What will it take for pharmacy to realise its primary care potential?

Yesterday’s Croakey post about a study examining whether pharmacists could play a greater role in community mental health care has brought a few responses.

One of the study’s authors, psychiatrist Professor Alan Rosen, has replied to some of Croakey’s queries about the barriers to wider implementation of such initiatives.

And Ron Batagol, a pharmacy and drug information consultant, has also written in, highlighting some of the obstacles to pharmacists engaging more usefully in primary care generally.

Professor Alan Rosen writes:

“Simon Bell  has provided  information to Croakey which may cast light on some current Australian research which emphasises the very useful role that  community pharmacists  may play as highly valued adjuncts to, or sometimes part-time members of,  interdisciplinary community health teams.

Our Sydney and Finland-based group’s research presents a practical study of pharmacy effectively engaging with the wider healthcare sector, in this instance community pharmacists working with community mental health teams, and their clientele, mostly individuals with complex, severe and persistent disorders.

In response, Croakey editorially commented “this study raises at least as many questions as it answers”, so I will try to answer the questions raised:

If the treatment of mental illness could be improved by community mental health teams working more closely with pharmacists, then how widely is this happening?

Hardly, if at all. Community mental health teams in Australia are not routinely funded to include community pharmacists as interactive part-time team-members. Some hospital-based pharmacists visit community mental health teams periodically. Despite often possessing good knowledge, their high workload means their role is often limited to checking the contents of the medication cabinets. These hospital-based pharmacists are usually very obliging and are prepared to answer questions on the hop, but are not given scheduled time to do so. In the recent past, such visits have been withdrawn when the hospital pharmacy is short-staffed.

If it’s not widespread, then why not? What are the barriers, and how might current models of practice need to be changed to enable such collaboration?

The obstacles are: a) the lack of provision in health service budgets for squarely allocating time and positions for pharmacists in wider more consultative roles within community teams, and with consumers and their families,  b) that most pharmacists in local private community pharmacies do not perceive offering sessions working within primary care or community health teams as commercially viable, or as part of their job description or professional mission, c) despite recent positive developments, there remains a lack of consistent training in, advocacy and support for these roles by education, employer and professional organisations. All 3 factors must be addressed.

In her address to the Pharmacy Guild of Australia’s annual dinner on 18 November 2009, Minister for Health Hon. Nicola Roxon, stated:

“Pharmacists are already involved in delivering services to patients in a number of areas. This role could be further enhanced through primary care reforms that support professional services from pharmacists. Patient services should be integrated and coordinated with the broader health system, and contribute to the continuous care of a patient, particularly those with multiple, ongoing, and complex conditions. A connected and coordinated primary health care system must involve pharmaceutical services and medicines while they continue to provide the key therapeutic intervention in the treatment of illness.”

Australian Governments and pharmacy professional organisations should work together  to  operationally realise such arrangements, as  enhancements ( not from existing budgets)  to community health teams.

Is there anything that individual patients and their families, carers and clinicians can do to obtain this type of service?

Yes. Clinicians can educate consumers, carers and the community as to the likely effectiveness of these roles, and all should advocate with their neighbours, colleagues and with pharmacy professional organisations and politicians for such positions to be established. Consumers and families can also lobby with their own local pharmacists and clinicians to initiate further trials of such arrangements. Consumers may request a Home Medicines Review (HMR) referral from their general practitioner. However, under the present regulations a HMR cannot be initiated directly by their community mental health team.  While waiting for more comprehensive arrangements to be put in place, all these constituencies could advocate  strongly,  in the meantime,  that these regulations should be simply amended to allow community mental health teams to be able to directly initiate HMR’s.”

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Meanwhile, Ron Batagol writes:

“As a pharmacist of 50 years experience, in both community and hospital practice, I have been involved with hospital clinical pharmacy practice since its introduction the 1970s, and have seen its successful development and growth over the past 35 years.

In the 21st century, pharmacists working in hospitals, here and overseas , with their comprehensive knowledge of the pharmacology, therapeutics, interactions and dosage requirements of drugs, are now playing a key role in the process of prescribing medications, in collaboration with doctors, and also advising patients on medication dosage, compliance and safety issues.

Whilst it was enlightening  to read of the work that Dr Simon Bell and his colleagues have been doing to devise strategies to optimise the use of medicines in a specific class of patient ( those with psychiatric illnesses), I believe that this type of expertise, can, and, indeed, should, be utilised, to produce better primary health care outcomes for all patients.

This can best be achieved by having pharmacists working alongside doctors, nurses and other health professionals, in a dedicated community care location, such as the “super-clinic” concept that is beginning to roll-out at various levels.

This would  require Medicare Funding recognition for services provided by individual pharmacists working in those centres, a concept that has gained support from some, but not all, peak Pharmacy organisations.

I, and others, have raised this concept, with the Minister,  by way of invited public comments to the Primary Health Care Strategy Draft Paper.

The reality is that community pharmacists have, in fact,  been providing professional services and advice in primary health care day-in and day-out for the past 40-50 years, on a wide range of issues, including the optimum use of medications, prevention and treatment of adverse reactions to medications, recommending patients seek medical advice for the prevention or treatment of potentially serious diseases, and a host of other health management issues.

Unfortunately, these professional services have been provided free of charge.  Furthermore, until very recently, none of the peak Pharmacy Organisations have, to my knowledge, formally documented robust health outcome data for these activities, as would obviously be needed to support any credible Submission  for Medicare recognition and funding of pharmacists’ professional services, such as statistics on outcomes arising from episodes of medical referral, prevention of adverse medication events,  reduction in mortality or morbidity from improvement in medication management etc.

Currently, the owners of location-based PBS-registered community pharmacies still hold all of the funding chips on the antiquated Medicare monopoly board, which is driven solely by the PBS prescription dispensing and supply process.

Short of dragging them kicking and screaming into the 21st century, Medicare funding to individual pharmacists for innovative professional  pharmacy services within the community, including the sort of model outlined by Simon Bell  for mental health patients, does not look like happening any time soon!”