GP pharmacist claims don’t pass the pub test


Moves towards integrating pharmacists into GP surgeries duplicate roles and may drain community pharmacies of talent, writes Catherine Bronger

Suggestions made in a recent report that integrating non-dispensing pharmacists into GP clinics may in some way be a panacea for our health system are misguided and misinformed.

The report, Snakes and Ladders: The Journey to Primary Care Integration, makes a solid attempt to – among other things – find ways to lift professional collaboration between healthcare professionals in the interests of patient outcomes.

This is a principle that I believe the vast majority of healthcare professionals support wholeheartedly on the proviso that populist expediency doesn’t override pragmatism when we look at the realities of healthcare delivery.

Quite bluntly, some of the conclusions and statements when referencing pharmacists and their role in this report don’t pass the pub test.

In fact, they go against the very principle that they’re purporting to support: recognising the importance of professional collaboration and team-based care within care settings and across all areas of care.

The report states: “The inclusion of pharmacists within general practice brings benefits for patients in terms of better medicines management, and to the system through better use of medicines and reduced adverse events. To speed up the desirable inclusion of pharmacists within practices, the Australian Government should dedicate a component of the professional services program under future Community Pharmacy Agreements to support models of care that integrate general practice and pharmacy services, and fund general practices (through increased funding of the Workforce Incentive Program or through PHNs) as an incentive to employ non-dispensing pharmacists.”

This statement is quite breathtaking in that it somehow manages to completely ignore the existence of the 5,700 community pharmacies across Australia, as well as those many pharmacists already working collaboratively with their health professional colleagues.

While strongly advocating the use of non-dispensing pharmacists in GP practices, the report also demonstrably fails to acknowledge the broad range of health services that are already being provided by community pharmacies.

Quite clearly such acknowledgment may have diluted the narrative of this report.

The report makes the leap to suggest that having a non-dispensing pharmacist co-located in a GP practice will bring better medicines management, better use of medicine and reduced adverse events to patients in rural settings. 

What it doesn’t articulate is that the services it so strongly argues for to be delivered in a GP practice are already universally available and delivered to patients in their community pharmacies right across Australia. And yes, that includes rural, regional and remote locations where dedicated community pharmacists are the stalwarts in health care delivery.

Not to mention some areas where the community pharmacist is the only health care professional available, with no GP, let alone a GP clinic, in sight.

Clearly, what the report is suggesting represents a mandated duplication of services. It is not innovation, but rather replication.

While advocates of pharmacists in GP clinics argue strongly in their favour, I am unaware of any cost effectiveness review or thorough evaluation of such a role in relation to any health outcomes achieved through embedding a pharmacist in a GP clinic. Until we have such evidence we are delving into the realms of fantasy as to the purported benefits of such a model.

What we have to take into account is that this debate is actually counter-productive.

At a time when rural Australia, including community pharmacy, is facing workforce shortages the concept of promoting roles for health professionals that duplicate existing roles, seek to create silos and fragment care can only be detrimental to patient care and to the overall health system.

Trying to attract pharmacists to clinics while community pharmacies are battling to fill positions is a regressive step and one which we must avoid.

The use of the Workforce Incentive Program as mentioned in the report will serve to exacerbate the already serious workforce shortages seen in community pharmacy small businesses in regional, rural and remote areas.

It is crucial that any workforce incentives are specifically aimed at encouraging pharmacists to practise in regional, rural and remote community pharmacies. The incentives also must support community pharmacies in their ongoing commitment to retain and enhance the professional roles of their existing pharmacist workforce. 

Rather than following the Snakes and Ladders path, I believe we must use these incentives to facilitate a “community pharmacy outreach model” which would result in true collaboration between GP practices and surrounding pharmacies focusing on genuine integration and collaboration across the primary healthcare sector, right across Australia.

Such a model would appeal to pharmacists attracted to the GP practice concept. It would give them the opportunity to work with other health professionals in a variety of settings while also providing greater opportunity to better utilise their skills and knowledge.

