Do in-practice pharmacists really make a difference?

The anecdotal evidence suggests the concept is proving valuable, but not everyone is convinced

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Non-dispensing pharmacists are up for a bigger slice of some controversial action under an expanded scheme to promote team-based care in general practice.

The new GP Workforce Incentive Program, announced in the 2018-19 budget, rolls together existing schemes helping GP clinics cover the costs of practice nurses, indigenous health workers and allied health practitioners.

In-practice pharmacists in all locations will join the list of allied health eligible for subsidy when the new program takes effect in July 2019.  Currently, about 70 pharmacists are said to be working in GP clinics around Australia.

“I think it’s a great way forward because it allows the general practice to decide how to construct the team to best support care of their patients,” Dr Shane Jackson, President of the Pharmaceutical Society of Australia, said.

The society is developing training programs so that pharmacists can “hit the ground running” as GP team members.

The move has been firmly backed by the AMA as a means of improving medications management in primary care and avoiding adverse medication events leading to hospitalisation.

However, prominent GP Dr Evan Ackermann says claims about the impact on patient care in general practice are overblown.

Dr Ackermann, who chairs the RACGP’s expert committee on quality, says it is already clear that medications management in primary care can be improved.

But from the mostly small-scale studies conducted to date, it is not clear that the pharmacists’ contribution brings a significant benefit to patient outcomes, he argues.

He has continued to call for large-scale, robust randomised controlled trials to test the concept.

“This is money that people have been using to pay their nurses. I don’t think too many would give up their nurse for a pharmacist,” he said.

Anthony Tassone, vice president of the Pharmacy Guild Australia’s Victorian arm, also aired criticism of the budget announcement.

Mr Tassone said rural pharmacy owners were concerned that the offer of a nine-to-five job in a GP clinic would make it harder for them to hire staff.

“The situation can only be compounded by offering inducement for pharmacists to work in GP clinics,” he wrote in the Australian Journal of Pharmacy.

“We do not want to see taxpayer money potentially picking winners and losers.”

Mr Tassone said community pharmacy must not be bypassed in favour of a “novel and new – and not yet comprehensively proven – bauble that is placement in a GP clinic”.

The remarks drew objections from readers, who said being part of a GP team appealed to pharmacists who enjoyed clinical work.

Canberra practice owner and GP Dr Mel Deery says she needed some convincing before joining a two-year experiment funded by Capital Health, the ACT’s PHN.

“I came into it with healthy scepticism, saying I really don’t know how beneficial a pharmacist is going to be in general practice, but I wanted to be at the table having the conversation. I have been won over by the benefits.”

She consults her in-house pharmacist, who is on site for 16 hours per week over four half-days, more frequently than she would a busy community pharmacist.

“There are times when I am trying to make a decision about a medication, or I’m worried about adverse reactions. The pharmacist can do some thinking and get back to me in half an hour, and I know she has done a really thorough job.

“It’s saving me time and saving the patient money and probably having a better outcome.”

As well as consults with patients changing medications, the pharmacist has helped train registrars and is kept busy liaising with specialists, doing audits of medications and home medicines reviews.

Doctors also ask her to review patients who have been hospitalised by an asthma flare-up; she spends about 40 minutes to review their controls and puffer technique and possibly recommending titrating their dose.

“That’s giving the patients much more time and education than we would,” Dr Deery said.

“Often she has found the patients were not using their puffers very effectively, and they have much better asthma control at the follow-up.  We can bill the asthma cycle of care, which is about an extra $100 of PIP money.”

The ACT pilot is due to end in July.  But Dr Deery is not for turning back, aiming to continue the value-add possibly by sharing a pharmacist team member across practices to defray costs.

“I think we are still learning how to use a pharmacist  in general practice.  The longer we have her, the more we use her. I found it’s really valuable.”

The pilot is one of five currently under way around Australia.

Dr Jackson said he expected evaluation reports from those projects to highlight the advantages of the team approach.

“My view is, the time for trials is gone, because there is enough evidence that it improves the quality use of medicines and the efficiencies of the general practice team,” he said.

“I think the trials going on now will provide evidence of what activities give the best bang for buck within general practice.”

Clinical governance activities – including audits and system-level reviews of chronic disease patient populations – and education of practice staff provide far-reaching benefits, in his view.

“I think you get better value out of a pharmacist’s expertise in education and training and clinical governance, because the learnings are applied to a greater proportion of people.”

GPs in a trial in western Sydney were unanimous in their support for the scheme, though each practice had taken an independent approach,  Associate Professor Dr Michael Fasher, said.

Dr Ackermann was critical of an interim report from the project, published in March, for lacking hard evidence to back up claims about patient outcomes.

Professor Fasher said the criticism was fair to an extent. But it put him in mind of the “ivory tower versus the real world”.

“The GPs who have had a pharmacist in their general practice team have, to a person, found it to be enormously valuable,” he said.

“The group of GP leaders at WentWest, our PHN, applaud the intervention.

“Evan is right in that the published article did not show that patient health is being improved. But that is taking the very tightest scientific view of the evidence,” Dr Fasher said.

“My colleagues and I have no doubt that what the pharmacist brings is important for patient outcomes. That is our experience on site.

“Having (the pharmacist) on board has improved our prescribing. If prescribing has a health outcome, then it has improved health outcomes.”

Dr Jackson said there was no estimate of how many practices might take the opportunity to add at least a part-time pharmacist to their roster.

“We hope (the incentive scheme) will provide an acceleration in the numbers of pharmacists working in support of general practice,” he said.