With pharmacists increasingly providing professional services, more than half (60%) of respondents to an AJP poll say they provide a significant amount of services for free

Community pharmacy finds itself in a difficult position, toeing the line between business and healthcare – and it’s often difficult to juggle the two.

In addition, there is a lack of understanding about what community pharmacists actually do, and they can get a bad rap in the mainstream press from time to time.

Contrary to just “slapping stickers on boxes” and selling products, pharmacists are often the glue that connects healthcare professionals and patients in the community.

There are many that go above and beyond in providing services and support to patients, sometimes without any clear cut remuneration pathways.

“Being a second-generation pharmacist, I grew up with the old-style community pharmacy model at heart,” says Caroline Diamantis, proprietor of Balmain Community Pharmacy in NSW.

“The transaction was NOT just selling products off the shelf. There was consultation, communication and an understanding that we are here any time, readily available, and at no charge to provide valuable professional advice.

“Many pharmacists still hold these traditional values close to their hearts; we are pillars of trust and information and personally I spend most of my days chatting to my patients about all aspects of their health and family life, from raising their children and looking after their elderly parents to issues with their pets.”

Ms Diamantis says she feels like the “glue” between health professionals in the community.

“Pharmacists are the central point where we hear about doctors, hospitals, specialists, physiotherapists, dentists and any other medical experience our patients are discussing,” she says.

“There are times during conversations that I can pick up alarming discrepancies regarding, for example, what happened in hospital and what the GP knows.

“In my experience more and more people are becoming confused and non-compliant with their medications,” she adds.

“We decided to do an awareness campaign with other health professionals, particularly doctors, providing education on the merits of Dose Administration Aids.

“Many patients were very happy with this service, which we provide free for those unable to afford it.”

Ms Diamantis is not the only pharmacist who takes the time to develop medicines compliance among her patients.

Nick Logan, who runs a pharmacy on Sydney’s lower north shore, shares one story of a patient who suddenly wanted to stop taking his important medicines.

“One of our patients, who has a diagnosed mental health disorder, has a good relationship with our pharmacists,” Sydney pharmacist Nick Logan tells AJP.

“One morning he entered the pharmacy insisting that he was discontinuing his tablets immediately because he didn’t need them.

“We sat him down at our interactive ‘pod’ area, and took time to discuss his stability and quality of life when his medicine regimen is working.

“We also called an outreach team and organised for his case manager to meet him at home at midday to reinforce the message,” says Mr Logan.

“The whole process took about 20-30 mins. His trust for our pharmacists meant that he was committed to taking all his medicines by the time he left the pharmacy.”

Professional services in the pharmacy

So what services do pharmacists perform on a regular basis?

Here’s the breakdown from a recent AJP poll according to how many respondents (n=242) were providing the service in their pharmacy:

General medicines advice

93%

DAAs

93%

Staged supply

89%

Disposal of unwanted medicines

89%

Blood pressure measuring/monitoring

84%

MedsChecks

79%

Diabetes MedsChecks

73%

Inhaler technique checks

71%

HMRs / RMMRs

65%

Smoking cessation advice & support

65%

Vaccination

60%

Blood glucose monitoring

51%

Needle & syringe program

48%

Compounding

41%

Breastfeeding advice & support

33%

Pharmacotherapy

33%

Health, fitness or nutrition programs

23%

Baby progress recording

19%

COPD screening

18%

Mental health/crisis support & counselling

17%

Aboriginal and Torres Strait Islander programs

17%

INR and/or lipid recording

14%

Rural support programs

7%

As seen above, most pharmacists provide extensive services surrounding medicines supply.

These are mostly covered under CPA funding.

Pharmacists also provide health checks and advice on a range of health states including asthma, pregnancy, weight loss, fitness and nutrition.

Many conduct blood pressure and blood glucose monitoring and screening for various conditions.

More than half provide smoking cessation support.

And about 20% of pharmacists are able to give mental health support to patients.

In fact, an increasing number of pharmacists are now completing mental health first aid training, to prepare them to support patients in crisis or who may present with a potential mental health issue.

“Being so integrated in our community, I feel an obligation to ensure that people are ‘OK’,” explains Ms Diamantis.

“I’ve completed my Mental Health First Aid course and am acutely aware of the emerging issues of stress, anxiety, and other mental health issues. I’m trained to determine when to refer on to the doctor and have been able to assist in obtaining correct treatment for better health outcomes and quality of life.

“Sometimes I just sit and listen – people often don’t have a sympathetic ear in their lives, so sometimes I sit with a person , hold their hand while they cry as they share their story, and then they feel better,” she says.

“These moments are actually the most rewarding for me as I know I’m making a valuable difference in my community.”

Western Sydney pharmacist Curtis Ruhnau also recently wrote in the AJP about supporting a patient through a crisis moment, during which she shared her experience of domestic violence as well as suicidal ideation.

Providing mental health and crisis support is certainly above and beyond what most people know and expect of pharmacists, and yet as accessible health professionals they often find themselves in the position of providing that support.

Do you get paid for your time and expertise?

None of the above services are covered under the government’s Medicare Benefits Scheme (MBS), despite several other allied health professionals being subsidised under it.

