Getting into practice


doctor holding up a bottle of pills

Does the AMA’s support for pharmacists working in general practice represent a policy shift for the doctor’s organisation, or is something else at play? asks Anthony Tassone 

A recent article I wrote for the AJP on the Rural Health Workforce Strategy budget announcement possibly worsening pharmacist shortages for rural community pharmacies, saw a suggestion I have a history lesson on the Guild’s part in the pharmacist workforce. 

This announcement involving the inclusion of non-dispensing pharmacists as allied health professionals that general practice could receive public funds to employ, was welcomed by the Australian Medical Association (AMA) and the Pharmaceutical Society of Australia (PSA) as having been a result of ‘direct advocacy’ by them.

Much can be learned from the past, especially from our peak medical bodies and their views on pharmacy and their views of the roles that pharmacists ought to stick to in their practice.

Australia’s doctor organisations like the AMA clearly will oppose the expansion of other health professionals’ roles – particularly pharmacists’ – in the name of ‘patient care’.

An AMA media release (18/10/2016), Bigger Risk, no reward, in expanding pharmacist’s scope opens with: “The AMA is often accused of engaging in a ‘turf war’ when it warns against pharmacists and other healthcare practitioners expanding their scopes of practice – for example, into prescribing.” And concludes with: “In the meantime, the AMA will continue to defend against profit-driven and unevaluated expanded scopes of practice.”

The legacy of the AMA’s hostility towards pharmacy makes the joint advocacy of the AMA and the PSA for government funding to support employing non-dispensing pharmacists under the recently announced $86 million rural health workforce strategy very interesting. 

So, after years of persecuting pharmacists and community pharmacies, have doctor organisations like the AMA experienced a miraculous conversion on the Road to Damascus as a result of this joint ‘direct advocacy’ with the PSA?

As former AMA President Professor Brian Owler put it at a National Press Club address following the signing of the 5th Community Pharmacy Agreement, the AMA’s initial proposal with the PSA in creating a role for non-dispensing pharmacists in general practice was supporting “pharmacists to be pharmacists.” 

He also went on to say; “The problems that we have with the latest CPA is really in relation to the roles of pharmacists and what they might be paid to do in the future…. And so, the only problem that we have in terms of the pharmacists is when we start talking about them taking a much more active role in doing some of the roles where it is really the GP’s role.”

Integrating pharmacists into general practice provides an opportunity to enhance collaboration between general practice and community pharmacy, and an opportunity to expand the scope of practice for pharmacists to better support people with chronic health conditions where there are GP shortages.

The Guild strongly believes the best way to integrate a pharmacist into general practice is through advancing pharmacists’ scope of practice to work as ‘Pharmacist Prescribers’, delivering high-quality patient care in collaboration with medical practitioners who have overall responsibility for diagnosis.

Overseas experience shows the greatest cost benefit and efficiencies involve the practice-pharmacist having prescribing rights.  But what will the Australian model be if the AMA has repeatedly categorically rejected pharmacist prescribing? Of course, pharmacists prescribing could potentially reduce the number of MBS claims made by doctors.  

There is no argument pharmacists can and should do more in the health system and the optimal model must fulfil three critical criteria:

  • Fully utilise the clinical skills of pharmacists including expansion of scope to help deliver the best patient care possible
  • Deliver maximum benefit to the pharmacist profession
  • Be commercially sustainable, including for community pharmacy which employs some two-thirds of registered pharmacists.   

Unfortunately, the ‘pharmacist in GP practice’ model being pursued is unclear.  Will practice pharmacists be allowed to prescribe if this becomes part of the pharmacist’s scope of practice? It seems that if the AMA has anything to do with it, they won’t ever be able to. 

National President of the PSA Shane Jackson recently told the AJP: “In my view, pharmacist prescribing is imminent. There’s no reason we can’t have pharmacists prescribing.”

“Most likely the first step would be collaborative prescribing, so in partnership with medical practitioners and within hospital institutions and others, by 2020. So, prescribing by 2020 is absolutely achievable.” And that it was a “travesty” that pharmacists weren’t already able to prescribe.

I couldn’t agree more, Shane.

But can this become a reality in partnership with the AMA? 

Will pharmacists be confined to ‘being pharmacists’ as the AMA hierarchy decrees whilst general practice collects government grants to employ allied health professionals on staff (to undertake the roles that doctors want them to)?

Has this been part of the discussions to during the joint and ‘direct advocacy’ between the PSA and AMA?

The current debate raises the issue of unintended adverse impacts on the broader community pharmacy sector.

First, providing government subsidies to pharmacists in a particular practice setting distorts the market with potentially serious flow-on consequences.  There is concern that including non-dispensing pharmacists in the GP program will make it harder for local pharmacies, already struggling with workforce shortages, to attract and retain pharmacists.

