with this pharmacy software package.

The problem here is first of all that medications issued without a script in a pharmacy must be substantially safe and without risk of misuse.

Clearly codeine is not safe and there is unambiguous international evidence of harm and misuse. So it makes no sense for codeine to be freely available in the pharmacy on the one hand but on the other be subject to real-time monitoring.

There are also serious problems with MedsASSIST. It is not an independent tool but owned by the Guild. Not all pharmacies use it so it is easy to get around for those who use codeine for the wrong purposes.

The Therapeutic Goods Administration has considered the evidence around MedsASSIST and found that it did not lead to a significant number of people being denied codeine medications in the pharmacy.

The TGA mentioned an example where an individual was able to receive 660 codeine tablets in one month despite their purchasing behaviour being tracked by the software. This raises questions about the efficacy and safety of the Guild’s preferred solution. Is it just smoke and mirrors?

The Guild continues to accuse others that they have done nothing to monitor the use of  drugs of dependence. This is also incorrect as many groups, including the AMA, RACGP and coroners have repeatedly asked for an effective national real-time prescription monitoring system, accessible by doctors and pharmacists.

What do consumers say?

The Consumers Health Forum has raised concerns about the Guild’s solution and said in their press release: “We do not support the proposal from the Pharmacy Guild of Australia and the Pharmaceutical Society of Australia to allow pharmacists to dispense codeine products without a prescription for people with one-off acute pain under certain conditions.”

“CHF supports the role of TGA as the regulator; we believe overall it does an excellent job of ensuring Australians have access to safety and high-quality medicines. We also note that this decision brings Australia into line with most other developed countries. As recently as July 2017 France has moved to make codeine products prescription only. The evidence for harm from codeine and other opioids is growing and their efficacy in assisting with pain management is coming under more and more scrutiny.”

Other groups also expressed concerns about the Guild’s undermining of the TGA. Pain Australia, the RACGP and the RACP have issued a joint press release. Painaustralia CEO Carol Bennett said:

“Chronic pain is a major health issue in Australia – we need to do much better than offering medications that are often both ineffective and potentially harmful in responding to chronic pain. Providing appropriate pain management should be a much higher priority, particularly in rural locations where reliance on opioids is a significant issue.”

“Painaustralia supports a co-ordinated, whole of sector strategy to address the issue of access to optimal pain management, including public and clinical education programs, linkages between rural health care clinicians via Telehealth with specialist city based services.”

And addiction specialists?

Last month, addiction specialists from the Royal Australasian College of Physicians (RACP) reaffirmed their support to make codeine-based medications available only with a prescription because of the many reports about misuse, addiction, and secondary harm.

The RACP said in a press release: “Addiction is a serious medical condition which should be avoided at all costs. (…) Addiction alters life choices, life chances and life trajectory. Addiction specialists have seen the number of patients with addiction to over the counter codeine grow at an alarming rate.”

“People with persistent pain should talk to their doctor to develop an appropriate treatment plan. This may include a referral to see a pain specialist or pain management clinic to manage their condition on an ongoing basis.”

The response from the Pharmacy Guild: “doctors are missing the point on codeine.”

Conclusion

Protection of the Pharmacy Guild’s significant commercial interests seems to drive behaviour that is not always in the interest of the health of Australians. Sadly, feedback or criticism is met with aggressive counter punches. Working with the community pharmacy sector is becoming difficult for other health groups.

It is sad to see because the Guild represents a respectable profession. It appears that the Australian healthcare system, which makes pharmacies dependent on commercial activities, is partly to blame for this situation. I am not accusing anyone of backdoor deals but this whole codeine saga is not a good look. Political donations and cash-for-access programs also seem highly inappropriate, especially in the healthcare sector. We desperately need more collaboration.

A victory for common sense (and patient care)

Yesterday Sonic Healthcare pulled out of their deal with Sigma’s AMCAL pharmacy chain to sell blood tests to pharmacy customers. I believe it was a wise decision to withdraw from this so-called ‘screening program’.

