Working conditions better in GP surgeries?


pharmacist with patient explaining medicines

The pharmacists’ union has thrown its weight behind pharmacists working in GP surgeries

Following the 2018 International Pharmaceutical Federation conference in Glasgow, Scotland, PPA cited a presentation by Matthew Boyd, Associate Professor in Patient Safety and Pharmacy Practice, University of Nottingham.

A/Prof Boyd was the research lead in a recent pilot study which found pharmacists in GP surgeries were highly regarded by the GPs and helped patients better understand their medicines.

He told delegates that “89% of pharmacists interviewed said they were able to work autonomously, and the same proportion reported feeling accepted by other members of the multidisciplinary team”.

“PPA has long advocated for pharmacists to be integrated into the wider health system,” says the union.

It says it “believes that there is no reason why there can’t be a mixed ‘business’ approach to professional services”.

“By placing pharmacists into GPs, it will broaden practice settings and employment opportunities for pharmacists, both inside and outside the four walls of pharmacy.”

PPA national president Dr Geoff March said that following the ongoing work value case examining pay for pharmacists employed in community pharmacy, the PPA will have a better opportunity to examine role classifications for pharmacists employed in a number of areas.

“One idea we have is making classifications align with the competency standards in pharmacy – that way it’s more skills-based rather than a career path of pharmacist – experienced pharmacist – pharmacist manager,” he said.

“This [GP surgery pharmacists] is a greenfields area at the moment, though not totally so – the award would still cover that to some extent. We’ll be working with PSA around that issue and hope to have further discussions as it becomes more substantial.”

He said that the issue is not just pay, however – working conditions for pharmacists in GP surgeries would “without doubt” be better than those employed in community pharmacies.

“A major issue is workloads in community pharmacy, and we’re really concerned about that.

“Pharmacists can take better care of patients when working in these areas, and out of that you get respect and trust. If we can focus on patient care, then other people understand the value of that.”

GP surgeries are not the only place where pharmacists are sorely needed, he said.

“There’s a crying need for pharmacists to be involved in the care of patients in the aged care sector,” Dr March said. “I think some further education around working with older people and understanding medicines in older people and so forth could be an area, dare I say speciality, certain a focus for career pharmacists.”

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22 Comments

  1. SPG
    17/09/2018

    A few comments from pharmacists working in the UK in GP practice surrounding role clarity and workplace culture: 1) Egos – people with their own agenda 2) GP and nurses work alone / in silos / in own rooms 3) GPs time very limited for mentoring 4) Short hours in part time role means lack of continuity/time constraints of part time working 5) too busy for learning / reflection / time pressures / training feels imposed 6) The quality and safety of medicines has little financial value 7) I’M ON LOW PAY BUT HAVE HIGH RESPONSIBILITY.

    https://www.nottingham.ac.uk/pharmacy/documents/generalpracticeyearfwdrev/clinical-pharmacists-in-general-practice-pilot-scheme-full-report.pdf (p.53)

    Once again advocates of the GP practice model are polarising the discussion by making generalisations regarding workplace culture in community pharmacy vs GP practices. There is no reason why community pharmacy cannot provide the rewarding, clinically focused career paths that pharmacists are looking for with appropriate support and funding.

    • Debbie Rigby
      18/09/2018

      I agree…”There is no reason why community pharmacy cannot provide the rewarding,
      clinically focused career paths that pharmacists are looking for with
      appropriate support and funding”

      I think many community pharmacists feel satisfied with their career paths in community pharmacy. Working as a practice pharmacist is simply an alternate career path that will evolve with time and outcomes.

      • SPG
        18/09/2018

        Hi Debbie, you say that this is an alternate career path that will complement the role of the community pharmacist. Can you please explain how the role/duties of a practice pharmacist will differ fundamentally from what a community pharmacist does/can do (apart from dispensing of course)? There has been nothing published so far that suggests that there is any real difference apart from the setting and nothing to show that a pharmacist practicing in a GP setting can produce better health outcomes for patients than a pharmacist based in a community pharmacy. If a practice pharmacist can charge the health system for the same services as a community pharmacist – how will we avoid a funding shift away from community pharmacy to owners of GP practices?