This is the way forward for patient care.  The Snakes and Ladders approach in regard to pharmacists in GP clinics, when broken down, seems to me to be little more than a poorly disguised proposal for additional funding for GPs, with little or no positive outcomes.

The report only exposes its interest in pushing a certain political agenda and ignoring the very needs of the people it is supposed to be representing – health consumers and patients.   

Those health consumers and patients deserve better. 

Catherine Bronger is a community pharmacy owner, national councillor for the Pharmacy Guild of Australia (NSW) and a member of the UTS industry advisory Board.

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35 Comments

  1. Andrew
    28/09/2018

    I’d prefer health policy was based on evidence and cost/benefit rather than this “pub test”.

    When community pharmacy can demonstrate superior outcomes to an integrated pharmacist there may be something to discuss. Until then it’s all conjecture.

    Stop protecting a dying model.

    • SPG
      30/09/2018

      This is the problem – there is no evidence that one model is superior to the other as the two models have not been compared.

      • Kevin Hayward
        30/09/2018

        We were a two pharmacist team, with one of us, part time based in our local GP practice, it worked extremely well for all, not forgetting the patient. I can’t see what all the fuss is about? We saw it as an opportunity, not a threat.

        • SPG
          01/10/2018

          One of our key concerns is that practice pharmacists will be funded to perform services that are already being performed by the local community pharmacy but for which the community pharmacy is not remunerated.

          • Kevin Hayward
            01/10/2018

            From my own perspective I currently provide medication reviews and health education, previously I have been tasked with health promotion, clinical governance, professional education data analysis and prescribing support. I have been asked to support commissioning of new local community services, I do not recall these activities detracting from the community pharmacy, in fact quite the opposite. Could you please elucidate?

          • SPG
            01/10/2018

            Debbie Rigby recently pointed us to this link to show us the sorts of activities a practice pharmacist might perform https://www.nps.org.au/australian-prescriber/articles/the-practice-pharmacist-a-natural-fit-in-the-general-practice-team. We consider there is strong overlap between the patient facing roles of a practice pharmacist and a community pharmacist and that there is a likelihood that GP surgeries will direct their practice pharmacists towards these sorts of activities as these are most likely to attract funding (as shown in the UK pilot). This raises the question of what the impact may be on community pharmacy.

          • Kevin Hayward
            01/10/2018

            If the HMR cap were lifted, it could be argued that some of the workload anticipated for PSPs could be met by community HMR pharmacists, but I have my personal caveat on untrained educators or clinical governance facilitators etc (see slow), and prescribing confuses the picture further.
            But in the current paradigm there is a restriction on HMR which prevents HMR pharmacists from providing review services

    • Kevin Hayward
      30/09/2018

      So correct, as a business educator I used to teach change management, a business model that does not evolve as you say will die. One of the few constants in our lives is the inevitability of change, failure to change will lead to failure of your business

  2. Amandarose
    28/09/2018

    What doesn’t pass the pub test is the blatant self interest of pharmacy owners over the public’s best interests.

  3. juanita westbury
    28/09/2018

    I worked in 5 GP practices in the U.K. I have also worked for over 20 years in community pharmacy in 4 states in Australia and the A.C.T. So I can speak to both practice settings. Can you Catherine Bronger?

    The work I did in GP surgeries did not replicate what I had done in community pharmacy but, instead enhanced it. I often referred patients to pharmacies for OTC products or services like BP monitoring. I also developed a real appreciation of GPs, practice nurses, community nurses and practice staff – and the complexities of prescribing (yes I was prescribing under GP supervision). Prescribing costs reduced in all of my practices (The NHS directly assesses this) as did reportable prescribing errors – and patients, although, often wary at first, loved the opportunity to go through all their medication with no interruption and without feeling as if they had to buy something on the way out. I had little time and support to counsel people in the community pharmacy setting where I was often stopped to answer queries, phone calls or check scripts.