Just think about it. If it is up to AMCAL pharmacies their customers will be able to purchase for example a vitamin D blood test for $89.50 to ‘screen’ for vitamin D deficiency.

Initially the president of the Royal College of Pathologists of Australasia (RCPA) said: “They are all valid tests and they can all be done on patients without symptoms or abnormalities in those areas.”

But look at the recent Choosing Wisely recommendation by the RCPA:

Vitamin D screening

The RCPA’s position statement on the use and interpretation of vitamin D testing also clearly states: “The testing of healthy individuals will reveal a significant subgroup with low 25OH‐D (vitamin D) levels. This leads to treatment and perpetuates repeat testing without information as to whether such patients will benefit from vitamin D supplementation.”

Although I am sure that AMCAL’s ethical standards would not have allowed staff to push vitamin D pills for customers with low levels, I understand why Sonic has withdrawn from the initiative as it wasn’t exactly the best example of ‘screening’.

It looks like it was just about commercial stand-alone pathology testing without pre-agreed collaboration with doctors. There was no medical involvement or integration with other healthcare providers and the out-of-pocket costs for patients would have been high – with no Medicare rebate.

I imagine there were also some ethical dilemmas. Take the RCPA’s Code of Ethics, which contains the following principle:

To protect patients from harm. This includes commitment by each individual to the achievement and maintenance of clinical competence and professional standards; to referring issues beyond their clinical competence, scope of practice or accreditation; and, taking appropriate action when the conduct or lack of competence of others places patients at risk of harm.”

I really like the online RCPA library. For example, I found an excellent document titled ‘Making sense of testing; a guide to why scans and health tests for well people aren’t always a good idea.’ It explains why and how testing can cause harm (see image).

Why and how medical tests can cause harm
Source RCPA Library: ‘Making sense of testing; a guide to why scans and health tests for well people aren’t always a good idea.’

The RCPA Code of Ethics further urges fellows and members of the pathology college to “maintain professional integrity” and to “recognise and eliminate conflicts of interest that interfere with free and independent medical or scientific judgment.” As it happens, the President of the RCPA is also CEO of one of Sonic’s pathology companies.

I congratulate Sonic Healthcare on its decision and I’m pleased to see that a corporate giant in Australia seems to have made the decision to follow ethical principles instead of prioritising commercial interests over professional standards. Let’s see what the pharmacy sector will do next.

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).

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.

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.

What health consumers want: interview with Leanne Wells

Generating consumer-led ideas to improve the health system – that’s what the Consumer Health Forum is all about, says new CEO Leanne Wells. Health consumerism around the world is changing, and Leanne sees a potential for big reforms in Australia. I asked her about a range of topics, including the Medicare rebate freeze, the RACGP draft vision for a sustainable health system, funding and the role of pharmacists.

“It is a terrific honour and challenge to be leading this organisation at a time of significant developments in the role of health consumerism globally,” she says. “I believe in a strong patient-clinician alliance.”

“Consumer leadership is as important as clinical leadership in developing modern health systems that reflect the importance of patient-centred care. We can achieve this by working together to influence policy settings, design and operation of health care.”

Consumer-led ideas

What health consumers want: intervie with Leanne Wells
Leanne Wells: “Integration has to be the name of the game given modern health care is about managing multi-morbidity and complexity.”

“Our members include a diverse range of consumer organisations as well as professional associations, researchers and individuals with an interest in health consumer affairs. Through our membership network, we reach millions of Australian consumers.”

“CHF is all about generating consumer-led ideas for a better health system. It is the pre-eminent national organisation advocating on behalf of health consumers on policy issues pertaining to Medicare, PBS and population health and on issues such as health system development, access to best available consumer-centred care and access to medications.

“CHF’s work has included research and national campaigns on rising out-of-pocket health costs and prescription medicine costs. We deal frequently with questions from media on issues such as health insurance and quality and safety in health care.”

