A GP’s call for collaboration with pharmacists is welcome, but must mutual respect is vital, writes Anthony Tassone

The call by RACGP stalwart and former Vice President, Dr. Edwin Kruys for greater collaboration between doctors and pharmacists comes at an opportune time and reflects the position advocated by the pharmacy profession for many years.

It also comes during a month when his own organisation has lashed out – yet again – in unprovoked attacks at pharmacy over the provision of patient centred health services such as health checks; services which are aimed at helping consumers and improving their health and wellbeing.

Dr Kruys made the comment at the end of National Diabetes Week during which the need for such collaboration was underscored by the revelation that undiagnosed diabetes in the community is affecting some 550,000 people and is costing the country more than $700 million a year

Also, during the week, the Daily Telegraph newspaper reported: “Half of the 1.2 million Australians with Type 2 diabetes are suffering major complications including blindness, kidney disease and limb amputations because of poor treatment by GPs. Diabetes is the most common reason for people to reach end stage renal disease or need a kidney transplant, it is the most common cause of blindness and limb amputations not brought on by a severe trauma. It is responsible for one in 10 deaths.”

Pharmacists, working with doctors, can and do make a difference which is known to the GPs who work closely with pharmacists at the grassroots every day delivering patient care.

With diabetes screening a growing service provided by pharmacies, there is huge potential for our profession to make an even greater contribution in helping to detect this disease early. Already the Pharmacy Guild is building on pharmacy services in the diabetes area with the 6th Community Pharmacy Agreement Pharmacy Trial Program’s dedicated diabetes trail which recently concluded with a published report of findings expected later this year.

Working closely with GPs will further enhance the role pharmacists can play in diabetes and across many other health chronic health conditions and the great beneficiaries will be patients – as they should be in true patient-centred care.

This view of the need for doctors and pharmacists to work together in the primary health sphere has finally been publicly iterated by our profession’s long-term and very vocal critic, Dr Kruys.

What has prompted this belated revelation following all of the barbs remains unclear but suffice to say comments by Dr Kruys that “the relationship between pharmacists and doctors remains sour at the expense of patient care” reflect pharmacists’ concerns that the RACGP’s default position of attack-pharmacists-at-all-costs can only be detrimental to the health outcomes of patients.

Dr Kruys points to pharmacist prescribing as an area which is likely to increase tensions between doctors and pharmacists but says that in the current debate there is no “joint strategy or a solution that would benefit both parties as well as our patients”.

His words as reported in the AJP are enlightening.

“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,” he writes.

“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.”

He concludes by asking the obvious question: “Who’s going to take the first step?”

One could argue that pharmacists and GPs at the coal-face and grassroots have long ago taken that step in collaborating for patient care. 

However, if we’re talking about peak professional organisations then one must question whether his own organisation, the RACGP is willing, despite pharmacy’s openness for collaboration.

As I mentioned, pharmacy’s health checks came under attack earlier this month from a senior figure amongst the RACGP, who was quoted in mainstream media as saying that with these health checks, pharmacies were “making health a commodity and further fragmenting Australia’s healthcare system…. These pharmacies are motivated by money, the opportunity to have more people in the store to buy other things.”

Interestingly later that week, the current president of RACGP, Dr Bastian Siedel, said it was “common” for longer appointments, and appointments for children or people with mental health conditions, to be refused at bulk-billing clinics for financial reasons.

“They are saying, ‘it’s 10 minutes and the patient goes out’. And people are being told ‘if you have a mental health condition you probably have to go elsewhere’,” he was quoted as saying.

This contradiction in approach by the RACGP was underscored by the Pharmacy Guild which pointed out: “Just three days ago the RACGP was criticising health checks provided by pharmacies because they were “motivated by money” – yet today the RACGP admits its members are turning away the sickest and neediest patients because they don’t make enough money out of them.”

The contradiction could also be indicative of the lack of commitment by the RACGP to knuckling down and getting serious about collaboration.

A divided and clearly at-odds-with-one-another RACGP leadership is either unable or unwilling to stop trying to appease its fractious membership through continual attacks on pharmacy. Perhaps publicly advocating for such a collaborative stance could be detrimental to maintenance of an RACGP leadership role and this is perhaps why Dr Kruys was somewhat silent on his views regarding collaboration when he held an executive role in the organisation. Now that he is immediate past RACGP Vice President and RACGP Queensland Chair the shackles may be off and he feels free to speak out.

Whatever the reason, it is a very positive development and one which the pharmacy profession and GPs must not let wither on the vine.

It has been said many times before, but I repeat that the Guild welcomes the opportunity to work with other stakeholders to help ensure there is affordable and accessible primary healthcare for the Australian public. 

However, to be productive, these discussions need to be based on the premise of mutual respect for each other’s roles in the healthcare system and with patient care. Unfortunately, in recent times the RACGP hasn’t demonstrated that – but the Guild will always hold open the door to work together in what’s best for patients. 

Saying you want to collaborate with a group of your health professional colleagues one minute, but then blindsiding them through attacks in the media the next does not foster trust and a positive relationship.

A good example of just how we could potentially achieve such collaboration in a form of pharmacist prescribing is being triaed in the Victorian chronic disease management pilot which is currently underway.

This pilot specifically looks at how pharmacies can work with an appointed general practice that they have a close relationship with so that the pharmacist can assist with chronic disease management in a GP-led plan that can include dose titration of prescription medicines within a defined range set by the treating GP for chronic conditions such as; hypertension, hypercholesterolemia, asthma and in use of anti-coagulants.

The Victorian Government and Department of Health have convened an expert advisory group made up of stakeholders that include representatives from peak medical and pharmacy organisations. 

Basically, GPs are directing care in collaboration with pharmacists to help Victorians manage their chronic disease and medication more effectively. Consumers with chronic disease will have their condition closely monitored by their pharmacist, who regularly consults with their GP about progress and care. The RACGP had been invited to provide input for the pilot and I see this as a casebook example of the opportunity for collaboration, if the RACGP were to take the full opportunity, of potentially working at its best with the patients the winners.

There is also the currently underway Inquiry into the establishment of a pharmacy council and pharmacy ownership in Queensland from the Queensland government, which as part of its terms of reference will consider; “the possible role and scope of responsibility of…  pharmacists’ and pharmacy assistants’ roles and scope of practice.

So, to return to Dr Kruys’ question of who takes the first step?

From a peak professional organisation perspective, ideally let’s take the step together and do so with mutual respect and with a clear vision of patient benefit.  The call for ‘time to leave the Machiavellian era of Australian healthcare behind’ must surely mean that peak medical representative associations like the RACGP put an end to dial-a-quote, megaphone through the media forms of diplomacy with their health professional colleagues.

The Guild has always had the door open, so let’s not let this opportunity go to waste.

Anthony Tassone is the Victorian branch president and acting national president of the Pharmacy Guild of Australia.

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