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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