Concerns about clinical pharmacy funding


The Small Pharmacies Group has raised concerns that the GP pharmacist model presents a threat to community pharmacy, in a letter to the PSA

The Small Pharmacies Group (SPG) has raised new questions about the model involving pharmacists in general practice, in a letter sent to the PSA this month.

SPG has three founding members – Terry Burnett, Fredrik Hellqvist and Katie Stott – who represent a growing network of small pharmacies in Australia.

“It has never been explained to us why there is a need to insert a second pharmacist into a patient’s health journey whereas such duplication is generally discouraged when it comes to GPs, specialists etc.,” says SPG in the letter.

“Furthermore, the question lingers about how a practice pharmacist resolves the problem of our daily need to consult directly with the patient’s prescribing GP.

New questions have also arisen regarding this model, says the group.

AJP has recently reported on the results of Chris Freeman’s 2017 survey of 43 Australian pharmacists working in general practice.[i] According to this AJP article, the survey found that there were ‘a significant number of referrals of patients to their community pharmacy for services such as MedsChecks, DAAs and HMRs.’

“We have not yet seen the research to be able to assess it fully, but it would seem to us that these results must be treated with caution given that we are not currently operating in the context of a funded model for practice pharmacists.

“It is interesting to compare Freeman’s results with an independent review of the UK clinical pharmacist in GP practice pilot program in the UK (which is a government funded program).[ii] In this review, researchers surveyed 78 GP sites where 373 pharmacists were employed as part of the NHS England scheme.

“This study found that ‘most CPs [Clinical Pharmacists] undertook patient facing work, focusing on complex medication reviews…For 70% they classified this as a major part of their role’.[iii]

“If practice pharmacists were to be funded by the government here would there still be the same flow-on benefits to community pharmacy in terms of increased medicine reviews that were seen in Freeman’s survey?

“PSA is strongly advocating for government funding for practice pharmacists. It is not clear exactly what funding model the PSA envisages but it would appear that an MBS-style model is one option that is being pursued.

“We are concerned that the pharmacist in GP model together with a potential MBS access can prove to be quite detrimental to the existing community pharmacy network in Australia if funding is diverted from CPA to MBS by the government to fund this,” says the SPG.

“It is quite probable that GP surgeries would like to capture as much of the MBS funding available before the patient leaves the surgery, including any funding through their ‘in-house’ pharmacist, blocking community pharmacists and pharmacies from access.”

“PSA seems to envisage that direct to patient activities would only occupy a small amount of a practice pharmacist’s time. However, patient-related activities are the activities most likely to attract new government funding and it is therefore hard to escape the conclusion that surgeries will push practice pharmacists towards funded services to make the position viable.”

SPG shares concerns that in the UK there have been “deliberate and systematic cuts to community pharmacy funding” with a lack of increasing funds and/or types of professional services for community pharmacy.

“At the same time, considerable amounts of funding have been invested in the GP pharmacist model. There is a limited timeframe on the government funding for practice pharmacists in the UK and that funding will eventually wind up. While there seems to be support from GPs in terms of the clinical aspect of the role, there has been acknowledgement that it is not particularly cost effective.[iv]

“If pharmacists are not kept on in this role, once government funding is reduced/ceased, the question arises as to where these pharmacists will find employment given that the UK community pharmacy sector has contracted.

“What guarantees does the PSA have that this is not part of the agenda of the Australian government? 

“Lastly, we feel compelled to raise concerns about the Workforce Incentive Program that was announced in the last budget. Members of SPG were not aware that PSA was pursuing this measure and are concerned by the apparent lack of consultation. Both PSA and the government have suggested that community pharmacies can be contracted to provide these services.

“However, if community pharmacy is placed in a position where it must tender for these services to GP surgeries we are likely to see a similar pattern as to what has happened with aged care – a race to the bottom to provide the cheapest service. How is this good for community pharmacy or for patients?

“In conclusion we would like to reiterate the need for greater transparency and more careful and collaborative strategic planning between the PSA and the Guild when it comes to mapping out the future of clinical pharmacy services – in terms of what services should be funded, who should be delivering them, where they should be delivered and how they should be funded.”

