The Battle Clinical Pharmacists Have to Win

I was pleased to see an opinion article by Jeff Shaw, recently published in Pharmacy News.
Basically, he was outlining how the pharmacy landscape had changed since 1996 where his pharmacy students at that time thought the class titled “Clinical Pharmacy” was one more designed for hospital pharmacists.

He said:
“Fifteen years on the whole landscape has changed, first with the introduction of Residential Medication Management Reviews in 1997, followed by Home Medicines Reviews in 2001, and then a host of other services funded through the various Community Pharmacy Agreements including MedsChecks and Diabetes MedsChecks. Cognitive services which have changed the “what” pharmacists do in primary care.”

In a succinct analysis, Jeff identified that while these services were distinct from the traditional supply service of dispensing, funding through the Community Pharmacy Agreement model inevitably linked both activities.
While 1997 marked the official change in the “what” pharmacists actually did in primary health care, many pharmacists were experimenting with different models up to that date, so change really had been a gradual process.
The cognitive services had difficulty initially in gaining acceptance by the medical profession, and it has been a slow process by dedicated pharmacy professionals to win acceptance on the quality of their work.

While the funding linkage for dispensing and cognitive services came from the same funding model, it was inevitable that cognitive services would be viewed as an extension of dispensing and therefore as an appendage – not a distinct and different service in its own right.
It soon became apparent that although pharmacy proprietors could become accredited to perform medication reviews, they did not necessarily have the time or the mental disposition to do them.
Medication reviews are a consultative process and require an unstructured time management while business management and dispensing require a more structured time management.
The two processes have a lot of basic incompatibilities.
Thus, the medication review process had to be delegated to pharmacists with the inclination and aptitude for genuine consulting work.
Jeff’s analysis is spot on as to the ultimate outcome for the model and its direction, as he states:
“This has proven problematic, as the demand for the services has outstripped the designated funding, which has lead to the recent imposition of limits on RMMR, HMR and MedsChecks.
These restrictions particularly on RMMRs and HMRs has been devastating to the vibrant community of accredited pharmacists engaged in delivering these services.
Comments from those in the Pharmacy Guild of Australia that medication management reviews were never suppose to provide a career are not echoed in reality, as for many pharmacists they have done just that.
They have allowed pharmacists to be self employed, and engage with patients on a one-to-one basis in order to assist them and/or their carers better managed their medications.
Demand beyond the capability of funding is not an indicator of failure of the services, rather an indicator of an unmet need. This is a success story, but the model needs rethinking.”

The PGA has never demonstrated the proper level of commitment to clinical services yet these services have always been part of the “core job” of a pharmacist.
Medication reviews conducted in patient homes are so totally different to dispensing in a pharmacy they were never going to be accommodated without a drastic restructure to a pharmacy.
Even today, you see very little physical demonstration that clinical services even exist in a pharmacy.
You may find the token unlabelled interview room required under the Pharmacy Act but virtually no design component or commitment to it – and certainly very little continuous clinical flows operating through it.
So without the commitment why did the PGA try to dominate and own these clinical services in their entirety?
The simple reason is that the PGA executive did not and still does not fully understand the consultative process and the adjustment to the model of pharmacy that was required.
They saw it only as an extra added income stream – not as a completely separate enterprise.
Not much has changed.
To accept it as a separate enterprise seemed to be some sort of a “horror story” for them as they envisaged all these small enterprises as being separate to the traditional pharmacy and in competition to them.
That could not be allowed to happen!
So they allowed themselves to become engaged in “conflict of interest” negotiations on behalf of accredited pharmacists limiting any future potential competition by artificially limiting or manipulating the budgets available for cognitive services.
i2P writers recognised these problems since it first began publishing in 2000 and was the primary reason for its being.
So, in 2014 we now arrive at the “pointy” end of the problem where we have a proven and expanding professional service in the form of the Medication Review being deliberately destroyed by the PGA concurrent with their need to have extra streams of income to replace lost PBS income.
They choose low grade commoditised types of professional services e.g. Medscheck, that really satisfy nobody unless they are supported with genuine consultant input.
This is a wasteful process and can only be regarded as a “knee-jerk” reaction to the total problem.

It also demonstrates that the PGA with this type of mindset is no longer qualified to negotiate on behalf of cognitive pharmacists and that cognitive pharmacists must organise themselves into an infrastructure that can represent their interests.
The next step for this new entity is to negotiate rental spaces within an existing community pharmacy and become a stimulant to dispensing and product sales (cognitive pharmacists will be the new prescribers with no pecuniary interest in a pharmacy – thus no conflict of interest).

These types of pharmacies will remain patient-centred and professionally satisfying to both sides and will represent one version of a new business model geared for survival-both financially and professionally.

Jeff Hughes in the last component of his analysis correctly identifies that cognitive services require reimbursement from a range of payers, not just government.
And reimbursement models may require the provider to take more risk as in a care model on an annual patient capitation as distinct from a direct fee for service.
It will be the clinical services cognitive enterprise that will be the driver of collaboration between primary health care providers, so until they become a visible reality, the profession of pharmacy will never reach its full potential.
The way ahead is quite clear:

1. Form a new organisation to represent clinical service practitioners and create independent practice standards and a code of conduct and all accreditation processes.
2. Lobby to independently negotiate with government on all matters clinical.
3. Negotiate with the PGA for an alliance partnership model. If not achievable, negotiate with willing pharmacy participants and other potential stakeholders.
4. Lobby for all members to be enabled as independent prescribers.

There are many obstacles to overcome but if a start is made soon there are great possibilities for a rich professional life.

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