Manya Angley takes a look at the pharmacist role in general practice—and the road ahead
The Australian Commission on Safety and Quality in Health Care (ACSQHC) concluded that 2%–3% of Australian hospital admissions are medication related and estimated there are 230,000 medication related admissions to hospitals annually, costing $1.2 billion (1).
In addition, a 2009 report by the National Prescribing Service concluded that approximately 5.6% of general hospital admissions and 30.4% of hospital admissions in patients 75 years and older in Australia are related to adverse drug events (ADEs). (2)
Of the Australian studies that assessed preventability, Roughead and Semple (3) found approximately 50% of ADE-related admissions (ADE-RAs) were potentially preventable.
I have been working as a consultant pharmacist in a general practice for almost four years. Most of my work is focused on providing Home Medicines Reviews where patient interviews are always conducted in patients’ homes.
My work focuses primarily on complex medication management and patient education and I also provide some drug information to practice staff. I have full access to patients’ case notes, with their permission.
Our practice has 19 GPs and employs 17 nurses. Various allied health professionals are associated with the practice which prides itself having a ‘Medical Home’ structure and delivering a team approach to care.
Contributions from all members of the team are acknowledged and valued but overall care is GP-led. When I receive a HMR referral, I am trusted to provide valuable medication-related information that can be accessed by all members of the patient’s team and will ultimately optimise the patient’s care. The information may also be shared with other medical specialists outside our practice involved in the patient’s care. Our model is described in detail elsewhere. (4)
I have had various roles during my 27-year pharmacy career including roles in community pharmacy, hospital pharmacy and academia (research and teaching). My general practice role has been my most challenging to date but also the most rewarding. I feel I am integrating and applying my undergraduate and post-graduate training as well as the varied experiences of my career.
The role also requires me to hone my communication and problem-solving skills and at times I’m required to be very creative. Having pathways for direct personal contact with GPs, especially via our ‘in house’ server that allows transmission of confidential emails, enables me to play a more active role in team care and builds rapport with GPs.
Mutually trustful and respectful professional relationships have been built which ultimately leads to optimal patient care.
A positive initiative in the Fifth Community Pharmacy Agreement, and a recommendation of the Campbell report, was that a direct HMR referral pathway was implemented from October 2011 whereby GPs could directly refer their patients for a HMR to an accredited pharmacist of their choice, where previously they had only been able to refer to the patient’s community pharmacy.
From October 2011, the direct referral pathway was embraced by many GPs. However, an unprecedented rise in HMR referrals after the direct referral pathway was introduced resulted in ‘budget difficulties’.
Subsequently, the HMR business rules were changed in March 2014 so that accredited pharmacists are now limited to conducting a maximum of 20 HMRs per month and patients are only eligible for a HMR every two years, unless there is a significant clinical need.
Since this time I have only been able to see the ‘tip of the iceberg’ of patients at risk of medication misadventure in our practice.
It is well understood that consistently high rates of medication errors have been reported as occurring when patients are discharged from both public and private hospitals to community settings (3).
Further, suboptimal communication between patients and health professionals, between General Practitioners (GPs) and community pharmacists, and at the transfer of care leads to medication errors and it has been shown that 29% to 50% of transfer-of-care documents have errors. (2)
Thus with only capacity to conduct 20 HMRs per month, I prioritise post-discharge HMRs in the belief that this service provides the system with maximum ‘bang for buck’.
Another significant issue is that although I can access a consulting room at the practice whenever necessary, the changes in the business rules mean more obstacles are encountered when HMRs are conducted on-site, even if it is the patient’s preference. A greater on-site presence of my practice pharmacist services would be welcomed, but to date remuneration is lacking to expand the on-site contribution I can make.
There is an urgent need for a flexible funding model to meet the heterogeneous needs of general practice that is independent of the community pharmacy agreement. The Australian Medical Association has included support for funding for pharmacists in general practice in their 2016-17 budget submission and proposes that “the Government should support the employment of non-dispensing pharmacists in general practice through the establishment of a funding model that is structured in the same way as the existing incentive payments provided for nurses working in general practice”. (5)
In their 2016-17 budget submission, the Pharmaceutical Society of Australia urges the Government to consider the implementation of this model of practice as an election-year Budget priority in its reform of the primary care system and have indicated they welcome the support from the medical profession. (7)
So it would seem that the moons have aligned and our respective professions have been able to put turf wars aside in the interests of our common goal of improving the health outcomes of Australians.
Most importantly, when the Consumers Health Forum conducted a survey to ensure that consumers’ opinions were canvassed regarding pharmacists expanding their scope of activities in primary care, and specifically integrating pharmacists into general practice, they concluded “consumers have made it clear that this is a direction they want the health care sector to explore more thoroughly. The task ahead for the Government and sector is to use and build on the existing evidence in this policy space for such models of care to be successful and improve outcomes for consumers.” (8)
Evidence for cost-benefit has been demonstrated and the need for pharmacists’ roles in general practice has never been greater. But is it is time to take the leap? Or should we be seeking a MBS item number in the interests of maintaining our professional autonomy?
Manya Angley is a pharmacist and the director of Manya Angley Research & Consulting.
- Roughhead L, Semple S, Rosenfeld E. Literature Review: Medication Safety in Australia Australian Commission on Safety and Quality in Health Care, Sydney.; 2013 [cited 2016 January 20]. Available from: http://www.safetyandquality.gov.au/wp-content/uploads/2013/08/Literature-Review-Medication-Safety-in-Australia-2013.pdf.
- Easton K, Morgan T, Williamson M. Medication safety in the community: A review of the literature. Sydney: June 2009.
- Roughead EE, Semple SJ. Medication safety in acute care in Australia: where are we now? Part 1: a review of the extent and causes of medication problems 2002-2008. Aust New Zealand Health Policy. 2009;6:18. PubMed PMID: 19671158. Pubmed Central PMCID: 2733897. Epub 2009/08/13. eng.
- Angley M, Kellie A, Barrow G. Integration of a consultant pharmacist into a general practice: development of a collaborative care model. Journal of Pharmacy Practice and Research. 2015;45:81-5.
- Australian Medical Association (AMA). AMA’s pre-Budget Submission 2016-17: Health – the best investment that governments can make 2016 [cited 2016 February 11]. Available from: https://ama.com.au/sites/default/files/budget-submission/Budget_Submission_2016_2017.pdf.
- Deloitte Access Economics. Analysis of non-dispensing pharmacists in general practice clinics 2015 [cited 2016 February 11]. Available from: http://www2.deloitte.com/content/dam/Deloitte/au/Documents/Economics/deloitte-au-economics-analysis-non-dispensing-pharmacists-general-practice-clinics-010415.pdf.
- Pharmaceutical Society of Australia (PSA). PSA’s 2016-17 pre-Budget submission: The role of pharmacists in Australian Health Reform – Improving health outcomes through cost-effective primary care: PSA; 2016 [cited 2016 February 11]. Available from: http://www.psa.org.au/download/submissions/2016-17-budget-submission.pdf.
- Consumers’ Health Forum of Australia. Consumer voices on expanding the roles of pharmacists into primary care services: what consumers expect in primary care and the roles they see for their pharmacists and doctors 2015 [cited 2016 February 11]. Available from: https://www.chf.org.au/pdfs/chf/Summary-of-Pharma-and-PHC-Consumer-Report.pdf.