The Rules of Engagement For Practice Pharmacists Being Debated

The two leadership organisations, The Pharmaceutical Society of Australia (PSA) and the Pharmacy Guild of Australia (PGA) have been involved in preparing position statements in respect of pharmacists working within the environment of a GP practice.
At this point in time I have been able to find a reasonably comprehensive document published by the PGA, but nothing on the PSA website that could be described as a position statement.
It is known that the PSA is negotiating conditions for practice pharmacists with the RACGP through various press releases, and has previously published a range of position statements that could be encompassed within a practice pharmacist position statement.

The PSA has also previously published a statement on non-medical prescribing and has asked for government to create a national framework for a set of principles for medical and non-medical prescribing activity.
Because this activity may not have progressed to any extent may be one of the reasons for the PSA not supporting practice pharmacist prescribing in their negotiations with the RACGP currently.
PSA should clarify their total position on pharmacist prescribing before creating unnecessary friction within the profession.

PSA in a media release on 5 October 2015 stated that there would be no version of pharmacist prescribing in their model because it was outside of a pharmacists’ current scope of practice.
That may be a reasonable statement if the PSA intent is simply to negotiate an agreement with RACGP that allows for a pharmacists to exercise their full scope of practice in any working agreement with GP’s, only limiting a practice so as to fill gaps and not actively compete with each other.
For example, a pharmacist should not be involved with the ongoing dispensing of various items except maybe for starter packs or special products that may be under trial with various GP practices.
Actively competing with community pharmacies through dispensing should be disallowed to ensure “friction-free” collaboration.

Future additions to a pharmacist’s scope of practice (which must include prescribing), should flow through into a GP practice by negotiation, also limited to filling gaps.

i2P has  previously published an article about the activities of a practice pharmacist (John Dunlop) in New Zealand.
Read : Practice Based Pharmacy – Is it the future direction for pharmacists?

John’s experience indicates that prescribing has become an important function within his scope of practice.
New Zealand have had prescribing powers established for their pharmacists for some time now while Australia still lags behind.
Intending practice pharmacists should read John’s article through the above link because his role will be a very similar role to the Australian version.

I take some comfort in the fact that in the press release noted above which states:
“PSA is committed to working with all stakeholders, including the Pharmacy Guild, to progress this model.” 
PSA has no right to hold back pharmacist prescribing rights when it is an established and successful practice internationally and it is always understood that to get a collaborative agreement going, something may have to be held back.
Pharmacist prescribing rights however, remain a separate and independent issue.

It will be absolutely necessary to have PSA and PGA on the same sheet of paper in full agreement, otherwise pharmacist despair will accelerate.
Attention to leadership details must be seen to be resolved quickly and efficiently.
This is not a time for in-fighting.

Because there is more detail in the PGA document there is more to discuss.
It starts with:

“Pharmacists in General Practice Guild Position Community pharmacy and general practice are integral and central parts of the health care system.
Closer collaboration between community pharmacists and general practice supported by integrated dispense and prescribing systems will improve the quality use of medicines, improve efficiency, reduce wastage and enhance the sustainability of the Pharmaceutical Benefits Scheme for the betterment of individual patients as well as the broader Australian community.
Integrating pharmacists into general practice provides both an opportunity to enhance the collaboration between general practice and community pharmacy, and an opportunity to expand the scope of practice for pharmacists to better support people with chronic health conditions, particularly in regions in which there are GP shortages.”

The above portion of the PGA statement is a sensible and self-evident proposition and should be agreed by a majority of pharmacists.

“The Guild strongly believes that the best way to integrate a pharmacist into the general practice setting is through advancing the scope of practice of pharmacists to work as ‘Pharmacist Prescribers’ to deliver high quality patient care in collaboration with medical practitioners who would continue to have the overall responsibility for diagnosis”.

i2P strongly agrees with this statement portion and there is more than sufficient evidence globally to support this position.
Australia lags the rest of the world until we have prescribing rights resolved as a part of our scope of practice.
It has always been an oddity to me personally that we stake a claim to be medicine experts but have to go to a prescriber to resolve a medication issue.
There was a proposition that most seem to have forgotten – doctors diagnose, pharmacists prescribe and nurses administer.
The blockage to this proposition is that a conflict of interest may exist between the prescriber and the dispenser if they are one and the same person.
This is a simple regulatory problem where prescribing pharmacists should not have a pecuniary interest in a pharmacy – or some other mechanism to eliminate an unfair professional situation from evolving.
Otherwise, there is nothing wrong with that proposition and it brings three professions collaboratively to any bargaining table.