    Working in GP practices was the most professionally satisfying role I have had to date in a very varied career across 4 countries and most of Australia. Before Catherine Bronger makes such an assertion that the two roles are basically replications of each other she should try working for a week in a GP practice.

    • Kevin Hayward
      30/09/2018

      My experience is similar, I completely agree with you

    • Debbie Rigby
      02/10/2018

      Juanita, I agree. I have worked in a general practice and also talk with many other pharmacists in the role in Australia, and and we all agree that the roles are not duplication or in competition with community pharmacists. The benefit is clearly working in the GP surgery, supporting GPs and other practice staff, and direct patient care. In my experience it is filling the gaps in the medication management pathway and acting as a liaison with hospital and community pharmacists.

      One of the most valued roles for me was providing drug information to the GPs, based on my skillset and experience, and knowledge in particular therapeutic areas. I’m not saying this cannot be provided by a community pharmacist, but having critical evaluation skills and university library access to publications certainly helped. I also set up a respiratory clinic, largely driven by the fact that the closest pharmacy did not provide any counseling of inhaler device technique in their business model.

      Roles are not clearly defined as yet, but will evolve according to local needs, patient demographics and practice pharmacists skillset and experience. I think flexibility and collaboration will be the key to successful implementation and sustainability.

  4. PrescribingSolutions
    28/09/2018

    Would the consumer prefer ‘outreach’ from a pharmacist who the previous day was complicit in trying to up-sell them a non evidence based supplement, or a pharmacist who is integrated into the general practice team unencumbered by conflicts of interest ?

    • Kevin Hayward
      01/10/2018

      In the first model we experienced as PSPs one of us was based in the local medical practice part time. To avoid favouring any single local pharmacy or patient group, that pharmacist was employed by the practice with funding from government, and due governance from both. With aims and objectives, and associated KPIs set externally, this removed any bias or duress

      • PrescribingSolutions
        02/10/2018

        The arrangements you describe sound reassuring. My concerns about the model the author describes are as much about perceptions of integrity from consumers and GPs. As we know perceptions are all important and it would be tragic if adverse perceptions hindered progress towards realising the benefits of general practice pharmacists.

  5. Greg Kyle
    28/09/2018

    Guild members and “representatives” have a history of using this same rhetoric. Essentially the Guild doesn’t want pharmacists have choice in employment sites, they only want pharmacists to have a choice of their members as employers. If Guild members are concerned about pharmacists leaving community pharmacies to work in GP practices, they should look at what they are offering. Money is one thing, but professional satisfaction is a major factor. What are the incentives for pharmacists to go to rural and regional areas? Personally, I have worked in these areas (as both a pharmacy owner and consultant pharmacist) and encourage pharmacists to “go bush”. However, there need to be the incentives to encourage this. If city-centric pharmacists are not happy working in city pharmacies, what will attract them out bush?
    I encourage pharmacists to practice to their full scope. This includes being a medicine manager, problem solver, consultant, prescriber (currently only OTCs, but watch this space) and dispensing. Do what you enjoy – you don’t have to do it all. I know sometimes you need to do practice in your less favoured areas to pay the bills, but always keep your eyes open for opportunities to expand your professional practice and fulfill your pharmacy dream.

  6. Shamsher Singh
    28/09/2018

    Hi Catherine
    I just read your article and found it really interesting. I completely agree with you on each of the points that you raised. Something that grabbed my attention the most is that this model will not be innovation but will be duplication of services that are already performed in community pharmacies. In relation to that, I refer to a Systematic Review and Meta Analysis published in volume 10 Issue 4 of Research in Social and Administrative Pharmacy; in this article they analysed 38 studies to review the effectiveness of pharmacist services delivered in primary care general practice clinics. Interestingly, 86.8% of the interventions were medication reviews, the service that already exists in community pharmacies where pharmacists in collaboration with doctors work towards better patient care.

