‘We have waited far too long for this to occur.’


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New studies reveal the value of pharmacists in general practice, and dispel the “baseless fear mongering” surrounding the model of practice, say researchers

Recent research demonstrates high levels of interaction between pharmacists in the community pharmacy and general practice settings, says Dr Chris Freeman, Clinical Senior Lecturer in QUM at the University of Queensland and National Vice President of the PSA.

However there is room for improvement if pharmacists who are working in general practice are better enabled to easily engage with community pharmacy, says Dr Freeman.

He shared the results of a 2017 survey of 43 Australian pharmacists working within general practice at a panel session held at PSA conference last week.

The survey found 77% of respondents had contact with community pharmacy at least once per week, and 70% believed that community pharmacists were accepting or very accepting of their role.

Sixty-seven percent said they referred patients to their community pharmacy of choice for professional services, while 63% said they were a point of contact for community pharmacy regarding clinical questions about patients.

The high levels of interaction “occurred organically without any framework guiding the pharmacist in general practice collaboration with the community pharmacy, a figure that will increase with a targeted framework being developed by PSA,” explains Dr Freeman, who has previously completed a PhD on pharmacist roles in general practice and other healthcare settings.

Not only were there high levels of contact between the pharmacists on a weekly basis, there were also a significant number of referrals of patients to their community pharmacy for services such as MedsChecks, DAAs and HMRs, he adds.

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

“These results are important as they start to dispel some of the baseless fear-mongering which has surrounded this model of practice and the potential impact on the community pharmacy setting.

“The models of pharmacists working in community pharmacies and general practices are not mutually exclusive, and there would be many occasions were the pharmacist in the community pharmacy would also be integrated into the general practice setting.”

Dr Freeman says that in regional and remote settings, or where the community pharmacist has an existing strongly established relationship with the general practice, it is likely that the pharmacist will be sourced from the community pharmacy.

“As a profession we need to be taking opportunities such as this with both hands and stop continually being paralysed when given the opportunity to work outside our comfort zones.

“The Workforce Incentive Program is a good start to see this model becoming sustainable in the future but is just a beginning.”

The models of pharmacists working in community pharmacies and general practices are not mutually exclusive, says Dr Chris Freeman
The models of pharmacists working in community pharmacies and general practices are not mutually exclusive, says Dr Chris Freeman

What do GP pharmacists actually get up to?

Newly published research describing the activities of general practice pharmacists over six months in a pilot trial has also been published this month in the Australian Journal of General Practice.

The initiative of the Capital Health Network – ACT’s PHN – saw three non-dispensing pharmacists complete 944 hours of work activity over six months.

They spent most of their time undertaking quality of practice duties (37%), the largest proportion of this being devoted to conducting clinical audits (47%).

Examples of clinical audit improvements include pharmacists identifying and addressing:

  • Patients with chronic atrial fibrillation not receiving guideline-recommended anticoagulant therapy and making the recommendation to GPs to initiate it, potentially reducing the risk of ischaemic stroke;
  • Use of dual antiplatelet therapy for longer than indicated following coronary angioplasty;
  • Ongoing oral corticosteroid therapy and risk of osteoporosis;
  • No record of HbA1c results for some patients with type 2 diabetes;
  • Patients with heart failure for whom angiotensin converting enzyme inhibitors or angiotensin receptor blockers had not been prescribed.

Communication with GPs was found to have increased gradually over the trial period.

The pharmacists spent 15% of their time providing medication information to practice staff, while contact with patients comprised medication review (19%) and patient education (11%).

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Dr Mark Naunton sees pharmacists in general practice as a ‘no brainer’.

Asthma, aged care, post-hospital discharge and polypharmacy (with the aim to deprescribe) were the main reasons for medication review referral.

Patient education was 51% medication related and 49% lifestyle related; the latter including smoking cessation when not directly related to medications used in cessation.

Administration duties took up about 34% of the pharmacists’ time – however this number decreased in the final months once they became more established in the practice.

Overall two-thirds of their time was spent in clinically related duties.

“The results from our study are important because they provide some important ‘real world’ data from pharmacists who have previously not worked in general practice,” says study author Dr Mark Naunton, Associate Professor and Head of Discipline, Pharmacy at the University of Canberra.

“We are starting to define what the roles may be for pharmacists working in general practice. It is also important because we have shown that pharmacists’ communication with GPs increases over time,” Dr Naunton tells AJP.

“Hopefully this helps take out some of the heat from different stakeholders who have been concerned about this. Some have questioned why we would need pharmacists in general practice, and our data is telling us that GPs (and others working within the practice as well as patients) really value the input from the pharmacists.”

Based on the results, does Dr Naunton think pharmacists should be included in all general practices across the country?

“Each practice should consider if they can use a pharmacist within their practice,” he says.

