Recent reports in various media cited research done in respect cardiovascular disease and pharmacist involvement delivered as a paid clinical service provided from a pharmacy environment. The research was undertaken by the University of Sydney’s Faculty of Pharmacy which conducted in-depth interviews with 21 NSW community pharmacists, based around the feasibility of a cardiovascular disease case study. The interviews and an accompanying literature review revealed a range of factors inhibiting their uptake of chronic disease management programs, including resistance from doctors, patient concerns, perceived knowledge deficits, lack of counselling areas and remuneration concerns. The abstract of this research paper is illustrated below:
Hanni P. Puspitasari , Parisa Aslani, Ines Krass Published: November 19, 2014 DOI: 10.1371/journal.pone.0113337
Abstract
Background
As primary healthcare professionals, community pharmacists have both opportunity and potential to contribute to the prevention and progression of chronic diseases. Using cardiovascular disease (CVD) as a case study, we explored factors that influence community pharmacists’ everyday practice in this area. We also propose a model to best illustrate relationships between influencing factors and the scope of community pharmacy practice in the care of clients with established CVD.
Methods In-depth, semi-structured interviews were conducted with 21 community pharmacists in New South Wales, Australia. All interviews were audio-recorded, transcribed ad verbatim, and analysed using a “grounded-theory” approach.
Results Our model shows that community pharmacists work within a complex system and their practice is influenced by interactions between three main domains: the “people” factors, including their own attitudes and beliefs as well as those of clients and doctors; the “environment” within and beyond the control of community pharmacy; and outcomes of their professional care. Despite the complexity of factors and interactions, our findings shed some light on the interrelationships between these various influences. The overarching obstacle to maximizing the community pharmacists’ contribution is the lack of integration within health systems. However, achieving better integration of community pharmacists in primary care is a challenge since the systems of remuneration for healthcare professional services do not currently support this integration.
Conclusion Tackling chronic diseases such as CVD requires mobilization of all sources of support in the community through innovative policies which facilitate inter-professional collaboration and team care to achieve the best possible healthcare outcomes for society.
While i2P agrees with the basic thrust of this research it seems to rule out an independent approach, promoting a collaborative approach instead.
We would suggest that an independent approach is possible, even necessary, to prevent complete ownership of clinical pharmacists by doctors, including the ability to undertake original research for clinical pharmacy practice.
Some of these issues relate to an outdated culture, beginning to be addressed by leadership organisations.
Resistance by doctors is a given and has been applied in varying degrees for nearly 100 years, so nothing new there. The fact that the AMA is running an adverse campaign highlighting pharmacy professional services being conducted between the “toilet paper and the toothpaste” is just their way of creating negative perceptions for their audience of politicians and the general public, to supposedly illustrate the low level of quality from pharmacists and the high level supposedly from GP’s.
The fact that they have to resort to this type of practice is testament as to how vulnerable they feel as other health professions catch up, creating a higher level of skill within each competing profession.
This would be good for service levels, quality and price.
Conversely, GP’s have evolved into traffic directors by referring patients to other disciplines rather than treat themselves.
The result is an expensive business model for patients who are continually visiting other locations, wearing out shoe leather in the process.
Hands-down pharmacy beats the medical and nursing professions in drug knowledge and their interaction and side effects. Medication reviews systemise those skills into a portable and understandable document that is valued by those recipients who rely on them for improving their own services to patients.
The fact is that with the HMR system being stifled because of budgetary constraints, we have some of the best brains in pharmacy simply leaving their profession or accepting more menial work to simply survive.
This would not concern the medical profession because most of their imagined competition would arise through these people.
Patient concerns are an interesting finding uncovered by the above research.
i2P has found this to be both true and untrue, which is why confusion exists for this point.
Original research by i2P in respect of a clinical pharmacist pilot study illustrated that even though perceived concerns of privacy and additional training were observed, there was hesitation when a patient was offered a service, in particular, a reluctance to entering a closed office properly fitted out for patient consultations.
This puzzled us initially and it took more than one approach (on more than one pharmacy patient visit) to persuade a patient to engage in a new service.
The answer to this conundrum came later from some Scottish research into service comparisons between GP’s and pharmacists.
We have previously published this material in i2P but because of its importance, it is reproduced below:
+ Author Affiliations 1. 1Strathclyde Institute of Pharmacy and Biomedical Sciences, University of Strathclyde, Glasgow, UK 2. 2Flinders University, Adelaide, South Australia 3. 3Health Behaviour Research Centre, University College London, London, UK
- Correspondence to Dr Wendy Gidman; wendy.gidman@strath.ac.uk
- Received 25 January 2012
- Accepted 15 March 2012
- Published 14 May 2012
Abstract
Objectives
To apply sociological theories to understand public trust in extended services provided by community pharmacists relative to those provided by general practitioners (GPs).
