The push for pharmacists to take on more primary care tasks has created tension but is it a solution to problems with health care delivery? Dr Karl Gruber asks the question.
Pharmacists are increasingly being consulted for advice on a range of minor health conditions – it’s free, they are everywhere, and you get a quick opinion and “something to make you feel better”.
Now, there is a new push to expand the so-called scope of practice among pharmacists to allow them to offer medical advice and medication for more than mild conditions. Can pharmacists really do some of the tasks traditionally done by GPs? Should they? Will they?
A key argument why some pharmacists are pushing for their involvement into GP territory is logical because according to a 2019 report from Deloitte Access Economics, there will be serious shortages of GPs by 2030.
The General Practitioner Workforce Report 2019 aimed to determine if there would be an under or over-supply of GPs in Australia over the next few years.
“Both urban and regional areas will become progressively undersupplied over the 10 years to 2030, resulting in a deficit of 9,298 full-time GPs or 24.7% of the GP workforce by 2030,” the report said. “The deficit is expected to more pronounced in urban areas (31.7%) compared to regional areas (12.7%).”
Following the publication of this report, the Pharmacy Guild of Australia issued various statements arguing the need for pharmacists to step in and help with the work of GPs. For example, in a statement for the Australian Journal of Pharmacy, George Tambassis, the national president of the Pharmacy Guild, said:
Adjunct to care
“Empowering pharmacists to take on a greater role in the healthcare system by doing things like giving more vaccinations, issuing repeat prescriptions for things like blood pressure and treating common ailments like asthma and migraine would relieve some of the pressure on already overworked GPs.”
There are also other issues affecting GP and emergency departments in Australia. High out-of-pocket costs, long waiting times, poor access to after-hours care and lack of enough GPs in rural and remote areas are some of the problems often associated with the Australian health care system.
According to a campaign from the Pharmacy Guild, pharmacists may be able to help with all these problems. According to the campaign, called “Community Pharmacies: Part of the Solution”, pharmacists can “administer basic healthcare services to drive down costs to patients and the health budget, reduce waiting times and increase frontline health accessibility.”
Today, pharmacists are already doing some of the work traditionally reserved for GPs, such as triaging.
“Pharmacists currently triage patients for minor ailments and medicine safety problems. Such initiatives will facilitate further interprofessional collaboration between doctors and pharmacists. Team-based care will provide the best outcomes for patients,” Dr Tin Fei Sim, president of the WA branch of the Pharmaceutical Society of Australia, told Medical Forum.
Perhaps the best example of a good use of a pharmacist’s skills can be found in Australia’s efforts to vaccinate millions of people as soon as possible in the midst of the COVID-19 pandemic. Early this year, the Australian government announced their plans to allow community pharmacies to dispense COVID-19 vaccines to the community. The vaccine will be administered by specially trained registered pharmacists, as well as nurse practitioners, nurses and Aboriginal Health Workers under the supervision of an approved pharmacist.
“Including pharmacists in the national rollout is in the public interest, to increase public access to vaccines quickly while increasing vaccination rates and pharmacists stand ready, willing and able to deliver COVID vaccinations to the Australian community,” said Associate Professor Chris Freeman, president of the Pharmaceutical Society of Australia.
However, not everyone is on board with the idea.
According to Dr Mark Morgan, GP and Professor of General Practice at Bond University, the roles of pharmacist and GP would work best in collaboration rather than competition.
“GPs and pharmacists work best together when each are using their unique skills and knowledge,” he told Medical Forum.
In terms of the tasks performed by GPs, Dr Morgan explained that GPs were experts when it came to assessing and managing undifferentiated presentations.
“We can manage uncertainty, organise tests, arrange follow up and set up safety net arrangements. GPs can often access detailed past medical history and results from investigations to help make the best plans with our patients. GPs help patients by explaining and facilitating non-drug interventions,”
Dr Morgan said.
“Minor illness presentations to GPs provide the venue for opportunistic preventative checks. They provide a time when lifestyle interventions such as smoking cession can be progressed.”
