Collaboration- What does it mean for health professions?

The new “buzz” word floating around the health professions is “collaboration”.
In the same breath it is linked to other expressions such as “patient-centred homes” or “patient-centred neighbourhoods”.

But what does it all mean – particularly when referenced in respect of community pharmacy?
Starting with the dictionary terminology we find collaboration means:

1. “the action of working with someone to produce something”.
(cooperation, alliance, partnership, participation, combination,association,concert)

2. “traitorous cooperation with an enemy”.
(fraternising, fraternisation, colluding, collusion, cooperating,cooperation, consorting, sympathising, sympathy, conspiring).

And we need to consider both definitions of collaboration because it will define the systems that will facilitate the collaboration, the rules of engagements, and the focus on establishing a unified vision.
The strength of that vision will relate very much as to the real extent of both types of collaboration that will come into play.
The reality is that collaboration will occur at some point between the two collaborative styles – but at what point will it be acceptable to pharmacy?
On this there needs to be more debate, but it has to occur from a “bottom up” perspective.

Another consideration to rationalise is what does collaboration in health really mean?
The following may give a guide:

3. collaboration between all health professions, one to the other
(pharmacists with physiotherapists, nurses, and others and each other).
This type of collaboration would seem to create opportunity for all health professions to explore genuine partnerships for mutual patient benefit, with job satisfaction for all at a level not previously experienced.

4. Collaboration between individual health practitioners and doctors only, with limited cross-collaboration available.
(GP to pharmacist only. GP’s have always claimed that collaboration would only work if it was GP-led, particularly in the area of primary health care – pharmacy’s traditional market space)

The last two points (3 & 4) are referenced only under the attitude articulated in point 1 (genuine partnership).
So how would you view collaboration when viewed from the perspective of point 2?
Who would you define as the “enemy”

Surely this must come down to those groups with which you have continuing fights with.
Who fits that category?
It has to be admitted that it comes down to government and doctors.
And within those parameters, these assume the dimension of an “enemy” of pharmacy as community pharmacy can well testify in respect of the bruising campaigns that have been deliberately designed to financially weaken the profession of pharmacy as well as destroy its morale.
Of course, doctors and government are “enemies” to each other as well, depending on the occasion.
But when doctors and government combine against pharmacists, the fight becomes unequal and difficult to win.

To win a war involves a strategy and one of the best known strategies is the “divide and conquer” one.
To date,the doctor strategy for collaboration is to take the non-owner pharmacists and have government pay directly to the doctor’s practice, monies sufficient to cover the costs of employing this type of pharmacist.

That strategy is an immediate “divide and conquer” strategy, because it separates some of pharmacy’s best and brightest clinical pharmacists and aggregates them in a general practice setting.
That is not to say that it is not an acceptable extension or environment for pharmacists to practice in, but what happens to the remaining pharmacists that primarily practice in a community pharmacy setting?
Working in a GP practice creates an elevation of job satisfaction even though you have only employee status (when a provider status is required).
This has already been identified as a major problem in some US settings where clinical pharmacists have had difficulty in negotiating hourly rates and in many circumstances have ended up receiving nil or inadequate reimbursement for some of their work.
Of course there are some good news stories, but the problem common to all of these types of pharmacists was the limited scope for expanding practice within the GP setting as it tended to be seen as competitive to the GP “turf”.
Some expansion has been achieved when the pharmacist demonstrated skill in certain practice activities and had negotiated with other health professionals within the same practice to have work delegated to them.

While pharmacists can value-add to a GP setting, they should also be able to value-add from within a pharmacy environment.
That this is not happening is due to an apathetic leadership within pharmacy’s governing bodies not being able to collaborate with each other and present a unified approach to government and doctors.
And they also need the political will to engage.
So it is my belief that the extension of the practice pharmacist within a GP setting, along with other health professionals to form up into a “patient-centred home” will initially provide patient benefit because of convenience and the quality of the health professionals practising within that setting.
Eventually job satisfaction of all health professionals will diminish through doctors only seeing their policies in terms of furthering their own selfish ambitions.
That will undermine a true patient focus.

