Broadening the scope of practice


A small but growing number of pharmacists are carving out a new role for the profession in their work as pharmacists embedded within GP clinics

There’s no such thing as a typical working day in Tanya Tran’s life; working across three different GP surgeries in rural South Australia, her four-day week offers her a lot of variety.

Ms Tran has already had a busy morning by the time the AJP calls to interview her after lunch. She’s been trying to get in contact with the daughter of a nursing home resident whose script has gone missing since the patient changed pharmacies. She frequently looks after owing script requests from the same residential aged care facility.

She has already seen a few patients in the morning, including one who comes to her for education on managing their diabetes, and has provided information to the practice staff about Sanofi’s new insulin glargine, Optisulin, including a nurse who has an appointment with a patient about this issue in the upcoming days. For other patients, she’s conducted medicines reviews.

She’s done a small audit on urinary tract infections, “looking at providing the right antibiotic, at the right dose, for the right length of time, and giving the patient the information they need”—and at lunchtime, she gives a presentation on antibiotic usage to her colleagues at the surgery.

“So, that was just this morning!” says Ms Tran, who is currently working towards clocking up her 1000 hours in practice in order to gain credentials as a diabetes educator.

“I do diabetes education, I do medicines reviews, I might go out to people’s homes—I go out with a nurse who does home health assessments, and I do the medicines part of it. They like that, as if they have any medicines-related questions I’m right there, and the nurse can look after the rest.”

Ms Tran is part of a small but growing group of pharmacists who work in general practice alongside doctors in what the PSA has identified as an emerging career path for pharmacists.

As at 2017, Pharmaceutical Society data showed that there were nearly 50 pharmacists working in general practice in Australia, PSA national president Chris Freeman—who was one of the first Australian pharmacists to work in general practice—told the AJP in March 2020.

He said that by March 2020, the PSA estimated that there were more than 100 pharmacists in general practice, and that the organisation expected the model to grow year on year—eventually becoming a “mainstream career path for pharmacist practice”.

Chris Freeman: “I think this is where the model will come from: pharmacists who already have a close relationship with GPs from working closely together in community pharmacy.”

An outreach model

Changes to the Workforce Incentive Program came into being on 1 February, which includes non-dispensing pharmacists for the first time under the definition of “allied health professionals”.

The WIP now rationalises major workforce distribution incentive payments into a doctor stream and a practice stream, which includes allied health professionals as well as nurses and Aboriginal and Torres Strait Islander Health Practitioners or Health Workers.

The concept is aimed at bringing greater access to quality health professional services, including those provided by non-dispensing pharmacists, to rural and regional areas where maintaining the workforce remains a problem.

The PSA remains concerned that the funding cap on the practice will limit GP surgeries’ ability to employ pharmacists.

In its 2020 Federal Budget submission, it called for the value of the WIP per Standardised Whole Patient Equivalent and the upper limit cap on larger general practices to both be increased by 50%.

“We estimate integrating pharmacists into general practice would yield a net saving of $544.87m to the health system over four years,” A/Prof Freeman says.

“In the meantime, PSA would encourage general practices and pharmacists to consider the opportunity the current expansion of the WIP creates and consider how they can work together to improve health outcomes in their local community.”

A dissenting view

Not all stakeholders are as invested in the concept, however.

The Pharmacy Guild’s position statement on GP pharmacists indicates that, in principle, it supports the integration of pharmacists into general practice, “as an opportunity to enhance the collaboration between general practice and community pharmacy”.

“A pharmacist working in general practice should be able to practise to their full scope, including prescribing, to better support people with chronic health conditions, particularly in regions in which there are GP shortages,” says the Guild’s position statement.

It says that for pharmacists to be most effective in the setting to provide maximum efficiency to the health system, they must make certain achievements, such as maintaining and strengthening patients’ relationships with their community pharmacy and the general practice; focus on areas of patient care that are not readily available through the local community pharmacy; and remain professionally independent from the GPs within the practice.

They should also not dispense medicines, or duplicate services already being provided in the local community pharmacies, according to the Pharmacy Guild.

“The Guild believes that the best way to integrate community pharmacy within the general practice setting is through an outreach model of care using local community pharmacists as non-dispensing pharmacists.

This is primarily due to the current maldistribution of the pharmacy workforce, particularly in rural and remote Australia.