        • Debbie Rigby
          18/09/2018

          Think of it this way – Working in a hospital pharmacy is an alternate career pathway for pharmacists. Working in an Aboriginal Health Service is another – there is a great podcast on Purple Pen where Chris Braithwaite details his role. Funding is provided in these settings for a pharmacist to dispense and/or provide medication management services and support to other healthcare providers.

          An article published in Australian Prescriber describes the roles for a practice pharmacist – see https://www.nps.org.au/australian-prescriber/articles/the-practice-pharmacist-a-natural-fit-in-the-general-practice-team

          The roles of the practice pharmacist can be considered under three categories – patient-directed roles, clinician-directed roles and system- or practice-directed roles.

          • SPG
            18/09/2018

            Debbie, this link that you have shared confirms there will be fundamental overlap between the roles particularly when it comes to the direct-to-patient activities, which are likely to be the activities that pharmacists working in a GP practice are encouraged to perform because these activities are likely to attract government funding. As shown in the UK pilot direct-to-patient activities took up a significant proportion of the GP pharmacist’s time – “Most CPs (98%) undertook patient facing work, focusing on complex medication reviews…For 70% they classified this as a major part of their role….” (p.18) “The largest proportion of respondents spent slightly less than half of their time in post patient facing” (p.50).

            https://www.nottingham.ac.uk/pharmacy/research/divisions/pharmacy-practice-and-policy/research/cpigp.aspx

            So given the overlap between roles the question still stands as to how to avoid a shift in funding away from community pharmacy which we envisage may occur in various ways – e.g. by the government shifting funding away from the CPA and into non-dispensing embedded pharmacists (which CHF has recently proposed – https://www.pulseitmagazine.com.au/australian-ehealth/4573-call-for-national-minimum-data-set-for-primary-care-health-care-homes-revamp) or by practice pharmacists charging for services via an MBS payment model and thereby blocking community pharmacists from performing/charging for the same service.

            Furthermore, this link you have provided fails to mention the follow-up to the Pincer trial (Elliott et al. 2014 (PharmacoEconomics (2014) 32:573–590), where it was shown that “PINCER produced marginal health gain at slightly reduced overall cost.” This result was further analysed and it was suggested that it may be more cost-effective to target certain errors such as those that individually were shown to be cost-effective rather than looking at everything.

            Our interpretation of these results is that it may be more cost-effective for society to target certain medication errors that have been proven to be cost-effective with interventions. This could be done by auditing practices and educating prescribers regarding these types of medication errors and/or do more specific training and intense data-mining of patient records at a particular surgery. This would provide snapshots of the performance of the surgery in a particular area that could be followed up at a later date. It seems that it is not cost-effective to have a pharmacist located in a GP surgery for this particular purpose at all times. The educational part of these audits could be done by
            the local pharmacist, or by accredited pharmacists that are already today providing training for nurses and prescribers.

          • Amy Page
            18/09/2018

            Hi SPG, you ask about why this work isn’t done by the local pharmacist or an accredited pharmacist. Imagine this scenario in reverse. How receptive are you going to be in the GP practice over the road comes into the community pharmacy to conduct an audit?

            External consultants just don’t have the established rapport and trust built up that a colleague can have. Quite simply, it’s a lot easier to make a difference from the inside rather than the outside.

            It’s not that there isn’t overlap, there is. But there is so much work that needs to be done to improve the quality use of medicines and reduce medication related harm.

            We addressed this question in this article, if you want to read further.
            https://onlinelibrary.wiley.com/doi/abs/10.1002/jppr.1136

          • SPG
            18/09/2018

            There is an assumption in this response that community pharmacy does not have an established rapport and trust with GP surgeries. Many of our member pharmacies in the Small Pharmacies Group are located in one pharmacy towns where the GPs and community pharmacists work very closely together – why not set up a funding structure that incorporates and acknowledges these existing relationships but that still gives each profession its autonomy?

            We acknowledge that there is more that pharmacists can do to improve patient health outcomes – but we dispute that the pharmacist must be located within a GP practice to achieve this (as there are no studies that have compared the two settings in terms of health outcomes).