“Although we have not presented the data yet, there will be significant cost-savings to society based on some of the activities the pharmacists undertake (e.g. clinical audits).

“As a pharmacist, I see it as a no brainer. I remember when it was a big issue about having nurses in GP and now they are pretty much routinely found in GP. With so many drug-related problems and so many new drugs hitting the market we need professionals with expertise to address and prevent them from occurring. Pharmacists are uniquely trained to do this.

“We have waited far too long for this to occur. Australia is lagging behind the world (for example, parts of Canada, UK) on this issue. The time for change is now. I am very proud to work with a team to deliver these results and we look forward to publishing second year results soon.”

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17 Comments

  1. Tim Hewitt
    02/08/2018

    Firstly, did the research examine the impact of ‘in house’ pharmacist consultations in GP Pharmacists on HMR referrals from those centres? ie increase/decrease/no change.. and in particular the GP’s perception of the role of HMR as opposed to practice pharmacist.
    Secondly, do the GP practice pharmacists undergo, or require further qualification or accreditation (as do HMR pharmacists via AACP), and if so, how does the cost stack up against the costs incurred by HMR accredited pharmacists?

    • Kevin Hayward
      02/08/2018

      I note that, quite rightly you have concentrated your thoughts on the clinical benefits of therapeutic and pharmacological reviews of patients.
      I thought I would just mention that this has only been part of my own experiences over the years, in my role as a GP practice support pharmacist. I have been involved in research, business and clinical audit, clinical governance, project management, formulary, GP education and currently, I am involved in patient education.
      GP practice support pharmacists can experience a whole new world of professional opportunity within the primary care team, and, if also working with a community pharmacy can bring that world into the role with them.

    • SPG
      02/08/2018

      Hi Tim – The following article suggests that whilst HMRs certainly increased, they were performed by the GP practice pharmacist rather than a HMR accredited pharmacist based in the community (Freeman et al 2014 (Int J Clin Pharm (2013) 35:5–13; figure 1; page 7). I would be interested if anyone knows of any further research on this topic that they could share?

      • Sheshtyn Paola
        03/08/2018

        Hi Tim and SPG,
        As written in my above article, Dr Freeman said: “Not only were there high levels of contact between the pharmacists on a weekly basis, there were also a significant number of referrals of patients to their community pharmacy for services such as MedChecks, DAAs and HMRs.”
        This is based on new research (the survey) that is in the process of being published.
        Kind regards,
        Sheshtyn Paola (author)

        • SPG
          03/08/2018

          Hi Sheshtyn, thanks for your response. Our question goes deeper than this though (as mentioned in comment above) – if practice pharmacists are eventually remunerated by government through a funding mechanism such as MBS – and they conduct medicine reviews at the GP practice – how will this affect community pharmacy? The government is unlikely to pay a pharmacist to do a medicine review at a GP practice and then pay a community pharmacy to perform the same service. Furthermore, the practice pharmacist will presumably benefit from in-house referrals – the GP surgeries will be sure to try and capture all the available funding before the patient leaves the surgery. Then there is the additional problem that the public purse is not infinite so money may be shifted out of CPA into MBS.

          The point we are trying to make is that you need to be very careful how you design the funding model for clinical pharmacy services so that it does not negatively impact the viability of community pharmacy or inadvertently constrain the clinical capabilities of pharmacists working outside of GP practices.

          • Kevin Hayward
            03/08/2018

            GP Practice Support Pharmacist should be in a position to support integration of community pharmacy and to help the primary care team to capitalize on the skills and resources that already exist within community pharmacy, not to detract from it.
            My overseas experiences of this work were very much targeted towards this goal, I was able to support my community pharmacist colleagues by including them in funded primary care collaborative initiatives at my practices. Far from detracting from their role, I may have increased their workload. I can see no reason why such a paradigm should not be created in Au, should the political will exist.

  2. Daniel Hackett
    02/08/2018

    Cut out all the middlemen and go straight to the drug rep I say. You know it makes sense.

  3. SPG
    02/08/2018

    Advocates of the practice pharmacist model seem to envisage a flexible, clinical role for GP pharmacists but leaves Community Pharmacy with the commodotised/packaged services like medschecks and HMRs that will become redundant if practice pharmacists become more prevalent. Community pharmacists have the skills to perform precisely the same clinical services as a practice pharmacist and there is no evidence to show that there is a greater benefit to patients when these services are delivered in a practice setting as opposed to a community pharmacy setting because that has not been compared.

    Furthermore 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 for this reason. As we have stated before, 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.

    The PSA and government say 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?

    • Debbie Rigby
      02/08/2018

      One of the key messages based on these two experiences is that the role of a practice pharmacist complements and enhances rather than duplicates or competes for patient care and services.

