‘There’s professional ideals of pharmacy that have almost been abandoned.’


doctor and pharmacist armwrestle

A prominent GP and pharmacy critic has told the AJP that community pharmacy is losing its focus on its area of expertise, that Health Destination Pharmacy is like selling pharmacy’s soul and that commercial interests are taking precedence over community health.

The RACGP’s Dr Evan Ackermann tweeted to the Pharmacy Guild and Health Minister Sussan Ley earlier in the week that when only pharmacists are included in management of patients post-discharge, re-admissions increase.

He also penned an MJA InSight piece recently claiming that any Minor Ailments Service implemented by pharmacists would just be “a push by the pharmaceutical industry and pharmacy business to increase drug sales under the guise of health innovation”.

Dr Ackermann says that as pharmacy grows and changes it’s “interesting to see what pharmacy wants to grow into”.

“They’re entering areas that they have little expertise and training in, and entering areas in association with the pharmaceutical industry, and I’m concerned about that,” he says.

“Health Destination Pharmacy is in association with about eight different companies, and a couple are drug companies.

“They’ve set an unprecedented partnership between the PSA and industry, and that’s not really a professional development, that’s sort of selling the soul.

“I think at some point in time, pharmacy and pharmacists have got to look at their core responsibility in the health system and focus on that community medicines management, because those failings now are becoming more obvious. It just seems wrong as someone outside that sector looking in.”

He cites sector lobbying to retain codeine-containing over-the-counter medicines as one of these failings.

“Putting sales of drugs of dependency like codeine over safety, they have these STOP programs in they know it doesn’t work. They continue their association with complementary medicines and nothing’s done about that.

“It’s like there’s professional ideals of pharmacy that have almost been abandoned.

“I think a fundamental problem has been the Guild negotiating the Pharmacy Agreement for over 25 years; that’s led to the promotion of the business issues over the professional issues.

“I actually feel for the pharmacists – these are professionals trying to do their job, and they’re struggling, but the big business owners and corporates are raking in money trading on the pharmacist’s professional persona, yet the pharmacists themselves are being ripped off.”

On the subject of hospital readmissions, Dr Ackermann told the AJP that international evidence for pharmacist management post-discharge is not of high quality.

“Hospital pharmacies actually do a reasonable amount of work in this area and they have been particularly good at doing reconciliations, things like that, and there’s some evidence that it’s helping hospital readmissions,” he says.

“But in the community pharmacy, with HMRs and RMMRs and so on the capacity to reduce hospital readmissions has quite minimal evidence to support it and that relates to one study about heart failure.

“So you can’t say there’s no evidence but there’s a low quality study. Internationally multiple studies on this haven’t been favourable.

“The AMA did a submission to the Government about pharmacy in general practice and proposed a payment for this; they said it would be cost beneficial and had a DeLoitte study saying that but there’s not one bit of evidence to support that they can reduce medicines adverse events.”

Dr Ackermann told the AJP that these claims would need to be formally quantified.

“From a professional point of view I think the argument should be settled with a formal study, and that should be part of the pharmacy trial program under the Sixth Community Pharmacy Agreement. We need a formal trial to say, ‘okay, this trial is set up to see if a pharmacy review can reduce hospital readmissions as claimed’.

“And if it goes against the grain of international evidence and finds that it does, great. But if it doesn’t, we have information on which to base our health decisions.”

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11 Comments

  1. John Wilks
    11/04/2016

    I will refrain from noting where I agree with Dr Ackerman, least I appear churlish in criticizing my professional colleagues, but am most willing to state that negative comments apropos the merits of the HMR and RMMR program to be without clinical merit. A number of studies have been published which show that HMRs have a marked clinical and economic benefit. The work by Peterson et al ” The Role of Community Pharmacy in Post Hospital Management of Patients Initiated on Warfarin” is one illustrative example.

    I would be more than willing to provide de-identified HMRs, with the clinical actions undertaking by the patients’s GP, to further highlight the vital clinical and economic role exercised by HMRs.

    • Drugby
      11/04/2016

      John is correct. There is good evidence of impact and outcomes for HMRs and RMMRs, as well as a few systematic reviews and meta-analyses showing benefit. I compile a list of the published literature for AACP, and there are over 350 citations. And the economic benefit has been quantified by Andrew Stafford in his PhD.
      The challenge for the profession, especially accredited pharmacists, is to improve both the degree of collaboration with GPs and the quality of the reviews. Unfortunately we will always be judged by the lowest common denominator, and some reviews continue to be superficial. I wish we had a formal mentoring program and peer review support for accredited pharmacists.

      • John Wilks
        11/04/2016

        Yes I concur with the idea of a mentoring process. Or, perhaps, we could submit de-identified reports to …..??? for collegiate comment and review.

        More to the point, could I suggest that an essential part of one’s tri-annual accreditation is the submission of said reviews for assessment. Passing open book exams does not, and never will mean that an accredited pharmacist is capable of writing incisive, didactic reports that benefit both the patient and the GP.