            We have outlined our concerns in a letter to the PSA.

            https://ajp.com.au/news/concerns-about-clinical-pharmacy-funding/

            Apparently PSA is hearing these concerns and is addressing them – we are looking forward to hearing what they have to say.

            https://ajp.com.au/news/most-in-favour-of-gp-pharmacists

          • Amy Page
            19/09/2018

            I know that community pharmacies often have established rapport and trust with GP surgeries, particularly in rural and remote areas, as I spent many years locuming in rural and remote community pharmacies. I respect and acknowledge that, but I don’t think that should limit new roles from being created. We are evolving and developing new professional roles. Those new roles do not need to, nor should be, defined by existing roles

            You know that line, though, that’s being thrown around a lot lately: “There should be a pharmacist everywhere there are medications being used”? That doesn’t come with an exception. It doesn’t come with a clarification that community pharmacy owners must be able to benefit financially from every role.

          • SPG
            19/09/2018

            While there might be enough medication management problems to keep us all occupied – it does not necessarily follow that there will be enough money to fund this. The money is going to have to come from somewhere and if the government allocates money from the CPA (as the Consumer Health Forum, for example, is proposing) or curbs investment in community pharmacy to fund this (as has happened in the UK), or introduces an open payment model (such as an MBS payment system) where we all have to compete with each other for funding – in the end this could have a negative impact on community pharmacy and on patients that has not been explored or addressed.

            Furthermore it is not necessarily a cost effective use of resources to invest in pharmacists in all settings when there are existing resources in place that could be better utlised. The PSA often refers to the Pincer trial but overlooks the follow-up study that we mentioned above where it was shown that “PINCER produced marginal health gain at slightly reduced overall cost.” Also when it comes to the UK practice pharmacist model concerns have been raised about the cost and therefore sustainability of the role (see e.g. p. 128).

            The same goes for Aged Care – the PSA is pushing for embedded pharmacists but completely sidelining the role of Community Pharmacy – relegating Community Pharmacy to a supply only role (see e.g. https://www.australianpharmacist.com.au/medicine-use-in-aged-care-a-pill-for-every-ill/)

            Why is the PSA and advocates of this model leaving community pharmacy out of this discussion – if the goal of this process is to improve collaboration between health professionals and improve integration for the benefit of patients in a cost effective fashion we must be included in designing models of care.

          • Amy Page
            19/09/2018

            “Why is the PSA and advocates of this model leaving community pharmacy out of this discussion”

            Quite simply because community pharmacy will continue to be a collaborator in this area. The funding does not need to flow through to them.

          • SPG
            19/09/2018

            There seems to be agreement that there is significant overlap in the clinical services delivered (many of which community pharmacy already performs but is not currently remunerated for) – why shouldn’t any additional funding flow through to community pharmacy as well so that we can be paid for the work that we do?

          • Amy Page
            19/09/2018

            The Guild’s insistence was that it couldn’t come out of the CPA funding, so other funding sources were sought. It’s been a lot of work over many years to get it to the stage it is at now much (most?) of which was unpaid.

          • SPG
            19/09/2018

            Wow… Your comments (as a PSA committee member) confirm our feeling that community pharmacy is actively being excluded by the PSA from being involved in discussions about the embedding model and that the push for this model is partly a reaction to perceived shortcomings of Community Pharmacy and of the Guild.

            Small pharmacies should not be the collateral damage here and we want to make it clear that we are also working to forge a more clinically oriented future for pharmacy.

            We may be owners but many SPG members are also members of the PSA and as such should have a right for our concerns to be formally addressed even though they may not conform to the agenda of some voices within the PSA.

            We want our representative bodies to support us to deliver clinical services to patients and to design models that involve us and are not going to undermine community pharmacy. We need our representative bodies to put aside their differences and work together to achieve positive outcomes for patients and the profession.

          • Jarrod McMaugh
            19/09/2018

            Every PSA member – including members elected to state branches – have the right to represent their own views in public discussions.

            Only the president, the CEO, or those nominated by the same, speak for the PSA.

            The strength of PSA is that it’s elected officials have a diversity of experience & opinion.