“There is potential for significant changes in Australia’s health system, particularly in Commonwealth-financed areas such as Medicare, primary health care and mental health, at a time when there are moves to put focus on reforms to Commonwealth-State health funding issues. In all of these areas, consumer-generated ideas for a better system will be crucial to success.”

Medicare rebate freeze

“CHF has supported the RACGP and others in the campaign against the rebate freeze. Nothing should compromise good quality, comprehensive, co-ordinated patient care. I support the concept of the patient-centred healthcare home.”

“Some consumers have capacity to pay a co-payment and will do so if they feel they get value. Others simply won’t go to the doctor if they are not bulk billed – and often those who don’t go to the doctor due to cost barriers are those from lower socioeconomic circumstances which we know are associated with higher rates of complex, chronic conditions: the very conditions that need ongoing, co-ordinated care. The issue highlights the need for the MBS review and a rethink of the way we finance primary care. Both are long overdue.”

“General practices need the flexibility to be truly responsive to their patient populations

“CHF seeks funding that is determined by the right models of care, not the other way around. At the moment we’ve got a system that is largely based on fee-for-service financing to drive and, at times, limit models of care.”

“General practices need the flexibility to be truly responsive to their patient populations. The expansion of health insurance to primary practice, may offer benefits in terms of better integrated care for some. The overall impact however is likely to be negative, setting up a two-tiered health system at the primary care level where insured patients would be likely to get preferential treatment.”

“The RACGP’s draft consultation paper ‘Vision for a sustainable health system’ makes the case for an alternative blended payment model offering flexibility and autonomy to respond better to contemporary care needs. The paper would be stronger if it articulated a vision for general practice emphasising how that could be done.”

“The paper lacked consideration of aspects of integrated care and placed ‘general practice’ rather than ‘the patient’ at the centre of the health system. We would have liked the paper to place greater emphasis on the patient as partner and on the consumer benefits of team-based care as well as the other non-financial levers that can work in concert to bring about change and innovation in general practice.”

Consumers as partners

“A big challenge is for health care to be much more consumer-centred. That works best when there’s a team of professionals looking after the consumer, when there’s an open flow of information and discussion between them about the patient’s needs and how to meet them together rather than separately.”

“We want to see a patient-centred approach to providing care – not disease-centred or system-centred

“Above all else patients want professionals who see them as more than just the ‘vessel’ of a disease to be cured, or a problem to be solved. Patients want to be recognised for who they are: unique individuals with their own unique lives. We want to see a health workforce which takes a patient-centred approach to providing care – not disease-centred, not system-centred, but patient-centred.”

“The National Safety and Quality Health Service Standards have consumers as partners in care as its second standard – solid recognition that this value must become inherent to the culture and operation of health services. Primary Health Networks have a pivotal role in bringing this about.”

“Having worked with divisions of general practice and Medicare Locals since the 2000s, I remain a strong proponent of the place ‘meso’ structures like these have in the system. The Primary Health Networks have great promise as disruptive innovators in our system.”

“With their distinct boundaries, alignment with hospital networks, relationship with general practice and the knowledge they will grow about their local communities, they are well placed to work with patients and clinicians to lead service and system development and innovation.”

“But they can only do this if they have mandate, the support and participation of patients and clinicians and the financial flexibility to invest in new approaches and new models of care.”

Dysfunctional state-federal funding

“The CHF supports a single level of government taking responsibility for leadership in health policy. We are diverse country with distinct regional communities. I believe moving to a single level of government, with regional purchasers administering pooled funding, is a concept worth exploring further.”

“The only way we are going to integrate the system is by having policy set nationally, and service commissioning undertaken regionally by single entities. Integration has to be the name of the game given modern health care is about managing multi-morbidity and complexity. Removing the dysfunctional nature of state-federal funding would surely be an improvement on what we have now.”

Devaluation of general practice

“Patients need to be seen as partners in care – assets not deficits. I agree that general practice and its place in the health system has become devalued over time. It is a very efficient and effective setting in which to deliver care close to where consumers live and work.”

