Clinical interventions: a ‘lost opportunity’?

Most pharmacists in this survey disagreed with the withdrawal of funding for clinical interventions

Nearly 70% of pharmacists surveyed in the UTS Pharmacy Barometer 2020 said payment for the clinical interventions program should have been retained in the 7CPA.

A quarter of the 360 respondents agreed with its withdrawal, with the remainder unsure.

Among the sample, half worked as owners/owner managers while 31% were pharmacist-in-charge/pharmacy managers, and 19% were employee pharmacists.

Clinical interventions were omitted in funding allocations for continuing community pharmacy programs as part of the 7CPA, which began from 1 July 2020. By comparison, the program was allocated nearly $20 million in the first year of the 6CPA alone.

Clinical intervention payments have been absorbed into other expenditure on professional programs, such as additional funding for Dose Administration Aids (DAAs), Aboriginal and Torres Strait Islander programs and rural pharmacy support, a Guild spokesperson confirmed to AJP in June last year.

“The CI payment was introduced in the 5CPA as an ‘incentive’ payment to record the routine clinical interventions undertaken by pharmacists as part of the dispensing process, in order to provide an extensive database for a previously unrecognised service,” the spokesperson said.

“Pharmacists will continue to exercise their professional and clinical judgement in managing the medication and related health needs of their patients – just as they did before the advent of the clinical intervention incentive payments.”

In their report published this month, the UTS Pharmacy team has queried why the funding was dropped.

For example, they ask, was there a lack of robust clinical evidence supporting the clinical and economic benefits, its cost effectiveness or lack of clarity on the definition of a clinical intervention?

Based on the results from surveyed pharmacists, “[there is] clearly a marked disagreement with the discontinuation of payment for clinical interventions,” commented UTS Adjunct Professor John Montgomery.

“Is this a lost opportunity or a reflection on expected versus actual outcomes?” Professor Montgomery asked.

When the 7CPA was signed, PSA national president Chris Freeman told AJP it was “unfortunate” to see clinical interventions no longer funded in the 7CPA.

“In the original research funded through the PROMISe research trials that led to funding commencing in the 5CPA, clinical interventions were show to save in the order of $280 in health care costs [per intervention],” he said.

“Unfortunately, the implementation of the clinical interventions program did not match the recommendations from the trials, there was a lack of data collected about the types of interventions, and there was not sufficient support in place to assist the delivery of clinical interventions.

“This has meant that clinical interventions have ended up being collateral damage when it comes to ongoing funding.”

However with such strong support for a program from the pharmacy community, the UTS team notes it is “surprising that greater efforts were not made to keep the funding available, or considerations made to restructure the program so that the required evidence could be obtained”.

“Why are we not listening to the overwhelming viewpoint from pharmacists?” said Dr Victoria Garcia Cardenas, Senior Lecturer in Pharmacy Practice, UTS Graduate School of Health.

“Let’s take the time to ensure these programs are viable.”

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  1. Peter Allen

    And don’t mention gaming the system.

  2. Chantelle Pennington

    Meds Checks over CIs should have been de-funded.

    Re: Meds checks. Working in community pharmacy in the past (but no longer), I have experienced that these are just a 2 minute consultation for most pharmacies, rather than spending time to clarify the list of medications that they are actually on. Or alternatively, owners wanting you to print out the medications they are on in advance, then just hand it to the patient with the claim form and ask them to sign it, plus being expected to do them with only one other (sometimes inexperienced) staff member. This behaviour smacks of profits over actual care and service for the patients.

    Whilst this is hopefully not the case for all pharmacies, the profession has to do better.

    • Jarrod McMaugh

      This is pretty despicable behaviour… but the reality it, nothing will change unless two things happen:

      1) People actually avail themselves of the guidelines on these programs and actually integrate them in to practice

      2) more critically – pharmacists report this kind of behaviour from their colleagues (including employers if this is the case).

      We have to take responsibility for self-regulating our profession

      • Sean Gannon

        Self regulation might never occur as long as community pharmacy owners and their lobbying-group-masquerading-as-a-professional-body (The Guild) hold so much power over employee pharmacists and the industry as a whole. Why should an employee pharmacist take the fall when their employer has asked them to do medschecks every day in addition to dispensing/checking 200 scripts, doing a dozen flu shots, checking 20 webster packs, administering methadone, and putting out 10 other fires throughout the day? What Good Samaritan would want the black mark of snitching on their reputation in such an interconnected industry? Especially when there’s a dearth of alternative employment opportunities outside community pharmacy and a healthy supply of young interns and early career pharmacists who are willing to take on high workloads for a pittance. Obviously not every case of substandard practice can be blamed entirely on high workload, but I bet it’s the major factor in most cases.

        Is self-regulation good enough when we’re talking about taxpayer money? I agree wholeheartedly with the principle of your two points, but they won’t solve the problem alone in my opinion. In order to have durable change for the better, the interests of patients and employee pharmacists need to be better represented, and the oversized influence of pharmacy owners needs to be reigned in. In my opinion.

