Ageing Population Chronic Illness Requires Integrated Care – That Requires Pharmacist Independent Prescribers

Australian pharmacists and their leadership organisations are a conservative and slow-moving group of health professionals.
Like most western economies, Australia has an ageing population that comes embedded with a range of chronic illnesses.
Chronic illness equates to high costs in providing health care.
Pharmacists have known about this problem for at least the past 20 years.
They also know that they can provide or develop many solutions to assist in the health management of this ageing demographic.
Has this knowledge translated itself into a range of forward-planned and timely pharmacy health systems?
The answer is a resounding NO!

Part of the problem is found in the basic structure in which the majority of pharmacists work in, which is the community pharmacy.
Community pharmacy requires a mix of retailing plus the provision of professional services.
Pressure to generate high levels of retail sales has been created by mainly wholesaler owned franchised marketing groups, because wholesaler income is derived from product sales.
This has left a lower level of investment, both financial and intellectual, in the provision of enhanced clinical services.

There is no doubt that community pharmacies derive good incomes from retail activities and you only have to look in the direction of the Chemist Warehouse franchise as a measure of success.
Two of its co-founders are reputed to be in the top 200 Richest List, with the franchisees representing approximately one third of the Australian pharmacy market.
Little wonder Chemist Warehouse franchise owners are looking to have pharmacy ownership rules opened up, because their next step would be to buy out their franchisees, concentrating their group into a wealthy powerhouse of market control.

The motivation is understood, but is the Chemist Warehouse model of pharmacy the model that pharmacy consumers really want or need?
The answer is no!

While you can buy a level of pharmacy consumers, most value the independent pharmacist and award them high levels of trust.
They are valuing the health advice they can readily obtain from their pharmacist of choice.
This is confirmed both by Pharmacy Guild of Australia commissioned surveys and private polling by i2P.
These same consumers would defect from Chemist Warehouse for their retail requirements if the independent pharmacy could match or better their retail prices.

So we now arrive at the conundrum for community pharmacy – how can the independents compete with Chemist Warehouse (and other major retailers) for retail sales and build professional services simultaneously?

The simple answer is that it is almost impossible to do both out of the same investment dollar, because the pressure of retailing would always win the contest.
The solution lies in sub-contracting clinical service pharmacists and have these specialist pharmacists fund their own development within their own independent business structure.

This collaborative solution has apparently been too radical for the Pharmacy Guild of Australia to contemplate, because they want to shoehorn the entire operation of clinical services under the direct financial control of a community pharmacy.
Nor will traditional franchised marketing groups fill the gap, because they are structured to extract the maximum dollar return from retail sales.
Except perhaps for the new proposed Ramsay model that is tied to its private hospital network.

That will be an interesting business model to watch and is one of the first pharmacy franchise groups to offer a point of difference.
Currently, history tells us that it is not feasible to do retailing and clinical services simultaneously under a single ownership.
Therefore a change in attitude is required before any progress will happen, and maybe Ramsay’s health network could trigger that change.

And this leads us to the next problem segment – that of the clinical service pharmacist themselves.
While representing a substantial component of pharmacy “core” business they have not been encouraged or substantially supported by any of the major pharmacy leadership organisations.
Because of this they have no advocacy support and difficulty in structuring a direction.
A number of them are seduced by the idea of working in medical general practice settings because they have no real base to anchor operations in a community pharmacy setting.
What they need to do is to form up their own organisation to politically represent their needs to government and other pharmacy leadership groups.

i2P has previously reported on similar problems that have occurred in other countries.
In the US, the message is that while collaboration with GP practices can work, it only survives if the pharmacist has their own provider number and receives income directly, rather than being paid by the GP, where pharmacist funding always undergoes a shrinkage eventually forcing a divorce.

In the UK clinical pharmacists have had higher levels of acceptance because they have worked in multi-disciplinary teams in publicly funded trusts and primary health care organisations.
However, they all complain of being inadequately supported by the GP’s as they attempt to provide patient benefit.

There is still a long journey before there is full collaborative acceptance of the clinical pharmacist.
Clinical service pharmacists in UK practice settings are generally defined by their independent prescriber qualifications.

In the UK currently there is now a call for Independent Prescribing to be developed as a component of all formal pharmacy education courses with the abandonment of the two year’s experience rule in favour of a measurement of embedded background knowledge.
This process is being encouraged by the Royal Pharmaceutical Society (RPS) and their policy document is found here.

RPS further states:
“Improved patient care, especially in an ageing population where roughly a third of patients have a long-term condition, requires that more pharmacists are trained in independent prescribing, the policy states. The Society also recommends that resources, including funding and protected learning time, are deployed to ensure existing pharmacists can access independent prescriber training.

Embedding Pharmacist Independent Prescribers into local planning arrangements as part of the core model of care, would, the Society argues, ease pressure on acute and emergency care — including out-of-hours services. The policy also reiterates the Society’s demand for appropriate read/write access to patients’ health records.

The policy calls for non-medical practitioners, including Pharmacist Independent Prescribers, to be allowed to supervise Pharmacist Independent Prescribers in training: something that was proposed by the General Pharmaceutical Council (GPhC) in its recent consultation on education and training standards for pharmacist independent prescribers.”

The message for all Australian pharmacists is quite clear and can be summarised as:

1. All pharmacy organisations should get behind the concept of Pharmacist Independent Prescribing as being the primary qualification for a clinical service pharmacist.

2. Clinical service pharmacists should form up into their own advocacy group to ensure that education, marketing and legal requirements are met, and that suitable agreements can be negotiated with academia, The Pharmaceutical Society of Australia and the Pharmacy Guild of Australia to ensure that pharmacy clinical services have a strong foundation in community pharmacy without any conflict of interest impediments (particularly in relation to independent prescribing activities).
Advocacy activities to also extend to other health provider organisations to negotiate equitable collaborative agreements and other representations.

3. That clinical services pharmacists have their own provider number to clearly separate their remuneration streams from more dominant sections of the health community.

4. That all existing pharmacy leadership organisations support and nurture the aspirations and development of a clinical services pharmacist advocacy group.

5. Pharmacy academia to commence training courses for independent prescribing immediately so as to create a future talent pool of clinical service pharmacists.

6. UK proponents of independent prescribing see positive impacts in the quality of the delivery of health care, as well as expanding capacity, while simultaneously reducing demand on primary care and acute and emergency services.
Measurement systems built around suitable metrics to substantiate the above need to be developed to negotiate additional remuneration streams with government.

It is time for all barriers to be removed so that pharmacists become full members of the health care system and that a more balanced community pharmacy “core business” results.

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