Some advocates for the scheme ask, “if rural pharmacies want to retain pharmacies, why don’t they offer more attractive remuneration?” This of course has been attempted repeatedly to the best of their capacity and ability.  A counter argument could be if a general practice wants a non-dispensing pharmacist, why does it need up to $125K a year in government funds to do so?

Other advocates for this model have pointed to community pharmacy having opportunities to retain staff through existing schemes, such as the Intern Incentive Allowance for Rural Pharmacy (IIARP) where eligible pharmacists can receive up to $10K plus GST in a given year.

Eligible pharmacies must be in a PhARIA 2-6 classified area, and there are widespread concerns of the current approach to PhARIA classification.  In any case, these are dwarfed by the GP rural health workforce grants. 

Second, pharmacists in GP practices replicating the work of community pharmacists can muddy a business case for employing additional community pharmacists.  It could fragment patient care by separating medicine supply from medicine-related support, while adding complexity for patients, pharmacists and doctors.

Advocates for the new government funding question the difference in a general practice employing a pharmacist compared to other allied health professionals such as nurses, dieticians or occupational therapists.  Quite simply, it is accessibility.  Community pharmacy provide the infrastructure of the most visited primary healthcare destination that is most accessible to the public at large.  

It would be hard to find a rural town that has a general practice but no community pharmacy.  It is quite often the reverse, thanks largely to pharmacy location rules, and that is why supporting the rural pharmacist workforce to community pharmacy is critical.

The Pharmacy Guild has never said pharmacists shouldn’t work in GP practices.  What we have consistently said is we need to get the model right for pharmacists and for patients. 

The model should be truly collaborative, building on relationships between GPs and community pharmacies.  It should not replicate the role of community pharmacists but build upon it. It should allow pharmacists to practise to their full professional scope, including prescribing when possible. 

It should involve community pharmacists outreaching into GP practices in a coordinated way, with targeted incentives that build the business case for employing and rewarding pharmacists who add genuine value for patients and the broader health system.  

And it should be developed by pharmacists for pharmacists and the patients we help care for, not by doctors for the benefit of doctors.

Anthony Tassone is the president of the Pharmacy Guild of Australia (Victoria)

 

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13 Comments

  1. Greg Kyle
    25/05/2018

    Anthony – you misunderstood my comment about the history – it wasn’t aimed at the guild, but to educate the younger pharmacists about the guild’s history of flip-flopping in workforce issues to suit their political purposes. I expect the guild to know what they have done … getting acknowledgement of it may be a different story…

    You make an excellent argument in this dissertation for a pharmacist practitioner role to be remunerated through Medicare or another funding model. That would keep you happy (no large sums of money going to GPs to employ pharmacists) and me – the push for long-awaited practitioners remunerated outside an employment model. I suspect many pharmacists would be ecstatic at this outcome also!

    However, I must take issue with your second dot point when you describe your criteria for optimal pharmacist utilisation in the health system – you say the benefactor should be “to the pharmacist profession”, whereas I believe this should be “Deliver maximum benefit to the patient”. ANy statements like this where the profession is just building itself up are merely self-serving and will play into the AMA political game convincing politicians and the public that pharmacists are just in it for themselves.

    • Anthony Tassone
      25/05/2018

      Greg, with regards to your concern about my second dot point, I had thought I had addressed the importance of patient benefit, through delivery of their care in the first dot point;

      “Fully utilise the clinical skills of pharmacists including expansion of scope to help deliver the best patient care possible”

      Kind Regards
      Anthony Tassone
      President, Pharmacy Guild of Australia (Victoria Branch)

  2. Kevin Hayward
    25/05/2018

    I have worked as a Practice Support Pharmacist in primary care for nearly two decades, oddly, only once when working as a prison health service manager in a remote facility have I wished for prescribing rights. I am not certain that prescribing is as big an issue as is made out.
    If pharmacist prescribing is to occur it should be done collaboratively with safeguards, as in the UK, using appropriately trained Pharmacists working with GPs under a structured patient group directive PGDs, or again, working with GPs as appropriately trained dependent prescribers. The physical location of the Pharmacists will influence the degree of collaboration, PGDs seem to support the needs of Pharmacists based in community pharmacy, whilst specialist primary or secondary care Pharmacist led clinics may prefer prescribing rights.
    I believe that the one size fits all approach to commissioning these services is inappropriate, localities should be allowed to select a model appropriate to the patient needs and the workforce capacity of the locality.

    • Owen Patrick Mellon
      30/05/2018

      To the people who question the role of pharmacists within a General Practice it has been utilised very successfully on multiple levels in the UK for over 20 years.
      Yes, we can debate or discuss who pays what however one key element remains a critical factor – the patient must remain at the centre of such a model.
      Having previous involvement in both private and public Clinics- there really are so many avenues open – Primary Care Groups, Deprescribing (has this become a lost art?) Pharmaceconomics, Teaching, the list is really endless..

