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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