Would pharmacists be able to fulfil all these tasks? For some the answer is simply no.
One of the most ardent opponents to the “pharmacist as GPs” model was the late RACGP President Dr Harry Nespolon who argued that pharmacists were not able fulfil the role of GPs as they lacked the necessary training, experience and expertise. Some statements made by Dr Nespolon on this topic included:
Vocal critic
“‘Empowering’ pharmacists to treat serious diseases like asthma is a recipe for disaster as we have discovered in places like the UK, where there is an increasing number of serious incidents, including deaths, due to unsafe practice. The fact that there is a shortage of GPs does not change the skill levels of pharmacists – patient care is more effectively and safely delivered within general practice.”
Other issues pinpointed by Dr Morgan is that a GP office offers a confidential environment with all the necessary diagnostic equipment at hand. This would not be possible at the nearest pharmacy.
But a more important point concerns the medications patients receive at a pharmacy. “A significant proportion of people with self-limiting minor illnesses are sold over-the-counter medications. The evidence supporting many of these medications, such as cough mixtures for use in children, is non-existent,” Dr Morgan told Medical Forum.
“Many community pharmacies create confusion and reduce health literacy by selling low value and unnecessary supplements and remedies. Many walls are lined with products that have more to do with profit than clinical benefits,” he added.
Finally, having pharmacists work as GPs may lead to fragmentation or even duplication of service, Dr Morgan says. “…patients receive overlapping care from multiple providers with inadequate exchange of information, which is associated with increased costs and poorer outcomes.”
The way forward
The government has not yet made its final decision. The rollout of COVID-19 vaccines would be aided with help from pharmacists, but more work is needed to reach a consensus on the best way forward.
One potential model could involve an association between pharmacists and GPs, Dr Morgan said.
“Imagine a world where pharmacists were funded to work in general practice engaged in medication governance and patient education as part of the team. Imagine the same world where immediately necessary medicines were dispensed direct from general practice while longer term medications were distributed direct from warehouses,” he said.
Collaboration is also in the mind of Dr Sim, who says that true collaboration between pharmacists and GPs is the key.
“When GPs and pharmacists work together collaboratively and putting patients’ health and wellbeing at the centre of focus, this is the best outcome. Ultimately, we need to work together to achieve the most cost-effective delivery of healthcare for all Australians,” Dr Sim said.
Another argument being pursued is a role for pharmacists in addressing ED overcrowding and long waiting times.
“People attend ED for a variety of reasons including deep concern that their condition needs rapid attention with timely investigations and treatment. Hospitals are often regarded as a place of safety and expertise. I think it is naïve to use economic arguments that patients can be sent away at the front door of ED to see a community pharmacist for equivalent treatment,” Dr Morgan said.
False economy
“The amount of assessment and triage needed to set this up in a way that is both acceptable to the community and safe for patients would amount to doing most of the consultation – making for very few savings if any,” Dr Morgan explains.
Pharmacists, as currently trained, are experts in medication use, not in diagnosis or multimodal management. So, what is the solution then? According to Dr Morgan, bigger investments in GP clinics may be the way to go.
“Examples include allowing practice nurses to work to full scope of practice with Medicare patient rebates, infrastructure and IT supports, increased patient rebates generally, CME allowances, slick systems with minimised red tape, streamlined referral systems to the wider team and subspecialties, shared care arrangements for complex and subspecialist care etc,” Dr Morgan said.
The idea of empowering nurses to expand their scope of practice is also backed by Dr Christopher Harrison, Research Fellow of the School of Public Health at the University of Sydney.
“There have been several initiatives to increase the scope of practice of other health professionals (such as practice nurses) to help address health workforce shortages. These have been successful because the practice nurses are a part of the health team,” Dr Harrison told Medical Forum.
Whether empowering nurses or pharmacists, the bottom line is that more research is needed to ensure that, at the end of the day, patients are the ones receiving a benefit.
“I think before any change is made, it should be considered whether this change will foster team-based or collaborative care of the patient. In a time when multimorbidity is increasing, the last thing we need is further fragmentation of care,” Dr Harrison added.