Patient-centred homes have already begun to fail in the US which has given rise to a broader concept of a “patient-centred neighbourhood”.
This concept has received wider support and it appears that it will rise to more desirable patient focus, primarily because pharmacy has been given a coordinating and triage role.
And it appears that the “bargaining chip” was the walk in clinics that had evolved to become profitable in their own right and successful in driving a whole of pharmacy bottom line.
CVS pharmacies in the US were the first to recognise this opportunity and has been selected on a sole provider basis to pilot the new “patient-centred” neighbourhood”, which it is doing very well.

Community pharmacy should likewise seize the opportunity presented here because it is already a pharmacy network established under PBS location rules.
While I have been against the rules as being non-competitive in the past, I have had cause to reverse these thoughts recently as the “patient-centred neighbourhood” concept has unfolded in the US.
It would be a shame for all concerned – government, pharmacists, GP’s and allied health, if pharmacy location rules disappeared at a point in time where it would be valuable as a primary and public health clinical service and triage unit for each pharmacy.
In the US, CVS has introduced elements of public health into the primary health care offering that they are creating for their patient “home”.
I2P has earlier suggested that Australian pharmacies can organise to embrace elements of public health such as emergency relief in natural disasters and after acts of terrorism, as a treatment point for a particular category of triage for patients being evacuated from disaster areas.
These should not be discarded as unrealistic ideas because they validate the caring role of a pharmacist.
In that role they would be seen as a valued resource, organised by a location network.
Will our leaders aspire to this level of thinking?

So how do we start the process of collaboration?

I believe that it should start with a grass roots movement in pharmacy first, meeting regionally and conducting workshops on establishing collaboration between all types of pharmacists.
Injected into that pharmacist movement should be a range of rolling workshops established to identify how collaboration can occur within pharmacy at all levels.
Next, I would begin to invite other health professionals to those workshops to find out what the word “collaboration” means to them, and set up working collaborations on a regional basis.
And the results of those workshops need to be documented as “white papers”.

The next phase after identifying the need for collaboration policy and procedure would to develop a communications system that can link “any to any” including patients and doctors.
At that point I would begin the collaboration process with doctors having first established a unified health community to balance out the political strategy of doctors.
The PCEHR (now MyHealth) system may not be the correct system for collaboration because it is already being used as a manipulation tool against doctors by government.
Doctors have been threatened that the PIP incentives paid to a medical practice may disappear totally if they do not enter a nominal number of patient records on to the system within a designated time-frame.
The practice cannot demand that doctors do the work of patient’s medical record note preparation and upload to the MyHealth database.
So the practices stand to lose a large some of money if the doctors do not cooperate – and they are resisting.

This is an instance of where the government are seen as an “enemy” by doctors and where collaboration is seen by government as doctors doing the MyHealth job free of charge.
The situation would be resolved if this requirement became an MBS approved activity and the doctor receiving payment for it.
Pharmacists have been put in this position many times over, and current “bottom lines” for community pharmacies are testament to this continuing government assault.
So pharmacy also needs to become less dependent on the government purse because government is always blowing its budget, and uses soft targets like pharmacy as the first victims to be used to balance the budget.

Collaboration between health professionals may also be developed to a higher political level to reduce the number of attacks made on all of them by government.
As they say, there is safety in numbers.
In summary, the collaboration process is as follows:
1. Universal pharmacist collaboration-work-shopping and white papers.
2. Collaboration with allied health professionals – work-shopping and white papers.
3. Develop and link collaborative communication and information systems.
Communicate agreed “white papers” as evidence of collaborative policy for government to back.
Continuous political lobbying to ensure an understanding of health issues by politicians.
4. Develop collaboration with GP’s and collectively with a unified “all of health” base.

Please add commentary in the panel below to give different perspectives.

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