        • Chantelle Pennington

          I agree, employee pharmacists need better representation! It’s not uncommon in other industries for there to be anonymous whistle blowing. Our code of ethics could be read as obliging us to speak up. You make a great point about tax payer money.
          The industry is so interconnected, there is fear of being seen as the pharmacist who “causes problems” or in reality, pushes back against the pressures being placed upon them.

          The profession needs more advocates for employees! So that they can feel safe to speak up when they see things that are clearly unethical.

        • BurntOut

          This very reason has permanently affected me; I was a dumb newly registered pharmacist and let a certain nameless pseudo-discounter bully/coerce me into pushing through conditions that left me with a permanent spinal injury. I’m going to have severe nerve pain and loss of feeling in my right leg for the rest of my life because of them and there’s nothing I can do about it

          Even if I did opt to take the matter to regulators, it’d destroy my career and I’d likely get nowhere anyway with how big a company it is

          People love to preach what SHOULD be done, but in practice it’s not so black and white; outting an employer for dodgy practices is a good way to end up unemployed. Like you said, there’s an abundance of interns and ECPs who’d take my place in a heartbeat

          • Sean Gannon

            I’m sorry to hear that happened to you BurntOut. People think of pharmacy as a physically undemanding white-collar job, but in reality many pharmacists are made to work long shifts without proper breaks and are actively discouraged from sitting down, not to mention the terrible ergonomics of the average dispensary. I wouldn’t be surprised if stories like yours are more common than we think.

          • BurntOut

            Thankfully I left that store long ago,

            It was a few years ago now and have thankfully ended up in a much better workplace that’s not only incredibly supportive and not the kind who coerce staff into unlawful practices or those who are willing to compromise the health of their staff to maximise the profit margin

            The condition is a lot better, but according to the specialist it’s likely never going to completely go away
            There’s so many issues in the industry now I just don’t see any simple fixes that aren’t considerable overhauls

          • Sean Gannon

            Legally enforced workloads would be a good start. Minimising wages is a big part of how discounters are able to get so cheap, and they minimise those wages by paying less and demanding more of their pharmacists. Perhaps excepting owner-pharmacists from these workload caps would be a good way to
            penalise absentee owners without harming the smaller owner-operated pharmacies.

          • Paul Sapardanis

            Absolutely agree. The regulators need to broaden workload issuesto not only include dispensing rate. They need to also look at S3 sales, vaccinations, medschecks, DAA packing, and other professional services. I am finding anecdotally that this is as much an issue as pay. As far as I know the relevant regulators do not look at S3 sales. Is adequate counselling provided during the sale of these products by certain groups? I wonder

          • Sean Gannon

            Great point Paul, and this will become a greater issue in the future as more medicines are downscheduled from S4 to S3.

      • Red Pill

        I worked for a large discount store in Sydney 3 years ago and the owner was adamant that every pharmacist should do at least 2 x Medschecks and 8 x CIs per day to make their role viable! He would generate a report at the end of every month and would publicly name and shame the pharmacists that didn’t pull their weight in front of all dispensary staff.

        The reality was there just wasn’t enough situations and encounters throughout the day that would justify doing 8 x CIs and 2 x Medschecks per pharmacist per day. Nevertheless, the pharmacists were bullied into writing up CI and Medschecks reports that were completely bogus or unnecessary and were leading to no difference to the patients health outcomes.

        Eventually the entire team including myself left that workplace but it left a bitter taste in my mouth. I realised all of these new roles being created for pharmacists are just a mechanism to milk the system to make additional profits for the business owners. Meanwhile, it is the employee pharmacist that put their livelihood on the line, by writing up bogus reports to keep their job. Owners make all the profits and employee pharmacists risk it all for a minimum wage + $2

        • Paul Sapardanis

          What I am seeing within our industry is how detrimental discounters have been to the provision of services to the community and to out profession as a whole. Discounters work by getting customets in store with prescription pricing and hoping for higher margin purchases as a reward. The problem is that with the exception of one notable group this has failed ( refer to class action against another notable discounter ). What happens then is these failing discounters have to milk their pharmacists dry to make up for loss of prescription margin. What needs to happen is that the regulators MUST crack down on workloads. Unfortunately they have not. This then continues to promote the status quo.

          • Sean Gannon

            And the ones who will suffer will be our most vulnerable patients, the elderly and people with chronic illnesses, who aren’t provided with the level of care they need and deserve from their pharmacists. Their pharmacists are too snowed under with meaningless busywork that only serves the commercial interests of pharmacy owners to actually use their education and help patients manage their medications.

            Everyone who has worked in hospital pharmacy has seen it; the over/undermedicated elderly patient with multiple diseases who has a suboptimal medication regime that any pharmacist worth their salt could find a dozen improvements for.

            Everyone who has worked in community pharmacy has seen it; the over/undermedicated elderly patient with whom you never seem to have enough time to go through their medication regime with a fine-toothed comb and fix the problems before they wind up in hospital.

            And since there’s little to no enforcement of standards for the provision of “professional” “services” like MedsChecks, the taxpayer ends up paying twice; once for the useless service, and again for the hospital system to try and pick up the pieces.

    • Sean Gannon

      CIs are just as easy to game. There needs to be greater oversight of the provision of all professional services in community pharmacy, including maximum workloads.

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