Lists for GPs of specialised pharmacies could set some worrying precedents, writes Jarrod McMaugh
The relationship between a patient, their doctor, and their pharmacist is a complex system made up of mutual respect between professionals, patient trust, and a level of authority from the health professionals that can sway the patient’s opinions.
The authority a health professional can hold over their patient’s opinions (whether intentional or not) can be very powerful, and can lead to a concept known as channelling – that is, guiding the patient’s choices when selecting other health care professionals to be a part of their health team.
There has always been an unspoken expectation in the health industry that it is perhaps unethical, and definitely frowned upon, for a doctor to direct a patient to a specific pharmacy or pharmacist. It creates a feeling of unease and distrust that shouldn’t be there… “What’s wrong with the pharmacists my doctor is not recommending?” “What’s the doctor getting in return for recommending this pharmacy?”
For quite a long time, pharmacies have been relatively similar, with pharmacists all having relatively equal qualifications, making it hard to justify why a patient would be directed to a pharmacy, rather than being left uninfluenced to make their choice.
Now that there is a resurgence in compounding, and a frontier of new professional services, a referral for a specific purpose can be justified: not every pharmacy can make a troche; not every pharmacy can provide spirometry; not every pharmacist is accredited for Home Medicine Review.
In recent times, there has been a trend towards restricted supply of some medications that require extra training, accreditation, risk reduction, or outlaying significant investment. Ms-2-Step is one example, as is lenalidomide, thalidomide, and clozapine.
For some medications, patient access is improved via direct subsidies from the manufacturer; vortioxetine is one such medication. The process of subsidising the supply of this medication requires that patients are able to easily identify the pharmacies that can provide this service.
In these situations, the publication of a list of pharmacists or pharmacies that can provide a specific service is justifiable, and arguably necessary to ensure that these patients have timely access to these types of medications.
This need for patients to access a select list of pharmacies has led to a point where it is more common and acceptable for these lists to exist – even if the justification for them is becoming more and more tenuous.
The latest program that publishes a list of participating pharmacies for GPs to refer to is provided by LEO Pharmaceuticals via the PharmaPrograms. The program itself is very timely and important for pharmacists to participate in – it involves an education module for pharmacists and patients alike, and ensures that pharmacists do not use the word “sparingly” when labelling or discussing the directions for corticosteroid-based preparations for psoriasis.
The rationale behind this is that patients are not utilising their corticosteroid treatments adequately; treatment failure may be more than standard non-compliance with treatment (as seen with many medications), with treatment failure occurring in patients who are diligent with their dose timing, but using too little of their treatment to be effective.
So this raises a question of whether this justifies the publication of a list that a GP can look up in order to refer their patients to “specialised” pharmacists and pharmacies. It can easily be argued that the program provides a valuable resource for patients, but is the service itself so specialised or prohibitive in cost or time that pharmacies participating are going above and beyond their normal practice to supply the service?
I would argue that this service is not specialised or prohibitive to the degree that would justify a GP to refer a patient directly to one pharmacy over another. While the service itself is valuable to patient compliance and treatment outcomes, and registering for the program is free, there still remains the fact that many pharmacies are already highly skilled in providing service and advice to their patients that maximise patient treatment outcomes.
There is also the issue of precedent – this program bases the use of this list on participation in the program. This involves (as stated earlier) directed learning for pharmacists (ie the equivalent of CPE), and the ‘re-education’ of pharmacists to ensure that patients are not scared to use their medication.
This model of service could be replicated by any number of medication sponsors for any number of compliance issues; inhaler techniques, patch application, the right time to take a specific medication.
The precedent this could create is two-fold – firstly, program developers may see less reason to develop vigorous training programs for health professionals that require rigorous development and implementation. Our industry needs to have a diversification in professional service delivery, and making a program more desirable by tacking on an “exclusive supplier” list isn’t the way to achieve this.
The second precedent this would create is more worrying – it is conceivable that in-house programs developed by pharmacy groups could be direct marketed to doctors.
If these programs are evidence-based and replicable, then well done to those companies that value-add to primary patient care. If the program is not so vigorous, and involves a few modules of CPE for pharmacist working for that group, then all that is happening is this group is taking advantage of a loophole created by this precedent.
We have already seen to devastating effect the results of banner groups that find a loophole and exploit it mercilessly.
Considering these arguments, I would call on Leo Pharmaceuticals and PharmaPrograms to reconsider the use of an exclusive list of pharmacists for their Dermatology Network Pharmacy Program. The training is valuable, (and open to everyone, so please follow up on it), and patient adherence to the correct treatment is vital to patient outcomes; but this program just does not justify the encouragement of GP channelling, or the precedents that may come along with it.
Jarrod McMaugh is a community pharmacy practitioner in the northern suburbs of Melbourne. He has extensive experience in developing and delivering professional services in the community pharmacy setting.