Currently people with chronic health conditions and a doctor’s referral can visit the following allied health practitioners and receive rebates under the MBS (with a limit imposed on how many services can be used for each per year): Aboriginal health workers or Aboriginal and Torres Strait Islander health practitioners; audiologists; chiropractors; diabetes educators; dietitians; exercise physiologists; mental health workers; occupational therapists; osteopaths; physiotherapists; podiatrists; psychologists; and speech pathologists.

Pharmacists are conspicuously absent from the list, partly due to having their “share” delegated through the CPAs, and also due to a lack of recognition and understanding of the work they actually do in supporting people with health conditions.

Some believe more funding should be unlocked for pharmacists providing such health services – via MBS, private health insurance or through the CPAs.

“As pharmacists specialise, there are areas of the MBS that should remunerate what we do, for example diabetes education, asthma management,” says Catherine Bronger, pharmacist proprietor of Chemistworks Broadway and Wetherill Park, NSW, who is a diabetes educator herself.

“There should be money in there for that, and it should be easier for pharmacists to provide these services.

“Professional services for pharmacists work well because patients are seeing us all year around – statistically about 13 times a year – we’re here to support people and keep them healthy between seeing doctors, who they only see about 1-2 times a year.

“Even though some doctor’s surgeries have diabetes educators, the benefit of having a pharmacist doing it is that they’re treating and supporting that patient in the pharmacy, they understand the pharmacology and health aspects…

“So while some MBS-style funding would be great, I think that funding should go into the community pharmacies.”

Pharmacist Dr Manya Angley has suggested that pharmacists could have two item numbers; one for a long consultation and another for a short consultation.

“Would love to see some MBS-style funding in the pharmacy … this will decrease the reliance on co-selling shampoo and vitamins, while showing the government and customers that pharmacist advice has value,” says AJP reader fiquet.

“Couldn’t agree more!” says pharmacist Ron Batagol. “MBS type of remuneration for professional services for pharmacists… Many of us have been advocating this for years, so far to no avail!”

AJP reader David wrote on the AJP late last year: “Why can’t we access private health fund money?? People are paying mortgages each month to have it, surely pharmacy services are worthy of some of the pie. Especially for services that prevent hospitalisations.”

So far, those in the industry have had to set up their own private fee schedules to keep up with the daily demands of providing services outside of DAAs, staged supply, HMRs, MedsChecks, Diabetes MedsChecks and RMMRs (which are covered under the CPA).

However a lot of the work pharmacists do still seems to go completely unremunerated.

According to a recent AJP poll (n=250):

  • 60% of respondents stated that they provide a significant amount of unremunerated services
  • 27% said their pharmacy charged fees for some services.
  • 13% said they charged fees for most/all services.

Ms Bronger says she charges private fees for most of her services, except for basic health checks including the monitoring of blood pressure and blood glucose levels.

NSW pharmacist Krysti-Lee Rigby says her pharmacy charges for blood pressure, blood glucose, cholesterol testing, staged supply and wound care services.

Ms Diamantis’ pharmacy provides some unremunerated services including mental health support and free deliveries (as do many other pharmacies, she points out) “as patients are often housebound, not mobile and have no family to assist”.

She also conducts free followups for patients who are discharged from hospital.

“We make sure their meds are ok, often we speak to a family member to check they will be ok, and offer our assistance in any way they might need.”

A successful model?

Elise Apolloni, managing partner of Capital Chemist Wanniassa – which won the Pharmacy of the Year 2017 award in the Professional Services Innovation category – is an advocate of charging for professional services.

“We charge for the vast majority of our professional services. Pharmacists are health professionals, and there’s not many health professionals where you can walk in and just get a service for free.

“Charging is about being valued and also ensuring your pharmacy is sustainable, so we’re able to continue providing these services.”

She says there are some areas they don’t charge for.

“There’s a couple we do for free but they often tie into another service. For example, we might provide a blood pressure check for free but tie it in with a health check later down the track.

“Our mental health support service is a free service. It’s a free service because the last thing someone wants to do is open up and share what’s happening with them, and find out afterwards that they have to pay a fee [for the time they spent].

“You have to think ‘big picture’ about this stuff. I can think of so many patients who we gave time and support to, who changed their pharmacy buying habits because of the time we spent with them.

“But saying that, pharmacists need to be remunerated for their time. It’s about finding that balance for your pharmacy and its demographic.”

Swarup Afsar from Pharmacy 777 Nollamara, WA, says he is proud to be part of a banner group that has built an “outstanding” model for professional services.

Mr Afsar’s pharmacy won Pharmacy of the Year in 2016 for its innovative work in the professional services space, and he agrees with Ms Apolloni about setting fees.

“It’s very important to charge for professional services. It’s to add value from a patient point of view and a pharmacist point of view.

“It’s about every team member being able to confidently provide the services. If they can do that, then it’s not hard to charge for them.

“We have pharmacists that attend to patient healthcare needs. We have a service for every product. It’s about selling our knowledge.”

He says their definition of professional services means attending to every single health inquiry and also referring them onto other health professionals when required.

This includes mental health support – with a counsellor onsite and mental health first aid training for all staff.

“Pharmacists need to spend as much time as possible with patients instead of just standing behind a dispensary computer,” he says.