“The Guild is concerned that the employment of non-dispensing pharmacists in general practice will exacerbate existing workforce pressures and the sustainability of the community pharmacy network. The key emphasis should be on the importance of not duplicating services or roles, but using the available workforce in community pharmacy to increase integration of pharmacists into the primary healthcare team, especially in areas with limited health workforce.”

“What is extraordinary, given the workforce shortages and challenges for pharmacies in rural and remote areas, that government would incenvitise GPs to recruit a pharmacist—but not do similar for community pharmacy,” said Anthony Tassone, Victorian branch president of the Pharmacy Guild of Australia.

“I can’t think of any examples where there is a GP in town, but not a pharmacy—but the reverse is certainly true. Why use taxpayer money to potentially distribute the pharmacist workforce away from the community pharmacy, instead of leveraging the existing infrastructure that we already have in these towns?”

He said that outreach should be considered in the first instance, because “the risk is that these types of incentive models may not necessarily attract new pharmacists to a town or region—but just shift them from an existing community pharmacy which may already have its own challenges in terms of maintaining a stable workforce.”

tug of war vector
Political differences over ownership and control threaten to hamper the growth of the program

Inclusive or exclusive?

However the PSA’s Chris Freeman says that the PSA/AMA model “is not exclusive of community pharmacy” but rather flows from work within the community sector.

“I would expect the community pharmacist who is in close location with the GP to be the one who predominantly engages in the integrated model—so you’ll see the same pharmacist working across both community pharmacy and in the GP surgery.

“That will increase professional satisfaction for the pharmacist, increase collaboration and the ties between the pharmacist and the GP, and overall is beneficial to patient outcomes and healthcare.

“I think this is where the model will come from: pharmacists who already have a close relationship with GPs from working closely together in community pharmacy.”

Chris Freeman said that work as a GP pharmacist could be part of a growing trend towards a “portfolio career” for pharmacists—a term used to describe having several part-time jobs at the one time, instead of a single full-time job.

“So somebody might work for part of the week at a community pharmacy, part of the week with a GP—they might also work for industry, at a university or in education services. With a greater trend towards the portfolio career, this will help support that model, and could improve satisfaction for pharmacists, as there’s variety in their role, but they’re working across settings.”

Tanya Tran, who graduated pharmacy in 2008, currently works across three GP surgeries in the Barossa area of South Australia, after about eight years in community pharmacy.

While she enjoyed her work in the community sector, she also appreciates the variety of working across three different locations: Kapunda one day a week, Tanunda another day and two days at Angaston.

“I’m funded by country South Australia Primary Health Networks, who are working together with the PSA,” she said.

Over the last couple of years several PHNs in different jurisdictions have announced the securing of funding for the integration of non-dispensing pharmacists in GP surgeries.

“It’s about doing different things: you get one-on-one appointments with patients, whereas in the pharmacy it’s more about multi-tasking. Having said that, in the pharmacy you’re always around people, whereas sometimes if you’re in a room with a patient you may not see your colleagues, the other staff, for a few hours.

“I like that I can set my own agenda. Each place is different to work in.”

Ms Tran said that she keeps in touch pharmacy colleagues who are doing similar work in both the GP and aged care settings.

“We’re all in the same WhatsApp group, we’re all in rural, and we can get connected and bounce off each other.”

The AMA’s suggestion

The non-dispensing pharmacist model remains distinct, however, from that suggested by the Australian Medical Association, which in 2019 formed a General Practice Pharmacy Working Group aimed at offering the Federal Government “strategic input” into the Seventh Community Pharmacy Agreement and lobbying for the removal, or loosening of the ownership rules.

The Royal Australian College of General Practitioners’ 2019 General Practice: Health of the Nation report showed that 28% of GPs said their practice was co-located with a pharmacy.

However, the AMA suggested last year that the lobby group would push a model whereby “hubs” centred on a GP practice would deliver patient care in a “one stop shop” to improve collaboration and access.

This would include bringing both pharmacists and pharmacies themselves into the GP space, alongside existing health workers such as psychologists, dietitians and physiotherapists. Pharmacies would be owned by the surgery owners.

However, both the Guild and the PSA stress that they do not support the concept of GP surgeries owning pharmacies themselves or employing dispensing pharmacists.

“One must wonder whether the AMA membership are satisfied with their elected leaders pontificating and spending an extraordinary amount of time working through a proposal that’s not legally allowed, that nobody is asking for, and that there doesn’t look like there’s any possibility of happening at any time in the near future,” said Anthony Tassone.