The PSA says it acknowledges the concerns raised by the SPG.

“It is understandable that at a time of exceptional pressure on the viability of the community pharmacy sector, the development of roles for pharmacists outside of the community pharmacy setting are perceived as potential threats,” the PSA tells AJP.

“A key pillar of the PSA Strategic Intent is to positively influence policies on pharmacist roles, recognition and remuneration.

“Our focus is to ensure that by 2023, remuneration and recognition for pharmacists is appropriate to their role and value,” says the PSA.

“This is why we are currently consulting on our discussion paper Pharmacists in 2023, where we are seeking input in the enablers and system changes that are required to ensure appropriate funding for pharmacist services and for pharmacists working in general practice.”

In regards to SPG’s reference to the Workforce Incentive Program, the PSA points out that the program “sits outside the Community Pharmacy Agreement and will receive no extra budget allocation”.

“It is simply an expansion of the type of health professionals who can participate in the program to include pharmacists,” says the PSA.

“PSA believes pharmacists should be meaningfully integrated in all settings in which a medication is being considered, which includes not only general practice medical centres but also aged care facilities.”

See the full letter from the Small Pharmacies Group here.

References:

[i] https://ajp.com.au/news/we-have-waited-far-too-long-for-this-to-occur/

[ii] Clinical Pharmacists in General Practice: Pilot Scheme Independent Evaluation Report: Full Report June 2018

[iii] Clinical Pharmacists in General Practice: Pilot Scheme Independent Evaluation Report, p.18

[iv] Clinical Pharmacists in General Practice: Pilot Scheme Independent Evaluation Report, p.20

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12 Comments

  1. Kevin Hayward
    30/08/2018

    Speaking from my previous extensive experience as both a small pharmacy owner and a practice support pharmacist, I can only tell you that having a pharmacist from the practice working in the local GP practice was very rewarding professionally, and of immense value, financially, to our pharmacy business.
    Far from posing a threat to the business, practice support pharmacy was a great opportunity, which we used to develop our business model into new territories, and allowed us to increase and enhance our professional role.
    As a management educator in latter years, I have used this scenario when teaching students about identifying threats and turning them into opportunities.

  2. Debbie Rigby
    30/08/2018

    It disappoints me that there is continued opposition to the practice pharmacist model by community pharmacy owners. The model is based on evidence of healthcare benefits and supported by experience of a number of pharmacists here in Australia, as well as overseas experience. PHNs have supported a number of trials, with positive benefits to patients, community pharmacies and GP practices.

    Our focus as a health professional should be on how best can we support patients along the medication management pathway. It has been said many times that the role is complementary to community pharmacists, not in opposition or duplication, and only enhances care provision across all settings, rather than fragmentation.

    Ultimately it can enhance communication and relationships with GPs, as well as enhance the image, respect and acknowledgement of our role in medication optimatisation and safety.

    We should be celebrating the support by medical and consumer organisations; and capitalise on the support to enhance other areas of the pharmacy profession.

    Unfortunately there are too many medication-related hospital admissions and preventable adverse drug events. Innovative models such as pharmacists in general practice have proven potential to address this; and work collaboratively to enhance the uptake of community pharmacy resources and services.

    Let’s work together to gain recognition for the valuable role pharmacists do play in medication optimisation and clinical governance no matter where they work, rather than have internal professional conflict..

    • Jarrod McMaugh
      30/08/2018

      Debbie when you comment like this and admonish others for criticising this model, you should also state that you have a direct interest in this model gaining public funding, since you are employed in this role now.

      There seems to be a pattern of public comments about topic where there has been or continues to be remuneration, which is not mentioned in advocacy for the topic at hand.

    • Anthony Tassone
      31/08/2018

      Debbie

      Whilst some of the comments about the general practice pharmacist model can be perceived as criticism – I think it is also important to understand that there are genuine questions and concerns raised about potential unintended consequences.

      Wherever there are medicines and patients, pharmacists can play a role for patient care – but it is important to best optimise the finite resources we have both financially and workforce wise.