    • Kevin Hayward
      30/09/2018

      So why did the Guild cap meds reviews?

    • Kevin Hayward
      30/09/2018

      Whilst I have always been involved in medication reviews, this has only been part for my role as a practice support pharmacist, currently a major part of my role centres around my skillset as an educator. Previously I have been involved in commissioning pharmacy services, management, data analysis,clinical governance, health promotion etc. The pharmacist activity in GP practice will be dictated by the funding stream available and the post graduate qualifications of the professional.
      Practice support Pharmacists need to be bringing value added services into commision, it may be my own choices of education and medicines reviews, or it could be prescribing or any one of the other areas I have found myself in, but it has to be more than just sending a basic grade pharmacist to work in a surgery, all this will do is duplicate what the pharmacy already does.

  7. Michael Post
    28/09/2018

    I see ‘pharmacy outreach’ as maintenance of the status quo. I think any new career pathway for pharmacists in general practice should be independent of Guild management.

    The pharmacy profession outside of hospital is in need of a dedicated clinical role in addition to the existing Guild /retail role in my opinion. Employee pharmacists supporting their owner and community have not thrived in many circumstances under the Guild model and are unlikely to thrive under their umbrella should an ‘outreach’ approach gain traction.

    Community pharmacy and general practice pharmacy can co-exist. Attracting staff will require innovation and steps to provide professional/ financial satisfaction in either setting.

  8. Stephen Roberts
    28/09/2018

    We all know the agenda of the author behind this article, who according to LinkedIn owns 3 pharmacies in Sydney. PGA members are worried they will lose their captive pharmacist workforce, which currently enables the imposition of excessive workloads while paying peanuts, thus improving store profitability. Pharmacists able to practice independently in GP clinics will surely be a superior career choice and provide a much needed respite.

  9. SPG
    30/09/2018

    If pharmacists are to be better integrated within the healthcare system the current and potential role of community pharmacy must be included in the discussion about collaborative care models.

  10. Kevin Hayward
    30/09/2018

    Dear Catherine, as a propritor of an independent pharmacy in the UK we benefitted greatly from having one of our pharmacists based part time in the local surgery. We had data to show improved prescribing indicators and cost benefit. We found the collaborative working challenging and rewarding. Our customers benefitted too from the increased professional services provision we were able to capture.
    I cannot see why Australian pharmacy sees this as a threat? It is a great opportunity!
    I should add, that it is easier for me to expound the virtues of the practice pharmacist model, because I have actually done it, in a number of settings and guises, and it appears to work on a number of levels for the many patients and professionals involved.

    • Anthony Tassone
      30/09/2018

      Kevin

      Your previous experience from the UK whilst being a proprietor of an independent pharmacy and having one of your pharmacists based part time in the local medical center sounds like the “community pharmacy outreach model” that Catherine referred to in her article as a preferred way forward for pharmacists based in general practice.

      I agree that a “community pharmacy outreach model” would pose opportunities for community pharmacy, but that is not necessarily the model advocated by proponents of pharmacists being co-located in general practice.

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

      • Kevin Hayward
        01/10/2018

        It should be made clear that in our model the pharmacist was an independent professional, not favouring thier own pharmacy or patient grouping, developing and providing services for all patients and pharmacies in the locality. The pharmacist was employed by the medical practice with central government funding, such as the forthcoming WIP funding in Australia. Due governance was implemented to ensure no conflict of interests with associated standards and scope of practice being defined.

        • SPG
          01/10/2018

          The PSA is saying that the model being funded through the workforce incentive program should largely be directed at system level activities within the general practice – clinical governance, education and training of practice staff and that community pharmacies should be able to deliver these services. But what measures or regulations will be in place to ensure this is the case? There is evidence to suggest (from the UK pilot) that practice pharmacists spend much of their time in patient facing roles, specifically performing medication reviews. This is a service that is currently already performed by community pharmacists or consultant pharmacists.