  3. Debbie Rigby
    26/05/2018

    It has been said many many times by pharmacists who are actually working in a general practice, that the role is complementary to community pharmacists, increases collaboration, and creates opportunities for community pharmacy funded and fee-for-service programs and services. Why continue with dialogue about internal turf wars? Advancing one sector of the profession does not diminish the value of work done by other sectors.

    The focus should be on what pharmacists can contribute to patient care and better medication management. Regardless of place of work.

    I do not believe that pharmacist prescribing is a critical role for practice pharmacists – more a “nice to have”, and even then it will be collaborative prescribing.

    It’s time to listen to those who have the experience (practice pharmacists, GPs and community pharmacists working with practice pharmacists), rather than publish articles based on opinion.

    • Kevin Hayward
      26/05/2018

      Thanks Debbie,. Practice Support Pharmacy for me has been primarily about working collaboratively with my GP and Pharmacist colleagues to improve patient care.
      When faced with the threat of an unknown paradigm, such as practice Pharmacists, a negative response is to be anticiapated.
      Making this more complicated is that it is hard to explain this uknown Pharmacist role to those who have no experience of it.
      Every practice I have worked with has had a different role for me, ranging from cost savings, quality prescribing, improving pharmacy services, public health, teaching etc etc, so making an an informed generalised comment about Practice Support Pharmacy is not really a rational or plausible option.

    • Jarrod McMaugh
      26/05/2018

      Can we just address this paragraph for a second:

      “It’s time to listen to those who have the experience (practice pharmacists, GPs and community pharmacists working with practice pharmacists), rather than publish articles based on opinion.”

      So it’s important to listen to the opinion of those people who will directly benefit from the new funding, but not to the opinion of the person who has been elected to represent the views and opinions of pharmacy owners for an entire state?

      I may not agree with some of the points that people make (including some in this article), but I don’t think it is ever appropriate to say that people’s opinions are invalid. That’s pretty much censorship.

    • Willy the chemist
      27/05/2018

      Pharmacist prescribing is not a “nice to have”. According to Dr Shane Jackson PSA, “ In my view, pharmacist prescribing is imminent. There’s no reason we can’t have pharmacists prescribing,”
      He goes on to say it’s a travesty.

      I speak from experience as I have 3 multiple disciplinary clinics attached to our pharmacies. We have great working relationships with 2 of the practices and the other one, good working relationship.

      The AMA and doctor groups primary motivation for non-prescribing pharmacists in general practice is more government funding. More money. Period.
      Over the years, the AMA and more recently RACGP denigrate themselves by taking cheap shots at pharmacy. There is barely any collegial collaborations between pharmacy and peak doctor groups….but not from pharmacy lack of trying. Have you seen any pharmacy meddling into doctors’ affairs generally?
      So to my pharmacy colleagues who think it’s their wishes come true, I’d say grow up.
      More collaboration is ideal. Do it independently of general practice funding model….unless you rather secretly enjoy the constant AMA snub!

      • Kevin Hayward
        27/05/2018

        Snub? I started working as Practice Support Pharmacist in the general medical practice system, as you describe it over 20yrs ago when I sold my pharmacy. I used my skills as a clinician, educator, a researcher and pharmacist, coupled with my business skills to the benefit of our patients, and without pretending to be a mini GP or a prescriber. My GPs were only to keen to set a challenge, stretch my intellect and ability, but I never lacked their professional support and encouragement. In all that time I have never been the subject of any form of snub from any member of the health community or heirachy.

        • Willy the chemist
          27/05/2018

          I think you mistook my comment.
          GPs are generally very happy for our increased interactions.
          How can any pharmacist be unaware of the constant denigrations and humiliation by the peak doctor groups?
          The funding model the peak doctor groups put forth isn’t really about pushing the practice model of pharmacists but to increase their “share” of the health dollars. This isn’t about the patient but about money.

          • Kevin Hayward
            27/05/2018

            Thanks, with you now

      • Debbie Rigby
        28/05/2018

        My point was that pharmacist prescribing is not an essential role for practice pharmacists working in a GP surgery. There are plenty of valuable roles existing now, both patient-focused and system focus

        • Wilson Tan
          28/05/2018

          In my opinion, pharmacist prescribing is a natural extension of our role, and in any case we already “prescribe” medicines and advice.
          Pharmacist prescribing can deliver same outcomes whilst reducing the burden on medicare, alleviate doctors shortages and reduce long waiting times.
          This is an extension of pharmacy, we do not have to feel apologetic to want to own a small part of this. Whether a practice pharmacist end up prescribing “on a pad” everyday or rarely is not the reason to call it “nice to have”.
          If AMA and RACGP are honest, they should support increasing pharmacist integration and scope that are well within our training.

          Ultimately it is about the money for the AMA and RACGP. They want the $100K money to employ a practice pharmacist…. there is a parallel here, money that was earmarked for pharmacist to perform medication review being paid directly to the nursing home operators and therefore the pharmacist do not get reimburse directly for the work. This was money allocated to pharmacy to perform work to improve patient outcomes.
          We don’t want that again.

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