  2. Neil Johnston
    11/04/2016

    You do get a bit fed up with the crap and nonsense that is continually spun by RACGP president, Dr Evan Ackerman.

    The reality is that he is running scared by pharmacy ambitions to expand its core business to include payment for a range of services that pharmacists have always provided, but have done so under a business model where the margin on medicines involved in that process paid for the service.

    In simple terms, pharmacy is just updating its business model to adjust to the disruptions that have occurred through technology changes and market changes.

    So, all that is being considered for the moment is what price- and a more concise list of what type of services.

    The Health Destination Program proposed by the PSA is but an initial component.

    It is slowly being tested over a period of time so that it arrives in a rational and evidence-based format.

    It is a good program – hence the rant from Dr Ackerman.

    It is a program that will see pharmacists mostly extricate themselves from the dispensary, and it will see robotic equipment installed along the way.

    Doctors seem to think they have the divine right to interfere in all other health professions.

    That is divisive and certainly damages any sense of collaboration.

    What pharmacist in his right mind would want to collaborate with Dr Ackerman?

    He fronts a profession that earns extra questionable income from Global pharma companies “under the radar”.

    There is also evidence that the medical evidence database is hopelessly corrupted so when he points the finger at pharmacy, he should think a bit about the quality of evidence he is quoting.

    The worst form of evidence is corrupt and fabricated evidence.

  3. William
    11/04/2016

    There is no doubt that the medical profession will fight to the end to maintain their monopole over all health matters. It is under attack by the nursing profession and in a lesser mode by pharmacist.
    Pharmacy is fighting to reinvent itself as they are no longer required to “compound” products, just document and label preprepared products. The “good old days” of mystery behind the mirror are well gone.
    Is it really necessary to have university degreed people to do this job? It can and will be automated in the near future. The same will happen with the writing of prescription where it could bear machine readable code(s).
    The driving force will be the government which is rightly concerned at the ballooning costs of healthcare and thus increasing overall healthcare productivity.
    Most pharmacies these days are just shop keepers.
    Rather than criticise the medical profession pharmacy need to determine a strategic plan for the itself.

  4. Drugby
    11/04/2016

    A systematic review and meta-analysis (ie highest level of evidence) has just been published in Journal of Clinical Pharmacy and Therapeutics on pharmacy-led medication reconciliation. Nineteen studies which involved a total of 15 525 adult patients were included. Eleven studies were randomized controlled trials. Compared with usual care, single medication reconciliation interventions by pharmacists at transitions in care (either admission or discharge) showed a significant reduction of 66% in patients with medication discrepancies (RR 0·34; 95% CI: 0·23–0·50) in favour of the intervention. Importantly, medication discrepancies of higher clinical impact were more easily identified through pharmacy-led interventions than with usual care.
    This is strong evidence that pharmacists can make an impact on patient care at this high-risk time, which will led to cost saving in preventing avoidable readmissions to hospital.

  5. Anthony Tassone
    12/04/2016

    Not content with his campaign against pharmacy on Twitter, Dr. Ackermann takes to (another) pharmacy journal to shout his ‘valid concerns’ as he says about the pharmacy profession.

    As others have mentioned, there is vast quality evidence of the important role that pharmacists can play around improvement around quality use of medicines particularly at critical junctures of transitions of care. This is all an inconvenient truth for Dr. Ackermann.

    Whilst Dr. Ackermann is a known advocate for the ‘No Ads Please’ campaign regarding pharma company reps visiting doctors for ‘educational updates’ – it is somewhat saddening that rather than advocate for this cause he previously joined, he would rather criticize a health professional colleague.

    An interesting recent article in ‘The Conversation’ seems to be completely overlooked in this debate “We can’t trust drug companies to wine, dine and educate doctors about the drugs they prescribe”;

    https://theconversation.com/we-cant-trust-drug-companies-to-wine-dine-and-educate-doctors-about-the-drugs-they-prescribe-56990

    An excerpt is below:

    “What the research says

    A study by investigative journalism group Pro Publica released in March provides important insights into the influence of industry payments on prescribing. The study combined reports of payments to doctors under the US Sunshine Act with prescribing records.

    The more money doctors received, the more brand-name drugs they prescribed. Those who were paid to speak at conferences or sponsored events prescribed more brand-name drugs than those just getting free meals.”

    The predictable response from peak bodies representing doctors, including the AMA were critical of these findings:

    “The response, unsurprisingly, is divided. The Australian Medical Association’s president describes industry-sponsored educational events as “in the best interest of patients”. Medicines Australia, the industry trade association, defends the industry’s role because: “No one knows medicines as well as those who make them”.