          • Kevin Hayward
            01/10/2018

            I personally don’t believe that as a community pharmacist I was in a position prior to my post grad training to assume a role in clinical governance, it took me a while to acquire this skillset. Equally as an educator working in the VET sector, I don’t hold with people providing education and training who do not hold the relevant qualifications. I would not attempt my current role as an educator in GP practice without the skillset and qualifications.
            If pharmacists in GP practice are anticipated to be spend the majority of thier time reviewing medications, you are correct, this would be an unnecessary duplication of services in Australia. The simple remedy would be to get rid of the HMR cap

  11. Jarrod McMaugh
    02/10/2018

    There are a few issues here – but it all boils down to the tension between what a pharmacist does in a GP practice, and what a pharmacist does in a community pharmacy, and whether these roles will either clash in some manner, or if it is viable to have two people doing these roles in a “small space”, so to speak

    The problem we have is the history of pharmacists doing things that aren’t in the best interest of their colleagues.

    You can see this in:
    > The style of business done by some discount chains;
    > The lack of reinvestment in to businesses or the industry at the time that PBS funding was not subject to price disclosure;
    > The fact that pharmacists will work for the minimum award instead of using their numbers to demand more
    > The fact that we needed caps on HMR (and then Medscheck)
    > The fact that caps are not reversed and replaced with audits.

    This is a pattern.

    Why is this relevant?

    Because we have people who are early adopters like Juanita, Kevin, and Debbie below, plus others such as Chris Freeman, Andrew Ridge and Amy Page who are doing great things now.

    We look at how they perform the role, and we expect that this is how it will be for every pharmacist working in a GP clinic everywhere.

    This isn’t realistic… but it’s also not a reason to suppress or control this growing pharmacist career pathway.

    I know how I practice as a community pharmacist. I know there are many like me. I know there are people who practice hospital pharmacy to a high standard.

    This is what we expect from all of our colleagues.

    But this isn’t realistic. We know that there are people who are practicing within our profession who do not live up to our own personal standards. This brings the perception of the profession down to a lower level than many of us should be comfortable with.

    The reality is, as GP practice pharmacists become more common (especially if their work is subsidised to some degree, even temporarily), we will see the same pattern of lowering standards. There will be practices who are driven only by the income these pharmacists may generate (some of which will come from the CPA, btw, which is not appropriate). We see this example in surgeries now, but also in nursing homes and other health-industry businesses….. there is a spectrum of good practice financially driven practice, and we WILL see this eventually.

    This means we will eventually see pharmacists working in general practice who are duplicating work done by local pharmacies…. for many, this would be the only way for the role to be viable.

    yet this isn’t a reason to prevent pharmacists working in GP clinics.

    The Small Pharmacy Group does have a good point though with regards to the workforce incentive payments. This is basically paying one business to employ a pharmacist in direct competition with a local pharmacy…… perhaps not for the work, but definitely for the workforce. I can only imagine how irate Peter Crothers would be if there were pharmacists lured to work in BH with this workforce incentive, while he offers very good employment that isn’t attracting good candidates.

    Here’s another issue, with regards to pharmacists working in a pharmacy who are contracted to work in a GP clinic…… the chances of this scenario happening in real life are pretty slim in my opinion.

    If there is clinical work to be done (HMR for instance) then I could see a small GP clinic creating an agreement with a pharmacy or a contracted accredited pharmacist to do that work as needed.

    For the governance work though, there is little chance of this being done by “outside” people who aren’t employed by the surgery. If someone came to me and told me that my business could be audited with feedback and education provided by an employee of another business, I’d tell them to wake up to themselves – that wouldn’t be welcome whatsoever. It is very short-sighted to think that this kind of model would ever be accepted (on any scale). Pushing for this role to be performed by pharmacists who work in the local pharmacy is ludicrous. For proof of this, just look at how pharmacists are currently spoken to by GPs when we ring about a prescription issue – lots of good examples, but the bad ones stick in your memory forever. There is zero chance that such a role would ever be accepted. Governance roles within a GP clinic would be welcome only where the pharmacist was part of the staff of that clinic, not an external person.

