RIC DAY. Community Pharmacists – Under-Utilised

Community Pharmacists spend too much time dispensing prescriptions and not enough time promoting the safe and effective use of their customer’s medicines. Reform is needed.

Expectation that Pharmacists strive to ensure optimal health outcomes from the use of medicines

Entry into the best Pharmacy degree courses requires a high ATAR score. The education pharmacy graduates receive in Australia is first-class and prepares them well to be significant contributors to the delivery of high-standard healthcare. Advising people about their medicines and monitoring these to optimize safety and effectiveness is also an expectation of pharmacist’s professional contribution that is captured in our National Medicines Policy and the Quality Use of Medicines (QUM) goal therein.

Through our taxes, the community invests over A$11 billion per annum in buying cost-effective medicines that are subsidised on the Pharmaceutical Benefits Scheme (PBS). The return on this investment, even in national health priority areas such as diabetes and hypertension, is diminished as a large proportion of the citizens diagnosed with these chronic health conditions are not adherent to their medicines, or their lifestyle programs. Far too many people experience avoidable adverse events related to their medicines. Errors in prescribing and administering drugs, and adverse reactions and drug interactions are common and costly.  The problems are increasing because of our ageing population, increased numbers of medicines per patient and poor communications between health care providers. Community pharmacists are exceptionally well placed to make a major contribution to reducing these negative outcomes from medicines.

Promise of better outcomes from medicines use unmet

Although Community Pharmacists are remunerated for activities to enhance the safety and effectiveness of their customer’s medicines therapy, evidence of significant, systemic gains from these activities is sparse. It appears that in many circumstances dispensing medicines trumps the activities critical to better outcomes from medicines use. Community pharmacists are trusted and respected in the community and although many do more than simply dispense medicines, most could and would do a lot more if appropriately supported to do so. An insight into the ‘drivers’ of this ‘misalignment’ is gained by stepping into a pharmacy belonging to a large pharmacy chain. Dispensing prescriptions is only a small proportion of activity in what looks like a supermarket of not only health care products with emphasis, it seems, on ‘over the counter’ and ‘complementary and alternative’ medicines but also, consumer goods with marginal relationship to medicines or health.

Stark contrast with pharmacists’ major contribution to safe and effective medicines use in hospitals

A large component of hospital pharmacist’s activity is reviewing and reconciling a patient’s medications, counseling and educating patients, advising prescribers and being a trusted source of drug information. In our major hospitals pharmacists are highly valued members of specialty and ward teams reviewing patient’s medications each day and on discharge from the facility. Commonly, dispensing of medicine is undertaken by pharmacy technicians. Increasingly, this step is undertaken by dispensing robots, not only in hospitals but also community pharmacy chains. It seems clear that pharmacists need to, and can be freed from dispensing to focus on achieving better medicines related outcomes for their patients.

Community Pharmacy Government Agreements have not delivered enough on QUM

There have been 6 consecutive, 5 year Community Pharmacy Agreements between the Pharmacy Guild of Australia (representing pharmacy owners) and Government. The Agreement sets the rules about how community pharmacies provide medicines under the PBS. A stated goal has been to shift the focus from simply dispensing medicines, acknowledged as important for intercepting prescription errors, towards interventions to achieve safe and effective use of medicines. Despite massive outlays from the public purse, achievements have been limited. Many promising research projects, as well as professional pharmacist services in support of QUM have been funded but there are few examples of effective, national-scale programs. For example, more was expected from programs enabling pharmacist’s provision of medication management services in patient’s homes and in residential aged care facilities. Improved adherence to medications, medications management through transitions of care and provision of medication information to consumers are other important needs where impact has disappointed. The accusation that Agreements were more to do with pleasing pharmacy owners with limited return for actual ‘health outcomes’ has been hard to counter.

The Sixth Community Agreement: More of the same or radical change?

The Sixth Community Pharmacy Agreement commenced in July 2015. It delivers almost $19 billion to community pharmacies and wholesalers. There is a major and welcome shift in emphasis from ‘supply’ to ‘non-supply’ services, including ‘medication review’, ‘medication adherence’, ‘rural and indigenous health’ and ‘e-health’ programs.

The Independent Review of Pharmacy Remuneration and Regulation has released its Interim Report. An important part examined community pharmacy programmes that have been allocated $1.6 of the $19 billion. In response, the Government has stated that

Under the 6th Community Pharmacy Agreement, all programmes and services will be reviewed for clinical and cost‑effectiveness and the health benefits they offer to the community by an independent health technology assessment body ….. This process will ensure pharmacy programmes and services are assessed against the same standards of evidence as for other health professions.”

This is a welcome and long-overdue reform.

Reducing the scope of future Community Pharmacy Agreements and including the Consumers Health Forum of Australia (CHF) (representing consumers) and the Pharmaceutical Society of Australia (PSA) (representing pharmacists) as parties to the negotiations”

deals with the long-term problem of transparency and stakeholder ownership around these Agreements.

 Involving the community, who after all pay for pharmacists and the drugs that are being dispensed, either directly or via their taxes, is well overdue. The PSA represents the professional needs and aspirations of registered pharmacists but inexplicably has not been party to the Community Pharmacy Agreements. Pharmacists want to be an effective part of the health care team in primary care. However, for many the realities of their role become obvious rapidly i.e. to dispense prescribed medicines. This is demoralizing for many new graduates. It is also poor economics; the national value that should be obtained from safer and more effective outcomes from medicines use is not accruing. The Review’s recommendations promote transparency and accountability around the 6th Agreement and start to restore Pharmacists to their proper place in our national health system.

 

Professor Richard O Day AM MD FRACP is Professor of Clinical Pharmacology at UNSW and St Vincent’s Hospital Sydney, visiting Academic Fellow at Macquarie University Sydney and with appointments to St Vincent’s public and private hospitals. He has a clinical practice in Clinical Pharmacology and Toxicology, and Rheumatology. He has particular interests in promoting the quality of use of medicines (QUM) and his research and teaching focuses on achieving QUM.

 

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One Response to RIC DAY. Community Pharmacists – Under-Utilised

  1. Ian McAuley says:

    An excellent exposition of the privileged position of retail pharmacy.

    Many years ago I was on the Pharmaceutical Benefits Pricing Authority, and was thrown off it when newly-appointed Health Minister Michael Wooldridge learned that I was trying to save public money rather than spending it on pharmacists. Reading Ric’s article it’s disheartening to find how little has changed.

    Pharmacists have been some of Australia’s most successful rent-seekers, and their success comes down to the arithmetic of rent-seeking. Drawing on the work of Mancur Olson, there is an optimum size for groups to capture rent. If a group is too small, it’s obviously not going to have much clout. If it is too large, however, it is difficult to herd its members, and it becomes too expensive even for the most generous governments to satisfy its demands .

    When I last looked there were about 6000 pharmacies, probably employing about 20,000 to 30,000 people.

    Pharmacists are in that optimum size band. It helps that they are geographically dispersed and that they have frequent contact with the public. It also helps that the Health Department sees its role as what Robert Reich calls “interest group intermediation”. That is, to try to satisfy rent-seekers within a limited budget, and if there is not enough budgetary appropriation to go around, to shift some of the costs to other parties, including state governments and patients. That’s a long way from the public service ideal of developing policies that deliver the most cost-effective services for the community.

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