A contentious case


High-profile GP Evan Ackermann has slammed expanded roles for community pharmacists citing lack of evidence, adding that dispensing should be ‘cashed out’ to general practice-based pharmacist positions

As part of a new regular debate section in the Journal of Pharmacy Practice and Research, the official journal of the SHPA, GP Dr Evan Ackermann has called for an end to the current community pharmacy model.

JPPR’s new debate section, ‘A Matter of Opinion’, identifies potentially contentious matters and invites experts in the field to contribute a brief piece that outlines their views, whether for or against, the journal explains.

Dr Ackermann, who is Chair of the RACGP Expert Committee – Quality Care, and has been a frequent critic of pharmacy, argues in his ‘case against’ expanded primary care services in pharmacies that the push for these has been founded by a desire to maintain pharmacy profits rather than to address a health sector problem.

He also argues that pharmacy interventions “do not reliably result in significant clinical benefit”, and criticises the concepts of pharmacy-based minor ailments schemes and pharmacy vaccination.

“There is now a considerable body of high-level evidence supporting limited or no health benefit from expanded community pharmacist roles.”

Arguing the ‘case for’ pharmacists to adopt expanded roles in primary care, consultant clinical pharmacist Debbie Rigby writes that innovative and expanded roles for pharmacists can add value to the primary healthcare outcomes for consumers.

“Pharmacists’ services and involvement in patient care have been associated with improved health and economic outcomes, reduced adverse drug events, improved quality of life and reduced morbidity and death.

“Our distinctive competency is our knowledge on pharmacotherapy and medicines management, much underutilised to date. Patients deserve better from the health system,” writes Ms Rigby.

“In many aspects, Australia has led research and implementation of professional services focused on medication optimisation.

“Home medicine reviews (HMR) and residential medication management reviews (RMMR) have been the most successful Community Pharmacy Agreement programs, funded by the Australian Government and backed by high-quality evidence.

“Pharmacist involvement in immunisation … has resulted in increased uptake of immunisations compared with vaccine provision by traditional providers without pharmacist involvement.”

Meanwhile Dr Ackermann’s solution to what he perceived as a lack of evidence about the value of community pharmacists involves “transferring the role of delivering PBS to this position in general practice… outside the retail setting.

“Dispensing and other fees normally associated with community pharmacy would be ‘cashed out’ to support a general practice-based pharmacist position, to develop appropriate wage structures and career pathways.”

He adds that the Pharmacy Guild “should have only a minor seat at future Community Pharmacy Agreement negotiations, with protected funds supporting a transition”.

Pharmacists in general practice… yes or no?

The Pharmacy Guild of Australia has previously suggested that doctors’ support of pharmacists in general practice may have an underlying agenda.

Anthony Tassone, President of the Pharmacy Guild of Australia (Victoria) recently wrote for the AJP that integrating pharmacists into general practice provides 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.

“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,” suggests Mr Tassone.

“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)?

“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,” he says.

“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.”

David Heffernan, President of the Pharmacy Guild of Australia (NSW) agreed with his colleague.

“We should stick to the service model,” he said at a recent Sydney event.

“I’m vehemently opposed to pharmacists in doctors’ surgeries, that funding announcement [for a new Workforce Incentive Program to include non-dispensing pharmacists in the latest Federal Budget] was basically a kick in the teeth.

“You do not have autonomy. Any pharmacist that thinks any of that GP funding is going to the pharmacist is really kidding themselves,” said Mr Heffernan, adding that it would potentially lead to more pharmacists being paid award wages.

PSA leaders Dr Shane Jackson and Dr Chris Freeman support pharmacists in GP practice as an addition – not a replacement – to the community pharmacy sector, and addressed the concerns of the Guild in a recent editorial.

“It is understandable that at a time of exceptional pressure on the viability of the community pharmacy sector, that the development of roles for pharmacists outside of the community pharmacy setting are perceived as potential threats,” wrote Dr Jackson and Dr Freeman.

“Soon to be published research reveals that investing in pharmacist integration into general practice may improve the uptake of professional services conducted in the community pharmacy setting as well as improving the rapport and collaboration between general practices and pharmacies.

“The data reports at least 42 pharmacists currently working within the Australian general practice setting with nearly two-thirds of those pharmacists actively referring consumers to their community pharmacy of choice for professional pharmacist services.”

A note from the SHPA: The article by Evan Ackermann appeared in JPPR’s new debate section ‘A Matter of Opinion’, in which the journal identifies potentially contentious matters and invites experts in the field to contribute a brief piece that outlines their views, whether for or against. The personal contributions are not comprehensive reviews, but rather brief expressions of opinion, backed up by some succinct supporting information, and do not reflect the editorial views of JPPR or SHPA.

