One pharmacist suggests a trial of triaging in pharmacy in the bush… given in some cases, it’s already happening
“We’re in a small, rural setting – not remote, but quite rural,” says Robert Baun, the pharmacist at Healthsave Pharmacy West Wyalong, in country NSW.
“And over the period of Christmas time, West Wyalong was without a doctor for three weeks.”
Mr Baun was responding to a recent AJP article where GPs reacted with “horror” to a suggestion that the NSW Government allocated funding to re-direct non-urgent emergency presentations to community pharmacy.
GPs had responded with concern, with one saying triaging involved being able to “adequately assess that it is a headache that can be treated with paracetamol, versus one that needs to be more thoroughly investigated” and not “just a fun, income generating exercise”.
But Mr Baun pointed out that across rural and regional areas, some pharmacies are doing this already.
He said GPs might consider pharmacy triage to be “an invasion of their practice boundaries, but there are certain environments where it’s probably very helpful for them, and for the community”.
Meanwhile in Queensland last week, Minister for Health and Ambulance Services Yvette D’Ath noted that 30-40% of monthly presentations were classified as non-urgent complaints which could have been seen by a pharmacist or GP.
Over Christmas, “Patients had nowhere to present. They had to potentially drive another 150km to Wagga to see a doctor, or to Temora, south of here,” Mr Baun told the AJP.
He said that the pharmacy was fortunate to employ a registered nurse who has 30 years’ experience is able to administer vaccines and is “amazing” at wound care.
“People came here often, as opposed to the hospital, because they knew there were no doctors there,” he said of the Christmas 2020 period.
“We’ve had people come in with great big abscessed wounds, the consequences of too much alcohol on Christmas Day. We tried sending photos to doctors in other towns. A week later one wound was 10cm by 2cm deep because he didn’t have immediate access to a doctor and so it just rotted.
“Pharmacy could take the burden away from an already overburdened system,” he said.
“In a rural area, there are a lot of farm incidents – last harvest there was an amount of people who got their fingers caught in farm machinery. Everyone’s working 24 hours a day to get crops in, everyone’s tired and trying to do things too quickly, so it’s a very accident-prone time – and of course that’s the same time as there’s no doctors in town.
“The telemedicine system has changed things, and that’s great. But at the same time, it appears to have its boundaries.
“The doctors are only available when they’re available, and then sometimes they sign off before the prescription gets sent – all scenarios, we’ve had it. The telemedicine system will change the way we operate out here, but that first-instance clinical stuff still needs to have a person there to deal with it.”
He said that the town has a hospital as well as four doctors in three different clinics, but “geographically, this covers a very large area”.
“The distances people travel to access medication or see a specialist can be big – the next specialist might not be till Wagga or Canberra or Dubbo. So in town, the four doctors are pretty much booked up, even the doctor in the clinic next to us, and they can’t take more.
“If you decide to move to West Wyalong you can’t get a doctor. They’ll triage you in an emergency but we get a lot of people in the pharmacy.
“We’re very fortunate to have a great professional relationship with the doctor next door – our nurse can sit down and do pretty much a full triage on a patient.
“She can go see the doctor and say, ‘I’ve got Mr Such-and-Such here, he’s presenting with high blood pressure, these are his symptoms, I think he needs fairly urgent attention,’ and the doctor will make time to fit that person in. We’re in a very privileged situation to have people working cooperatively like that.
“There’s a real lag period before people can see a doctor, and by the time they get there it’s often manifested into something that needs far more attention. We’ve had multiple scenarios: one gentleman had his medication all messed up, we sent him to the hospital and he didn’t get very good attention there.
“We ended up resolving that by finding he’d been given the wrong dose, and it was only through being able to contact the doctor directly, even though he was on holiday, that we resolved it.”
He said that the doctors in town were “quite comfortable” with the concept of people presenting to the pharmacy in their absence.
Mr Baun added that regarding the remark about headaches and paracetamol, “I’d respond that quite often we do go beyond that headache and find out that there’s, for example, a mental health situation, a response to a marriage breakdown, or finding out that a family member has been diagnosed with a terminal disease”.
“You can get to a bigger picture,” he told the AJP. “Some of the [doctors’] comments are made without full respect to the more caring or communicating pharmacist.
“Perhaps some people see pharmacists as having a limited realm of training, which I fully respect – but I honestly think, sometimes, that our understanding of human physiology and disease process is probably underestimated. When you talk to a patient, if you actually care, you do ask the right questions to try and resolve their problem.
“In these types of settings and in rural environments, people don’t have the privilege of multiple medical resources: you’ve really got to go with what’s the next best available option, and in this case that’s the pharmacy,” Mr Baun said.
“We’re in a good position to be clinical, but the boundaries of our profession at the moment really hamstring us as to what we can offer the community in the setting we’re in.
“I’d like to talk with the Pharmacy Guild about setting up an example site where you can prove just how functional a clinical setting in a pharmacy can actually be.
“This is with full respect to GPs. They have control, and ongoing control, of the care of that patient with that patient, but there are situations where we can take the burden away from them using a nurse, triage and refer when necessary, making the rural pharmacy scene a bit different.
“I do understand that in some pharmacies in bigger cities, you’re two or three barriers away from the pharmacist and don’t get that one-on-one patient connection, whereas in a country town, as a pharmacist you know your customers.
“You know how their crops are going and possibly even more about their day-to-day lives than their medicines! It’s more personable and they’re quite happy to share private information with you, and respect your feedback.
“If you get into a battle about who’s better at their job, you’ll never make progress.
“If there was ever an opportunity to prove that a clinical environment could work in a pharmacy, the setting here [in West Wyalong] would be an ideal site for a case study, as we have a nurse, good relationships with doctors in town and a community that would benefit from having that extra service, because of the lack of convenience with health care in the bush.”