The PSA’s Chris Freeman said that the organisation does “not see any advantage to that model”.

“There also comes into this area perceived conflicts of interest, where the clinical governance would have to be very carefully considered if a GP owns both the GP practice and the pharmacy,” he said.

“Unfortunately this conversation [about GPs and pharmacists working together] gets distracted by political manoeuvring about who owns the pharmacy, who owns the medical centre, where does the money flow to—and it distracts from the conversation about having pharmacists located where medicines are, fundamentally improving the quality use of medicines and medicines safety.”

The bigger picture

International evidence about outcomes continues to grow. For example, in March 2020, UK researchers looked at 140 pharmacists in Scotland who had been funded to work in general practices across the country.

These pharmacists undertook bespoke training developed by NHS Education Scotland, which included e-learning access as well as its main delivery method, which was face-to-face.

More than 93% said they were either satisfied or very satisfied with the training and, importantly, the participants reported that their experience, confidence and competence in the role developed over time, describing changes to practice including increased clinical and consultation skills, improved teamwork, communication and support, and greater autonomy.

A prospective observational study from 2018, also in Scotland, saw GPs record the time they spent dealing with special requests, immediate discharges, outpatient requests and other prescribing issues for two weeks before the study began.

During the study, specialist clinical pharmacists performed these prescribing activities, and the GPs again recorded the time they spent on them for two equivalent periods.

The GPs and practice staff were surveyed to assess their expectations at baseline, as well as their experiences during the data collection period at the end; prescribing support staff were also surveyed during the intervention.

The study found that the pharmacists were able to reduce GP time on these activities by 51%.

Lowering the rate

A 2019 study from The Netherlands found that fully integrated non-dispensing pharmacists in general practices led to a lower rate of medication-related hospitalisations among high-risk patients compared to usual care… but the same lower rate was also found among community pharmacists trained to perform medication reviews.

This study randomised general practices into three arms—nine intervention practices with a full-time embedded non-dispensing program; 10 were sorted into the usual care arm, where pharmaceutical care was provided in collaboration with community pharmacists; and six practices offered “usual care plus,” where usual care was added to by collaboration with community pharmacists who had completed an accredited training program in performing medication reviews.

Between 1 June 2014 and 31 May 2015, there were 822 medication-related hospitalisations among 11,281 high-risk patients across the three study groups.

The adjusted mean rate of medication-related hospitalisations in the intervention group was 4.4 per 100 high-risk patients per year, compared to 6.4 in the usual care group—and the rate was lower, at 4.2, in the usual care plus group.

In Australia, a pilot study reviewed the work of one pharmacist embedded in a general practice in Canberra over 13 months; this study involved 136 patients, 119 of whom had their asthma control recorded on their first visit.

After the pharmacist’s interventions, asthma control test scores improved for 19 patients, grew worse for three patients, were unchanged for one patient, and data was incomplete for three patients.

Before pharmacist review, 17% (4/23) patients in the improved group had good asthma control, increasing to 52% (12/23) afterwards.

In total, 42% (8/19) patients with poor control in this subset moved to well-controlled asthma following review by the practice pharmacist; at least one avoided hospitalisation, which was attributed to the practice pharmacist’s interventions.

GPs also reported that the pharmacist had educated them about asthma.

A deeper insight

Tanya Tran told the AJP that she has gained a deeper understanding and appreciation of the work done by her colleagues at the medical practice—and the feeling is mutual.

“You get to see how things work from a different perspective,” she said. “The GPs have been really great. They’ve been totally on board, and really supportive.

“At the practice I started at a couple of months ago, the GPs check and see how I’m going—they make sure they’re referring patients, and they let you know that they appreciate your recommendations. They say thank you, and even if sometimes they don’t take your recommendations, they do note it down and say they’ll keep it in mind and perhaps consider it another time.

“You don’t get talked down to. Nobody says, ‘What right do you have to say that?’ Having mutual respect and learning from each other is really cool.”

Chris Freeman said that he felt concerns about the new pathway were “a bit of fear of the unknown”.

“Yes, we do have workforce issues in rural and regional community pharmacy—but we’ve had various initiatives which have tried to increase the attractiveness of pharmacy to those areas and clearly they have not worked yet.

“One way to do that is to diversify the role. A pharmacist’s main role could be in community pharmacy, but they could also work at a GP or aged care facility, and that could be coordinated by the community pharmacy, that would then be connected to the GPs in the area..” 

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