Read Evan Ackermann’s opinion piece here

Read Debbie Rigby’s opinion piece here

Read Anthony Tassone’s opinion piece here

Read Shane Jackson and Chris Freeman’s opinion piece here

What do you think about the debate surrounding expanded pharmacist roles, including non-dispensing pharmacists in general practice? Let us know in the comments section below.

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17 Comments

  1. Amandarose
    20/06/2018

    This guy is just being a pot stirrer- what a twat.

    • Jarrod McMaugh
      20/06/2018

      The problem is, he has political influence, as demonstrated by the ill-advised decision by JPPR & SHPA to invite him to write this in the first place.

      His response is completely predictable, especially since he has made these same points in the past – ironically called for a complete change to the delivery of medications without any evidence, while at the same time accusing our profession of operating without evidence.

      Everyone involved in this farce should hang their heads in shame for giving him a platform. The editor of JPPR Christopher Alderman should seriously consider resigning, while the CEO Kristin Michaels & the president Michael Dooley should be asking some serious questions about how an otherwise respected journal and organisation could deem this worthy of publishing, especially since there are many pharmacists & other health professionals capable of taking on this argument without lacking the capacity for balance or rational argument.

      • Andrew
        20/06/2018

        But Jarrod, isn’t he just another stakeholder with an opinion as valid as anyone else?

        His opinion can be refuted as aggressively as one likes – but when he’s presenting an argument backed by a body of evidence it becomes difficult to land a punch. Even more so when the other side’s argument consists of things they “strongly believe” rather than “we have shown” or god-forbid….“references available”. The evidence-based stuff has been defunded, the stuff without evidence is funded…..no wonder outsiders are critical.

        Also I’m not comfortable with an admin advocating for censorship of an opinion he doesn’t agree with. I’d just like to place that on the record.

        • Jarrod McMaugh
          20/06/2018

          He doesn’t have a body of evidence to draw on. Each point he makes is based on opinion. He also ignores significant evidence from within Australia and overseas that undermines his arguments.

          At the same time, Debbie Rigby’s side of the argument is well constructed & contains evidence to back up her stance – the only criticism I have of Debbie’s part of the article is that she engaged with Evan in the first place (especially since there are plenty of people to make the counter-arguments who aren’t as clearly biased as Evan).

          His main thesis of “cashing out” pharmacy is completely without evidence and without merit, nor is it present in any jurisdiction outside of Australia. He is inflammatory for no purpose than to stroke his own ego.

          “Evidence based stuff” has been defunded – stuff without evidence is funded…. would you like to provide details of what you’re getting at here?

          If you’d like to look at instances of “stuff that works” being undermined, look no further than Evan Ackermann himself – his influence within RACGP lead to the Victorian Faculty withdrawing from the Pharmacists’s Chronic Disease Management Pilot in Victoria – Quite convenient that programs implemented by Victorian DHHS to gather evidence that would support pharmacist roles are attacked and undermined by the organisation that Evan belongs to, allowing him to continue to claim that there is “no evidence”

          You’re drawing a long bow claiming that I an advocating for censorship. Evan Ackermann has every right to spout his bullshit all he likes – this doesn’t mean that (previously) respected publications like JPPR should provide him with any sense of legitimacy by publishing them.

          • Andrew
            20/06/2018

            I can’t access the full text but I can see it has referencing – those I can see are to do with his discussion of the commercial agreements associated with some professional services, which seems appropriate and serves his argument. I can only assume the rest of his claims are similarly referenced otherwise it wouldn’t make it past pre-pub review. Debbie’s article I can’t access either but I’ll get behind pretty much anything she has to say – she’s consistently on the money and should be pharmacy’s Benevolent Dictator for Life.

            On the “cashing out” comment – isn’t that the nucleus of what we’re discussing – whether health outcomes are better from a pharmacist in a GP practice, or in a retail setting? If the evidence shows that is the case, then taxpayer’s money should absolutely be “cashed out” of the dispensing process and allocated to more productive and higher RoI processes? That’s how I interpreted that line and my understanding of the evidence supports that statement. Interested to see any evidence to the contrary, if it exists.

            Taking the extreme reductionist approach the pharmacist should only be concerned about patient outcomes – everything else is secondary. I think this is where Evan is coming from and I think his argument is that all the commercial and retail aspects of pharmacy serve to only distract from this core role.

            How can someone’s honestly held opinion upset you so much? You know what they say about opinions…with respect to their their relative occurrence and inherent value.

          • Jarrod McMaugh
            20/06/2018

            It’s not an honestly held opinion – he is a hypocrite. Evan’s opinion takes the form of opposition whenever there are non-GPs involved.

            The concept of “cashing out” is not what is being discussed.

            The opinion piece is supposed to be about the contribution of pharmacists to primary care. Evan has not been able to make this argument, and instead immediately changes the focus of his argument away from the question asked, and instead he determines to criticise community pharmacy.