“I applaud the RACGP’s efforts to get general practice better recognised and valued

“I applaud the RACGP’s efforts to get general practice better recognised and valued. However, in the campaign video, the doctor is represented as the sage authority while the patients are represented as passive recipients of the doctor’s view of them and their lives.”

“The characterisation was at odds with all the evidence showing that approaches which encourage patient-centred and patient-engaged care produce better outcomes. This aspect of the doctor-patient relationship could have been better reflected.”

Pharmacists and General Practice

“CHF supports a stronger role for pharmacists in general practice in areas such as medication support. It would be in the patient’s interest for general practice to have non-dispensing pharmacists as part of the team available to advise on quality use of medicines, hopefully freeing up GPs to focus on time-consuming, complex cases requiring medical expertise.”

“Expanding the scope for dispensing pharmacists to provide medical advice in pharmacies would also be supported by CHF provided the role was strictly within the pharmacist’s qualifications, was coordinated with the patient’s GP or local GP and where necessary, the services performed in a private area. Both options are good ways to make better use of an existing valued workforce.”

Patients or consumers?

“There is a continuing debate on the patient-consumer dichotomy. We prefer the use of the word ‘consumer’ when talking in terms of the health system generally. In that context we think the word consumer more accurately expresses the non-dependent status of a citizen and customer of health services and products.”

“The word ‘patient’ is appropriate when referring to an individual under treatment of a clinician where the patient’s outcome is directly dependent on the clinician.”

Can pharmacists and doctors work together? YES WE CAN!

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.

The evidence

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.

The benefits

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 may be no change at all.

Don’t go to your doctor, the minister wants you to see the pharmacist instead

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.

Questions

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).

What do you think, is this good policy or not?

The looming war between pharmacists and doctors

The looming war between pharmacists and doctors
Image: Pixabay.com
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.

Follow me on Twitter: @EdwinKruys

5 reasons why task substitution by pharmacists needs more thought

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.

Not what the doctor said

Not what the doctor said
Image: Pixabay.com

In 1976 two researchers, James Pennebaker and Deborah Sanders, published and interesting study. They placed two kinds of signs in university toilets, one reading: “Do not write on these walls under any circumstances,” and the other: “Please don’t write on these walls.” Result: the amount of graffiti on the walls with the first, more authoritative sign was significantly more.

This phenomenon is called reactance: when something or someone threatens to restrict our freedom, our intuitive response is to undo this – even if our response may have negative consequences.

Reactance can occur on a massive scale as, for example, in the case of Japanese whaling. The consumption of whale meat in Japan is decreasing – it is considered traditional food and younger generations are not interested in it. Yet, Japanese people respond furiously to the actions of the Sea Shepherd activists against their whaling fleet. Travel writer Sam Vincent, who wrote a book about this topic, concludes: “Japan isn’t pro-whaling. It’s anti-anti-whaling.”

AMA response to the ‘skin spot check’

This week a new pharmacy initiative was in the news: ‘Skin spot checks’. For $35 people can have a single skin lesion of their choice examined at certain pharmacies. The response from the Australian Medical Association was as expected. Dermatologist and president of the NSW branch of the AMA said: “It is irresponsible and inappropriate for pharmacies to offer in-store skin checks.”

Although the AMA has a point, the response can be: “If the AMA doesn’t agree, it should be approved.” Reactance in action! This may be followed by: “The AMA is probably protecting their members’ interests, so let’s give these entrepreneurial chemists a fair-go!”

If the AMA had said: “Look, doctors are busy and fed up with all these people worried about their freckles, so please go away and visit the pharmacy,” the response would probably be the opposite. I’m not arguing that they should have said this, but the point is that most doctors care about their patients’ wellbeing and this is unfortunately not always taken into account in the media and comments.

The following scenario happens often in my practice: a patient asks my opinion about a pigmented but benign skin lesion, and is not aware of the (more common) non-pigmented malignant or pre-malignant lesion elsewhere on the skin. These spots will likely be missed at the ‘skin spot check’ in the chemist store.