      The National Evaluation of Clinical Pharmacists in General Practice conducted by the University of Nottingham (2018) provides useful insights on the UK experience:

      https://www.nottingham.ac.uk/pharmacy/documents/generalpracticeyearfwdrev/clinical-pharmacists-in-general-practice-pilot-scheme-full-report.pdf

      In the Conclusions section, below are some of the pertinent points

      “The clinical pharmacist in general practice role is already causing variance and potentially gaps in the wider pharmacy workforce. Workforce planners need to take this into consideration.”

      This national evaluation in its summary of recommendations outlined a range of measures of the need to collect more and different types of data to better inform future evaluation and policy development;

      “Key performance indicators for the scheme should be evidence-based and localised. There has been limited value to the monthly return data collected so far, and no feedback, creating resistance from sites. Future national reporting should be limited to key information only and localized reporting should be encouraged and facilitated. Evaluation should actively inform future iterations of scheme developments.”

      The same evaluation presents a range of positive examples of experiences of patients and GPs working with a general practice pharmacist which is not and should not be overlooked. However, I think it is important to acknowledge that some of the evaluations of the concept itself that the available evidence to date of broad financial and social benefit may not be as compelling as some believe.

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

      • Debbie Rigby
        03/09/2018

        Hi Anthony. You express valid concerns about unintended consequences of any new models of care. First and foremost should be the benefits to patients.

        I’m at FIP now and today’s morning session was about pharmacists in the UK, with very positive evidence and feedback presented and discussion on the impact, satisfaction and implementation barriers and challenges of the practice pharmacist model and roles. All very positive and exciting for the profession and healthcare. There is indeed some opposition from pharmacy owners in the UK. Resistance to change is universal.
        I’ve also had the opportunity to talk with pharmacists in the roles and aspiring to be.
        The UK health system is different to ours, with different drivers and funding. So care needs to be taken in translating the benefits and challenges.

        Heathy debate is useful. Understanding the drivers and potential outcomes is essential. Focusing on patient outcomes should be the priority, but professional and business implications must be pragmatically considered.

        I’d like to suggest a panel discussion at APP to present the model as trialed and proposed in Australia to unpack concerns and benefits. Consumers, researchers, practice pharmacist innovators, GPs and pharmacy owners could contribute.

        • SPG
          03/09/2018

          Hi Debbie – just to clarify SPG is not resistant to change nor are professional/business concerns the only drivers of our advocacy. We are also concerned about patient health outcomes. If community pharmacy is undermined by this embedding model patients will be affected. It is also worth pointing out that career satisfaction (and not just health outcomes) is a major driver for the embedding model. Advocates for embedding have a tendency to polarize community pharmacy (on the one hand) as non-clinical, business focused, and embedded pharmacists (on the other hand) as clinical and patient focused – this is not a fair or accurate assessment. It could even be argued that advocates of the embedding model are deliberately polarizing the debate in order to advance their own agenda. We agree that the corporatisation of community pharmacy (and the focus on supply throughput and associated low wages and poor working conditions) is part of the problem here (indeed support for the embedding model appears to be very much a reaction to this) but there are many community pharmacies that are very patient focused and want to see reform to the remuneration system so that we can continue to improve and enhance our service provision and offer more clinically rewarding career paths within community pharmacy. If PSA and others keep pushing for the embedded model without working together with the Guild and considering the impacts on those community pharmacies that are also working for the same outcomes, existing resources will be overlooked and our pharmacies (many of whom are servicing high needs areas) and our patients will be the collateral damage in this endeavour. It is not just about whether there will be unintended negative consequences of the embedding model – it is a question of whether the embedding model is fit/appropriate for universal roll out across Australia and whether there may be other ways to achieve the same outcomes. As mentioned SPG would also like to see ongoing and public discussion between the Guild, the PSA and other stakeholders on the delivery of clinical pharmacy services – in terms of what services should be funded, who should be delivering them, where they should be delivered and how they should be funded so as not to put community pharmacy at risk.

  3. Tamer Ahmed
    30/08/2018

    “It has never been explained to us why there is a need to insert a second pharmacist into a patient’s health journey?