Design
Qualitative study involving focus groups with members of the public.
Setting
The West of Scotland.
Participants
26 purposively sampled members of the public were involved in one of five focus groups. The groups were composed to represent known groups of users and non-users of community pharmacy, namely mothers with young children, seniors and men.
Results
Trust was seen as being crucial in healthcare settings.
Focus group discussions revealed that participants were inclined to draw unfavourable comparisons between pharmacists and GPs.
Importantly, participants’ trust in GPs was greater than that in pharmacists.
Participants considered pharmacists to be primarily involved in medicine supply, and awareness of the pharmacist’s extended role was low.
Participants were often reluctant to trust pharmacists to deliver unfamiliar services, particularly those perceived to be ‘high risk’.
Numerous system-based factors were identified, which reinforce patient trust and confidence in GPs, including GP registration and appointment systems, GPs’ expert/gatekeeper role and practice environments.
Our data indicate that the nature and context of public interactions with GPs fostered familiarity with a specific GP or practice, which allowed interpersonal trust to develop.
By contrast, participants’ exposure to community pharmacists was limited.
Additionally, a good understanding of the GPs’ level of training and role promoted confidence.
Conclusion
Current UK initiatives, which aim to implement a range of pharmacist-led services, are undermined by lack of public trust.
It seems improbable that the public will trust pharmacists to deliver unfamiliar services, which are perceived to be ‘high risk’, unless health systems change in a way that promotes trust in pharmacists.
This may be achieved by increasing the quality and quantity of patient interactions with pharmacists and gaining GP support for extended pharmacy services.
So when this finding of reduced trust perception for pharmacists was published we could not believe it because every poll involving the general public trust in pharmacists had always been massively in endorsement of pharmacists, compared to other health professionals.
Then we recalled our earlier study that noted patient hesitancy when invited into a closed office space and suddenly realised that these patients had no reference base.
They had never been previously treated in this manner and had no comparison to new service cost and quality.
Patient distrust of pharmacists only faltered because it was a new service and challenged the patient’s GP existing channel of relationship in competition.
Being a new experience with no previous comparator, the pharmacist service was sceptically refused.
I can report that the i2P pilot study went for a 12 month period and was highly successful.
The missing link was appropriate marketing, both on a personal and local catchment basis, to properly familiarise patients with the service.
Professionally designed pamphlets written in lay language filled the most important gap, vouchers offering a free or discounted consultation filled another gap.
Training for all clinical staff (pharmacists and clinical assistants) was also considered an appropriate and very important step. All clinical staff need training in mentoring patients, appointments need to be kept to 15 minutes with second and third appointments booked to complete the patient service.
Internationally, pharmacist clinical services have been in vogue for some time, particularly in the UK.
The government of Scotland has had no hesitation in endorsing pharmacists within their 10-year plan published in i2P under the title of “Scottish Government 10-Year Plan”.
Perceived knowledge deficits is an important point and can only be solved with educational organisations tailoring their education for clinical pharmacist needs.
Importantly, this should take the form of regular, economically priced modules conducted on a regional basis (not city centric), and while involving prescribing techniques and processes, should cover obvious knowledge gaps.
For example, I have never used a stethoscope and this instrument is commonly used in patient work-ups.
It does not require expensive or lengthy educational processes to fill my knowledge gap, and I would venture to say that the knowledge deficits uncovered by Sydney University researchers would evolve around these simple gaps.
Putting it more bluntly, if an educational organisation offered a workshop in my region around the use of a stethoscope, I would book it immediately.
If prescribing techniques were added as a bonus I would become really enthusiastic particularly if the price was an economical one.
Remember, if you can offer cyclical workshops ongoing, you can build up a good business model based on new services.
This perceived knowledge deficit uncovered by the researchers is not a real barrier.
Lack of counselling areas is not a real problem it is a reflection of the lack of planning by pharmacy proprietors who have been waiting for the PGA to solve their problem.
Until recently, the PGA was simply not at home regarding this and for well over a decade, was even opposed to clinical services promotion, hence a lack of research on what I prefer to call “clinical spaces”.
For the very reason relating to patient trust, an enclosed office area is not recommended for an initial interview.
What is recommended is the “health bar” utilised by the Lloydspharmacy group in the UK and Europe. It is based on Apple’s “Genius Bar” created by Steve Jobs for his retail stores. This is expanded upon in another article in this edition of i2P titled “A Pharmacy Industry Model”.
i2P has also introduced economical ideas for private clinical spaces based on all the above research, but specifically the patient trust factor.