            The hypocrisy of the piece is particularly evident with his call for this “cashing out” concept. He discusses many services offered in pharmacy that have evidence (of which, he provides one reference in each case for why these services are bad, overlooking any that balance this point of view) stating that “more evidence is needed”, then goes on to say that pharmacists dispensing within a GP surgery is the best path forward, despite this model not existing in any comparable jurisdiction, and zero evidence that this would work or be effective, or in the best interest of patients. This is the definition of hypocritical argument.

            He criticises all pharmacists throughout the piece, and cherry picks references that allow him to state that not one single intervention by pharmacists has any impact on patient outcomes.

            To quote him directly:
            “High quality systematic reviews have failed to unequivocally support the clinical value of medication review or management interventions by community pharmacists. At best, there are minor improvements in surrogate markers (e.g. HbA1c, blood pressure, lipids) and minor medication error detection. There are no consistent effects on quality of life, hospital admission, deaths or medical costs. The same outcomes recur for medication review in aged care facilities and medication
            reconciliation on hospital discharge.”

            So, here he says interventions by community pharmacists and hospital pharmacists in any setting show no real benefit. He relies on a narrow range of references to make this claim, ignoring the wider evidence available that Debbie uses to make the opposite assertion.

          • Andrew
            20/06/2018

            >>>So, here he says interventions by community pharmacists and hospital pharmacists in any setting show no real benefit.

            You’re misrepresenting the article now. He’s being critical of retail pharmacy – for the paucity of evidence and dodgy commercial relationships. Hospital pharmacy, which (as far as I can tell he hasn’t mentioned), is strongly evidence based and has lots and lots and lots of outcome data.

            Medication reviews by Accredited Pharmacists (distinct to retail pharmacists) are strongly evidence based too – I’m sure he’d concede that point as the evidence is unequivocal.

            We’re not really having a discussion anymore though, so I’m going to leave it there.

          • Jarrod McMaugh
            20/06/2018

            “There are no consistent effects on quality of life, hospital admission, deaths or medical costs. The same outcomes recur for medication review in aged care facilities and medication
            reconciliation on hospital discharge”

            That is his statement. Get a copy of it and read for yourself.

            If you are sure he would concede on anything, then you don’t know Evan very well.

          • John Wilks
            20/06/2018

            Hi Jarrod,
            On this issue I am very much on your side however could I respectfully suggest that your tone, whilst passionate and plausible, should be tempered with a dose of diplomacy. Using words such as bulls… and hypocrite leave you open to accusations of mounting an ad hominen argument.
            Ciao,
            John

          • Jarrod McMaugh
            20/06/2018

            I’m comfortable with those descriptions.

          • John Wilks
            20/06/2018

            I was thinking more of other contributors’ comfort, which is enhanced with more decorous tones. But I suspect we diverge on this point?

          • Jarrod McMaugh
            20/06/2018

            Yes John we do.

            AJP has a guideline on language as well…. As yet not breached.

  2. Anthony Tassone
    20/06/2018

    This belief of Dr. Ackermann that pharmacy should be ‘cashed out’ to support a general practice pharmacist position are neither new or evidence based.

    Rather than invest any further time or energy in rebutting this serial critic I will point out a two part comment piece I have written for AJP in October 2016 to rebut similar flawed views put forward by Dr. Ackermann at the time.

    https://ajp.com.au/news/face-facts-doctor/

    https://ajp.com.au/news/face-facts-doctor-part-two/

    Anthony Tassone
    President, Pharmacy Guild of Australia (Victoria Branch)

  3. JimT
    20/06/2018

    he’s a wanker….don’t waste your time with this…I’ve already put too much pen paper !!!!!!!!

  4. Willy the chemist
    20/06/2018

    Sigh, all about protecting turf and income stream. Dr Ackermann as the peak GP groups view pharmacy as a threat to them.

    Their push to have funding for integrated pharmacist service in general practice is all about protecting & growing revenue.

    How many naive pharmacists are walking into their honey laden traps?

  5. Toby
    24/06/2018

    If we let this sort of insult pass, then pharmacy is not a profession. Just the doctor’s servant. Which do you want to be?

  6. Debbie Rigby
    25/06/2018

    WentWest PHN has released a document outlining the role of a general practice pharmacist.

    Please read with an open mind to see the role described and how it enhances the role of community pharmacists, and most importantly, improves team-based care to consumers.

    “A General Practice Pharmacist (GPP) is a non-dispensing pharmacist who delivers clinical and education
    services to patients within the general practice setting. The GPP is integrated as a member of the patient care team to foster true team-based care and support the Patient Centred Medical Home principles.
    Their role complements the dispensing role undertaken by Community Pharmacists but can bring core pharmacist skills into the general practice setting. The role of a GPP is diverse and can be tailored to meet the needs of the patient to ensure they experience effective team-based care in the primary care setting being at GP practices, the patient’s home or in the community.”

    See http://wentwest.com.au/documents/resources/reports/WSGPPP2018-_WEB.pdf

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