    It appears that the writer of this comment has no idea that there are other types of pharmacists that are included in any patient’s journey ex. Hospital pharmacists, HMR pharmacists ,etc …..

    or is he proposing that there should be only community pharmacists?

    “Furthermore, the question lingers about how a practice pharmacist resolves the problem of our daily need to consult directly with the patient’s prescribing GP?

    Could it be that since he has more time than the GP and he is closer to the gp he could help you with your request

    in the same way, I as a hospital pharmacist have better access to hospital physicians and can help a community pharmacist.

    Is that really hard to comprehend?

    The community pharmacy as a scope of practice has failed to provide the pharmaceutical services that patients need

    mainly due to the proliferation of the discount model which is linked to a failing ownership model dominated by complex corporate agreements.

    As the health policymakers have no way to dismantle the monster that they have created and which led to chemist warehouse owning almost the 3rd of the market

    They need to find creative solution to be able to separate the supply model from the services

    The GP practice pharmacists are simply a part of that plain and simple.

    • SPG
      31/08/2018

      Hi Tamer – to clarify we are concerned about inserting a second pharmacist into a patients’ healthcare journey within primary care where the two roles will overlap considerably. We are not referring to transitions between different levels of care. The proposed clinical activities of the embedded pharmacist by the PSA do not differ fundamentally from what a community pharmacist does.

      In our view consultant/HMR pharmacists will probably also suffer from the GP pharmacist model because the work will be done by an in-house GP pharmacist to fund their position.

      “Furthermore, the question lingers about how a practice pharmacist resolves the problem of our daily need to consult directly with the patient’s prescribing GP?”

      We are concerned about legal implications in relation to the professional responsibility of the community pharmacist under the PSA’s model. A community pharmacist will still need to talk directly to the prescriber regarding issues. Speaking with a practice pharmacist will not eliminate this need as the community pharmacist is ultimately responsible for the medications they have dispensed. Consideration needs to be taken as to which pharmacist is liable in the event there is an error resulting in patient harm during such an interaction.

      “The community pharmacy as a scope of practice has failed to provide the pharmaceutical services that patients need”

      What SPG is asking is for the view of small pharmacy owners to be considered and addressed in this discussion about embedding. Our views should not be discredited just because we are pharmacy owners, or because of any perceived shortcomings of community pharmacy or the Guild. We are stakeholders in this discussion and like everyone we are working hard for the benefit of our patients and would like to see the clinical role for pharmacists supported and enhanced. Our concerns are not being addressed and we would like to see a public discussion where advocates answer our concerns and involve us in the design and delivery of clinical pharmacy services. Many of us are located in rural and remote areas, including single pharmacy towns, and we do not think that the potential impact of embedded GP pharmacists on community pharmacies in such areas has been properly explored.

  4. Fredrik Hellqvist
    30/08/2018

    The embedding model is one part of ‘Pharmacist 2023’ discussion paper in which the PSA invites the profession to put forward its opinion, which we have done. It does seem though that the PSA is, surprisingly, unwilling to discuss parts of it (this part?). We are unsure about the reason for this but it seems that the PSA and the Pharmacy Guild have had differences of opinions with regards to clinical services in the past. However, it does not seem fair that any pharmacists should be caught in the middle just because our professional bodies have disagreements.

    Regarding the evidence I agree that it shows a benefit to the patient if a pharmacist is involved in their care, which is a very good thing. However, no studies have compared the embedded model with a pharmacist based in a Community Pharmacy. Hence, it cannot be said that a pharmacist situated within the four walls of a medical practice is able to perform superior clinical work. In addition, when you look at the follow-up studies to the PINCER trial it shows that it was not cost-effective public spending – it was argued that specific medication-related issues should be targeted for it to be worthwhile. This is not to say that when a pharmacist solves a medication problem, any medication problem, that this is not appreciated by that particular patient. However, as we are talking about a model that is proposed by the PSA to go on a national scale it needs to justify that public spending – otherwise the money could potentially be better spent elsewhere for a greater overall benefit to patients

    Reading about this model there is a notable omission – the Community Pharmacist. If the PSA is truly on a mission to equip and make use of the great resource that Australian Pharmacists comprise it must truly incorporate this part of the sector in its modelling/discussion. We have proposed to both the Pharmacy Guild and the PSA that a national inventory is needed of what types of informal, non-remunerated, non-captured clinical services are performed in Community Pharmacy to better inform all stakeholders of where ‘to go next’. As Community Pharmacists/Pharmacies do not get paid for these direct patient interactions and the data is not captured, other than through the black hole of clinical interventions, they are not available to be analysed.