So it is extremely important to negotiate the prescriber role in any dealings with GP’s even though it is not currently within a pharmacist scope of practice.
Make a lemon into an orange, and negotiate an ideal situation then have government “rubber stamp” it – all in one movement.
The PGA statement continues:

“The inclusion of a Pharmacist Prescriber into the primary health care team should increase the clinical capacity of general practice and assist in addressing the increasing demands in primary care. The role of a Pharmacist Prescriber would include strengthening the link between general practice and the community pharmacy as well as improving a patient’s access to the health system and ensure the most cost-effective outcomes. Importantly, these roles should not duplicate the support that patients already receive from their local community pharmacy but address the gaps in primary health care, particularly with the management of patients with more complex, chronic health conditions”

Recently, i2P had a Q & A that our writer, Peter Sayers, had with an Australian practice pharmacist (who wished to remain anonymous), covering some of the issues that have arisen during PSA/PGA debate.
Read: A Former Community Pharmacist Now a Practice Pharmacist- We Have a Q & A With Him

And here is an extract from this interview:

“Q. Although you are now successfully working from a GP clinical practice space, do you intend to try and link back to a community pharmacy that has a range of clinical activities and facilitate extended collaboration between the GP practice and the community pharmacy?

A. No I am not looking for clinical space in or a formal linkage with a community pharmacy, and there are several reasons for this.
The community pharmacy is physically and philosophically independent from the other health care providers in primary care.
Clinically focused pharmacists need to establish a therapeutic collegiality with the other health care providers and this would be extremely difficult to do from within a community pharmacy environment.

Q. Given that community pharmacy has always been involved with primary health care why would a linkage be so difficult?

A. The clinical pharmacy roles in primary care are new and both trust and respect need to be built between different practitioners before roles can be established.
This incidentally takes time.”

Note that this practice pharmacist is not too keen to liaise with community pharmacy and I guess this could be put down to the conflict of issues that have arisen in the past, particularly over HMR budgets.
But a liaison role would seem to be one of the bridges that would assist in communication, education and as a result, improved overall collaboration between GP practice settings and community pharmacies.

However, these issues will resolve with time but there are a number of contentious issues in the remainder of the PGA paper that may continue division.
See the full paper here :
Position Statement – September 2015 Pharmacists in General Practice

One area of contention is that of employed clinical pharmacists (by a pharmacy) contracted out as sessional outreach pharmacists.
While advocating for professional separation within a GP practice setting, the PGA seems to see no conflict in being their employer.
With prescribing being an issue, how would professional separation be undertaken with the clinical practice pharmacist as an employee?
This does not resonate appropriately, and the PGA needs to accept that the clinical pharmacist role can be a much wider one and is really a separate business model which has already been successfully utilised by some HMR pharmacists.

i2P sees the over-arching title for this separate business model as Clinical Services Pharmacist Incorporated as a private limited liability company.
One division of the clinical pharmacist total role would be the GP Practice Pharmacist.
Another may be the Hospital Clinical Pharmacist having the role of managing a patient’s re-entry back into their home (or other setting) and ensuring collaboration with other health providers, including pharmacists.

The clinical service pharmacist basically can build a model of service that is as wide as their licence will allow – and they should practice to the maximum allowed by their licence.

For the moment, PSA should put prescribing back into their position paper and use this moment in time to gain agreement from the medical profession that this will eventually be a role for their practice pharmacist (but under their supervision).
Do the work to make this happen.
There is evidence in abundance.

While PGA has more to say on this matter, they still not seem to be able to get out of the control issues surrounding clinical pharmacists in a pharmacy setting.
If both organisations succeed in getting through the above issues we may finally see clinical pharmacists spearheading many new initiatives, through their own initiative and investment, for the benefit of the entire profession.

Clinical Service Pharmacists should help the momentum by forming up into their own association to advocate for their specific issues.
That way you will have earned a place at the table when negotiations for recognition are on offer.