            Whether you disagree with the opinion put forward or not, you shouldn’t criticise someone for expressing it.

          • Amy Page
            20/09/2018

            The views that I put forward are my views only. I don’t speak on behalf of PSA or any other organisation.

          • Shane Jackson
            19/09/2018

            Dear Fred and Katie,

            I wanted to clarify some comments here on behalf of PSA.

            1. The PSA maintains that 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.

            2. We maintain that community pharmacists from local community pharmacies should be able to deliver the services within general practice, and that is likely to be the option in many rural areas. We also believe that there may need to be capacity building grants for community pharmacies to be able to deliver some of these services.

            3. The effort of PSA is being directed at ensuring that duplication is minimized and that services that can be delivered by community pharmacies are supported by pharmacists who may work in general practice.

            Kind regards

            Shane

          • Karalyn Huxhagen
            20/09/2018

            Thank you Shane for this clarification of the objectives of PSA in this matter.

          • SPG
            20/09/2018

            Thanks Shane, we very much appreciate this clarification. We also look forward to working with the PSA in order to ensure that small pharmacies are not disadvantaged by this model and are supported in their efforts to deliver clinical services to their communities. Regarding the points that you make our chief concern is the extent to which the PSA will have control over how funding is used by GP practices – i.e.

            1) How will PSA ensure, for example, that money is directed towards system level activities rather than patient facing services that will overlap with community pharmacy and may therefore result in a funding shift away from community pharmacy and lead to a deskilling of community pharmacists?

            2) How will the PSA ensure that local community pharmacies are given the opportunity to perform these services – rather than being excluded by the practice hiring an in-house pharmacist or cycling a FIFO pharmacist or alternatively putting services out to tender (as has happened with Aged Care contracts) to find the cheapest bidder thereby creating a race to the bottom that undermines our clinical role?

          • Debbie Rigby
            21/09/2018

            There will always be limited funding in healthcare; therefore funds need to be provided where the greatest impact will be achieved. Worldwide healthcare models are moving towards collaborative care, with all health professionals working to the full scope of their skills and knowledge. No one model will fit all populations and environments. Flexible models, with robust controls to avoid over-servicing, are needed. Just like there are different ‘models’ of community pharmacies, different models for integration into primary care and aged care are required.

          • SPG
            21/09/2018

            Yes but any collaborative models of care must take into account what community pharmacy is doing/can do because we are an existing resource. Modelling must also take into account what the potential impact might be on community pharmacy in terms of viability, scope of practice, existing patient relationships etc.

            As we have mentioned before, the failure to incorporate community pharmacy in the modelling is one of the identified shortcomings of the UK scheme.

            We think this is particularly an issue in small communities – if a non-dispensing pharmacist takes over the clinical role/duties of the community pharmacy which may already be working across a number of settings (e.g. in collaboration with surgery/aged care facility/aboriginal health service etc) this may affect the viability of the pharmacy and lead to the deskilling of the community pharmacist. It does not make much sense for a small community to gain a non-dispensing pharmacist if it puts the community pharmacy at risk.

            As Shane mentions below the PSA is working towards placing some controls on how this model might work in practice but will these be regulated once funding starts to flow? It is risky to rely on the goodwill of the owners of the doctor’s surgery to utilise the resources of the community pharmacy if the incentives are there to hire their own in-house pharmacists rather than work collaboratively with existing resources.

            It is also worth noting that we are not the only ones who think that the model proposed by PSA/AMA/RACGP may not be applicable to rural communities. It would seem that the RDAA also has concerns. See, for example, the recent testimony of Dr Kangru from the RDAQ as part of the Inquiry into the Establishment of a Pharmacy Council who stated that the UK model “is not necessarily applicable to rural Queensland.” https://www.parliament.qld.gov.au/documents/committees/HCDSDFVPC/2018/Pharmacy/trns-ph-pharm-10Sep2018.pdf

  2. Debbie Rigby
    21/09/2018

    The day pharmacists stop trying to bring other pharmacists down will be a great day not only for the profession, but for the patients who will benefit from a united workforce regardless of sector or experience

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