    Granted Dr. Ackermann is not an elected official of the AMA (he is often known to be critical of the AMA on a number of issues), he represents the RACGP. Interestingly an initiative called ‘Medi-Messages’ that appears to be endorsed by the RACGP is a phone message taking system that helps pharma companies promote their brands and vouches to ensure that the “doctor personally handles your brand…. on the message delivered to the doctor” with “each Medi-Message slip communicat(ing) important patient information to the GP” and that the “RACGP recommends Medi-Messages as a private message archiving system.”

    Not satisfied with receiving free dinners, doctors even need their phone messages sponsored by drug companies?

    Please.

    I recall a few cliche’s something about ‘cleaning up one’s own backyard’ and something about ‘stones and glasshouses’.

    A somewhat sigh when another pharmacy publication has decided to give a platform to a known critic hell bent on ensuring the role of the pharmacist is not expanded.

    Thankfully, the thoughts of Dr. Ackermann are not representative of local GP’s that many of us work well together with each and every day that respect the skills and expertise of pharmcists.

    The twitter profile for Dr. Ackermann reads “A GP who puts patient safety first. Chair RACGP National Standing Committee – Quality’.

    For somebody to truly put ‘patient safety first’ would they not want medicine experts assisting at the critical juncture of transition of care to ensure the correct medicines were being administered in the correct way? That would be a reasonable assumption rather than taking every single opportunity to denigrate a profession.

    Putting patient safety first means collaboration, working together to get the best outcomes, not shameless self promotion in a quest to criticise health professional colleagues.

    Perhaps Dr. Ackermann should consider re-reading the Code of Ethics from the Medical Board of Australia regarding respecting the skills of health professional colleagues.

    Till the next rant I see from him on twitter.

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

  6. Nicholas Logan
    12/04/2016

    Dr Ackermann seems to be routinely spouting inflammatory rubbish to maintain his relevance these days.

  7. Leopold Hamulczyk
    12/04/2016

    Unfortunately Dr Ackermann is mostly correct, except that he fails to take a critical look at his own group’s issues.

    ‘He also penned an MJA InSight piece recently claiming that any Minor Ailments Service implemented by pharmacists would just be “a push by the pharmaceutical industry and pharmacy business to increase drug sales under the guise of health innovation”.’

    For in what other way can pharmacists help people’s health problems other than selling them a product? They can’t.

    But then, why do doctors keep prescribing antidepressants when the evidence shows they are no more effective than placebo except for the most severe depression???? Why not utilise all the non-drug therapies available for many conditions as a matter of first preference? Why just write a script…see you later…? Patients need education, and then many of their problems could be prevented, or eliminated. NIDDM is a lifestyle issue. It can be reversed/eiminated with lifestyle measures. Hypertension and other related cardiac issues ditto. No concerted effort is being made to inform people of the type and magnitude of lifestyle change necessary to accomplish such a thing. No, people get told to improve their diet. They make a small change, it makes a small to no change to their parameters, and then the drugs get prescribed. Unfortunately both our professions have been sold to pharmaceutical companies. Nothing else gets much of a look in.

  8. Karalyn Huxhagen
    24/05/2016

    The post discharge critique is an interesting angle to consder. John Wilks and Debbie Rigby have pointed out the evidence that is there. From an antecdotal point of view the majority of my work is led by comments from the GP ‘Please see Mr X as he has recently been in hosptal and there is confusion as to what he should be taking and why’. I spend a lot of time tracking back who prescribed what and why to assist the GP unravel the whys and wherefores. A lot of confusion is caused by poor communication at the hospital level and also by medicions not being available on the SDL so they are changed. I am so busy that there is often enough work for more pharmacists and I share my workload due to the silly cap. I also take phone calls and emails from the CHEK discharge nurses who warn me of potential issues and who may need a HMR. The fact that the Transition Care Program does not involve a HMR process is a travesity and we are seeing that issue come home to bite phcy depts who are under funded to provide this role. as for minor ailments do not light that fire. Pharmacists have been triaging minor ailments since we were called apothecaries. It is what we do all day and every day. Maybe we should call it ‘Pharmacy Category 5 program’ as basically we are assisting to keep cat 5 patients out of ED. Any good pcist knows when to refer on. we know our scope of practice and we are darn good at it. Currently 60% of the Rxs from the GP practice next door are for antihistamines for children for rhinitis and colds. I could perform that role and currently no one pays me for my expertise or time. I work within ny scope of practice with the GPs and collaboratively we make a difference to patient outcomes.

  9. Dr Evan Ackermann
    16/12/2016

    Thank you to AJP team for reporting on issues that I have raised regarding Pharmacy this year. I do believe these issues are fair comment, relevant to pharmacy, the primary health sector and need to be addressed. Naturally I stand by my comments and am prepared to defend them.

    However the festive season is upon us. Our thoughts and actions are primarily with our friends and family. Can I wish all AJP readers a safe and loving Xmas period.To all in the health professionals who will sacrifice personal time to work during this period, thank you for ensuring our health service continues.

    That little present under the tree marked “codeine decision” needs to be opened at some stage – lets hope common sense prevails.

    Look forward to addressing these issues in the New Year.

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