    Our letters to the PSA have been an attempt to highlight various issues regarding the embedded model – we find it disappointing that PSA does not value input from their own profession (even towards their own advertised discussion paper) but instead publishes ‘myth-busting’ fact sheets as well as accusing perceived opponents of this model as spreading ‘base-less fear mongering’. Why should the opinion of a pharmacy owner be of any less validity than any other pharmacist? We all have vested interests in this discussion and most of us are PSA members. In my opinion the PSA should encourage pharmacists, from all corners of the profession, to put forward their opinion so as to strengthen their policy position – not turn their back on voices that do not fit with their own agenda.

    It is worth pointing out that we sent this letter to the PSA on the 8th August 218 with a specific request for a formal written response to concerns and no response has been forthcoming. If the PSA truly believes that this model is the way of the future it needs to be able to accept constructive criticism and address shortcomings – not just deflect and avoid discussion.

    • Kevin Hayward
      31/08/2018

      In the majority of my time as a Practice Support Pharmacist, I have worked in community pharmacy and in GP practice simultaneously, the two are synergistic, not mutually exclusive. With regards to cost benefits, my original contract of engagement stipulated KPIs which specified rational cost effective evidence based prescribing, in every year we achieved sufficient cost savings to justify our services.

  5. Fredrik Hellqvist
    01/09/2018

    Hi Kevin,

    Thank you for sharing your experience. It is great to hear that your Community Pharmacy in the UK is part of a system that remunerates clinical services.

    Our concerns are arising from the fact that the PSA appears to be working towards a funding model that is not conducive to Community Pharmacy involvement, will incentivize GP surgeries to hire their own “in-house” pharmacist, and could in fact be detrimental to community pharmacy. The PSA is saying the Community Pharmacy can offer services on a contractual basis but we believe that such a model will lead to tendering and will not be good for Community Pharmacy or for patients. We completely support your view that there is value in a model that encourages collaboration between community pharmacy and GP surgeries but a funding model must be developed whereby Community Pharmacy is properly and fairly remunerated for its role.

    It is also interesting to note your situation where you have KPIs tied to your role. I assume that the KPI you are mentioning is tied to the UK Government’s Prescribing Incentive Scheme which financially rewards GP surgeries for meeting certain prescribing targets? We have raised concerns previously that once clinical services are funded, and those services are available to both GP surgeries and Community Pharmacies, medical centres will tie those clinical services to KPIs for their pharmacist as to capture as much funding from the patient before they leave the surgery and your situation seems to confirm this scenario. As we probably will not be able to claim for the same service twice Community Pharmacy loses out – potentially with less overall funding to support the roll-out of these ‘new’ services. As the activities of the embedded pharmacist proposed by the PSA is not fundamentally different from what a Community Pharmacist does/can do we end up in this situation with extensive overlap and issues of funding potentially.

    Our preference would be for a model that fairly remunerates CP for its clinical role – for example, we think there is merit in the idea of the patient centred medical home – where the patient chooses their GP surgery and pharmacy who work together to provide care – and the funding model is based on bundled payments that incentivise health outcomes rather than “fee-for-service” that encourages volume/throughput.

    • Kevin Hayward
      01/09/2018

      We were fairly remunerated for our professional services to the GP practice, with a fee for attendance rather than per item of work. Remuneration was not an issue.
      The business also benefited from the increased exposure of having our Pharmacist co located in the surgery. So it complemented the strategic business plan.
      The Pharmacist had the benefits of increased professional diversity, training and experience.
      Practice Pharmacists had the opportunity to be involved in promoting and developing community pharmacy services in general. So we had commitment to continuing professional development.
      I can see no reason why the same benefits could not be gained by engaging Australian community pharmacists in GP practices?

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