    TL;DR – this role should exist, there WILL be lowering standards as it is established, there WILL be duplication of roles, there WILL be those in this role who are focused on financial return at the expense of clinical benefit; there will NOT be a demand for these services to be provided by community pharmacy businesses to GP clinic businesses.

    • Kevin Hayward
      02/10/2018

      Dear Jarrod, I believe your synopsis is probably likely to eventuate, although I sincerely hope that other pharmacists in community pharmacy will get the opportunity I did, to use thier extended skills or special area of expertise working in a GP practice.
      I hope that unecessary duplication of services is not a result, I believe a resolution of the HMR issue may go some way to resolving this.
      Now is the time to work collaboratively, to make certain that this change in practice is an opportunity, not a threat, for all, especially patients

      • Jarrod McMaugh
        02/10/2018

        With all due respect to your experiences Kevin, I don’t need a change in where I practice to extend into areas of interest or expertise.

        I’ve been practicing in a manner that has pushed the boundaries of “scope of practice” long before titles like ”advanced practice” were dreamt up as a way of adding prestige to a title but adding nothing to the profession.

        I’ve managed pharmacies that delivered spirometry, asthma education clinics, quit smoking motivational counselling, sleep apnoea screening, bone density screening, & cardiovascular screening, while also coordinating an ORT program with the local health service, delivering NPSmedicinewise programs as a clinical educator through the Bendigo PHN, and providing HMR home visits in rural areas.

        Pharmacists who move in to GP practice should do so because it interests them, not because they think it will broaden their scope of practice. If a pharmacist can’t push their boundaries in a community setting, they wont do so either in any other setting.

        Btw taking caps off HMR won’t really I pact on the viability of GPpractice pharmacists…. Mainly because their role shouldn’t be built around HMR.

        MBS provider numbers, however…….

        • Kevin Hayward
          03/10/2018

          Dear Jarrod, we have both been fortunate in having sway over the community pharmacy we work in, to develop our professional services. The truth is that I have worked in many community pharmacies where the employee pharmacist would not have this opportunity, and would even be discouraged.

          • Jarrod McMaugh
            03/10/2018

            I think that’s a bit of a cop-out Kevin.

            My first employers were supportive, but also very mindful of waste, and weren’t interested in me chasing after pipe dreams.

            My second employers were also very mindful of waste, especially since they had partnership shake-ups a few times while I was there.

            I was given “sway” because of the conviction I had for these services, the clear benefit it brought my patients (and therefore goodwill for the business), and the professional satisfaction that we all earned by making it work (or killing things off when they didn’t).

            Pharmacists have a lot of negotiating power if they would just utilise it…. those who allow their ambitions to be crushed by a disinterested manager or employer should take on some personal development work and figure out how to present their plans again…. or move on.

          • Kevin Hayward
            03/10/2018

            No cop out! Please remember small town and regional pharmacists do not have the luxury of jumping ship, and moving from one employer to another. It can be a case of make yourself unpopular, find yourself out of a job, or moving town. Not so easy if you have commitments.

          • Jarrod McMaugh
            03/10/2018

            up until I purchased my pharmacy 3 years ago, all of my employment was in rural and remote pharmacies.

  12. Angus Thompson
    15/10/2018

    In my experience as a general practice pharmacist in the UK, key roles included prescriber and practice team education, modifying IT systems to support formulary guided prescribing, audits and reviews to improve the quality, safety and cost-effectiveness of prescribing and focused clinics to address areas of identified need. It was routine for me to drop in to local community pharmacies to keep them informed of the work we were doing with practices and the rationale for that work. I would suggest that claims general practice based pharmacists duplicate services provided by community pharmacy are unfounded, as are claims that such pharmacists work in silos.

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