An illustration is shown to the left of this text:
These spaces featured translucent and sound absorbing partitions that are modular and very economical.
This is the area you would utilise after meeting the patient at the “Health Bar” and then escorting them to an open plan partition clinical space.
Patient trust is not an issue with the design of these clinical spaces and a patient would readily agree to go into an enclosed office space from this more open space if privacy was indicated.
The patient is “coached” by degrees.
See also an i2P article titled US Clinic Design: The Exam Room
Remuneration concerns are valid because government and private health insurance does not cover pharmacy clinical services as yet, simply because they don’t exist in an organised format, excepting some primitive formats organised by PGA e.g. Medschecks.
It may well eventuate that government will pay for some pharmacy clinical services, but my belief is that they would subsidise an existing model rather than a future development version.
So the primary need is to start privately, and target patients with the capacity to pay.
This may also reinvent pharmacists within primary health care that have something to bargain in a variety of collaborations. What does this say for the average pharmacy?
i2p says that to start, simply target the patients with an ability to pay.
To find these patients set up a decent marketing program that separates all marketing from the “toilet paper and toothpaste”. Personalised email campaigns directed to your own customer base would constitute a start.
These campaigns would highlight packaged type services (such as a cardio screen) that can develop into individualised advice delivered in a mentoring style for follow-up appointments.
Some of these consultations may result in referral to a doctor or other health practitioner and as long as you are practising to the limit your registration licence permits, then you will build your clinical practice.
i2P experience indicates that patients of all socioeconomic status will readily pay for a quality service.
Many pharmacists have had money offered to them after providing a quality service, the author included.
It is frustrating to have to decline payment by these patients simply because that pharmacy policy is “free services”.
Independent clinical service providers are more likely to get involved with research activities that could benefit the pharmacy profession overall.
This may not happen in a GP environment.
Collaborative clinical service providers e.g. a pharmacist working in a doctor-controlled environment, will certainly develop good outcomes for patients.
A mix of private and collaborative enterprises would be the ideal.
All that the Sydney University research has uncovered is a basic lack of confidence among pharmacy owners.
To solve this problem we respectfully request that a pharmacy proprietor retain suitable consultants to develop clinical services.
i2P can arrange an initial no-obligation conversation with a suitable consultant (telephone: (02) 6628 5138).
The alternative is to secure the services of a suitable clinical pharmacist who owns their own clinical services contracting company.
Then provide space on a serviced rental basis i.e. the pharmacy leases the space and some pharmacy staff to a practitioner for a split of the gross revenue.
That split can mirror the GP model where a GP practice company manages any clinical space on a 70:30 revenue split, with the practitioner receiving the 70 percent component and clerical services provided under the 30 percent component. Practitioners would need to work across more than one pharmacy ownership for taxation reasons (as a contractor company) and for sufficient income reasons as one pharmacy may not have sufficient work initially.
If the practitioner provides staff the revenue split should then be 80:20.
You also need a starting point and that could be Medscheck reports, which provides some income.
With patient investigation, extra appointments may be leveraged from this service which initially can be offered at no charge to the patient (reimbursed by government).
It is important to establish value for every service provided.
Even if it is provided for a nil charge, there should be a price list or invoice reflecting that fact, and the discounted value.
While the Sydney University research highlights some of the perceived stumbling blocks, they do not inhibit clinical service development overall, with a bit of determination.
The basic ingredients include:
1. A properly resourced investment budget so that implementation can progress smoothly.
This should develop into a formal business plan.
2. A resolve that this is a service you must provide.
Without the mental discipline and a willingness to overcome all the negative impediments, you will not succeed.
3. A well thought out marketing campaign to include a brand and a price list that can be prominently displayed and openly included in brochures and display advertising.
Forget about competitors copying (even discounting) your service retail price.
The price list should include all the health service packages that you can reasonably provide at an economical price.
Prices need to be based on a $120 per hour fee, with smaller segments of that hour marked up accordingly.
4. Average consultation to be 15 minutes, varied according to service type.
If you wait for a collaboration offer by a GP you could be waiting indefinitely, given the hostile campaign building within the AMA.
Some pharmacists have secured collaborative positions through their HMR association and service.
These pharmacists are in the minority and were the group hit hard when budgeting constraints were unnecessarily imposed. The Sydney University research should not be used to delay implementation of clinical services as all impediments can be overcome and a balance needs to be structured between pharmacy generated clinical service and GP collaborative clinical services.
Too heavy a reliance on either generator may impede future development and control of this important activity.
But it’s any “port in a storm” until an optimum business model evolves.