      A fundamental principle is that dispensing and prescribing are separated. The practice pharmacist may evolve to include prescribing, but not dispensing – and I use the term dispensing in the holistic sense, the technical aspect of right drug, right person as well as the critical decision making and patient advice aspects.

    • Kevin Hayward
      02/08/2018

      Community pharmacists have the skills to perform precisely the same clinical services as a practice pharmacist ?
      A few years back to broaden my perspective as a pharmacy owner practitioner, I thought it would be interesting to become a part time GP practice support pharmacist. Like you I thought I would have the necessary skills, particularly as I had just completed a higher degree as part of a multidisciplinary team at my local university medical school. I was surprised to discover that I did not have the necessary skills to be a practice support pharmacist. It took me several years of study and guided practice to achieve the necessary level competency.

    • Kevin Hayward
      02/08/2018

      In my previous many years experience as a GP practice support pharmacist, I have always found my work complemented the role of the community pharmacy, and often facilitated joint working projects and additional funding opportunities for community pharmacy. As a pharmacy owner having one of our two pharmacists working part time in the local medical practice was shown by the data to beneficial, for the GP achieving key prescribing indicators , it had great spin offs for my pharmacy business, above all else, patients appeared to appreciated it.
      If I were a pharmacy owner still, and the opportunity arose, to have one of my pharmacists engaged in supporting the local GP practice, I would be delighted with the option to develop my professional practice, to enhance my skills and enjoy the coexisting commercial benefits of joined up working with a GP practice

      • SPG
        02/08/2018

        Hi Kevin,

        It is great to hear that you are benefiting and I firmly believe that increased collaboration is the way of the future. My concern going forward is that if we get MBS access in conjunction with the GP pharmacist model, funded through medical practices – how do you keep up the current flow of paid services to your pharmacy? My view is that the medical centres would catch on pretty quickly that it is in their interest to charge as many MBS items for a particular patient before they leave the building. My assumption is that the MBS system would work the same then as today, where a medical practitioner cannot charge for the same MBS item for a particular patient within a certain time frame. As a result, how do you deal with the fact that your dispensing remuneration probably diminishes , due to the public purse not being infinite, and you are practically barred from accessing clinical funding?

        In terms of the particular situation you describe I am unable to comment. Our view is based on the range of activities of a non-dispensing pharmacist that the PSA is proposing. I consider all of them to be within the scope of all pharmacists (community/hospital/other). If there is a perception of clinical deficit in terms of the professional capabilities of pharmacists in Australia then the question should be how well universities are educating pharmacy graduates – not to design models to cover a perceived problem.

        If PSA could design a funding model that properly incorporated community pharmacy PSA would have a lot more support for this.

        • Kevin Hayward
          02/08/2018

          When teaching Leadership and management, I remind my students firstly of Heraclitus, who infered that the only constant is change, and secondly of Rockerfeller, who challenged himself to turn every disaster into an opportunity. So I concur with you, we need to accept that working collaboratively is inevitable, and we need to exert our influnces to ensure that opportunity not disaster is the outcome

  4. Kevin Hayward
    02/08/2018

    I have not been waiting for this to occur, I have been doing it! General Practice Support Pharmacists, a great opportunity for pharmacists to work in extended primary care roles. Over the years I have gained new competencies and formal qualifications, widened my experinces, working in formulary, audit, research,governance, project management and education, all in addition to my traditional clinical review role. The model can also be used to support and engage traditional community pharmacy. So don’t wait for it to be done to you, go out and do it!

  5. SPG
    03/08/2018

    Freeman is saying that “Not only were there high levels of contact between the pharmacists on a weekly basis, there were also a significant number of referrals of patients to their community pharmacy for services such as MedChecks, DAAs and HMRs.”

    Interesting to compare these results with what is going on in the UK where GP pharmacists are funded by the government: “Researchers surveyed 78 GP sites where 373 pharmacists were employed as part of the NHS England scheme… Medication reviews were the “sole task” for 70% of the practice pharmacists in the study.”

    So 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?

    https://www.chemistanddruggist.co.uk/news/most-gps-continue-employ-clinical-pharmacist-once-funding-ends:

    • Kevin Hayward
      03/08/2018

      If additional funding were to be provided, it would be as a part of a strategic plan, with specified aims and objectives.
      The resulting operational plan would determine the distribution of work and specify the individual targets for providers.
      As I have seen a proposal of neither, it would be hard to second guess where the funding and benefits will be distributed.

      • SPG
        03/08/2018

        This is exactly what we would like to see from the PSA – where is this strategic plan? What are the benefits and pitfalls of this idea in terms of how it will affect the future of pharmacy? It would seem that the UK has been culling money from community pharmacy and putting it into practice pharmacists. However, it now seems that this funding is drying up too with surgeries having to fund the pharmacist themselves and there is concern that these pharmacists may not be kept on.

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