The pharmacist in a primary healthcare setting

Abstract

In May 2015, the Australian Medical Association (AMA) proposed the addition of practice pharmacists to Australian general practices as a strategy to improve patient safety.1 As a general practitioner (GP) and a consultant pharmacist (AP) who recently implemented an integrated model of patient care, we welcome this announcement. Medication-related harm is a major public health issue. Overprescribing, non-concordance and adverse drug events can contribute to poor health outcomes. Adverse drug events cause an estimated 230 000 (2–3%) Australian hospital admissions annually;2 moreover, Australian GPs reported that more than 10% of their patients had experienced a preventable adverse medication event over the preceding 6 months.3 Clearly, strategies optimising medicine use can significantly improve public health outcomes. Currently, GPs refer most home medicine reviews to the local community pharmacy. In turn, the community pharmacies outsource these to third-party consultant pharmacists. Although local pharmacies tend to be on good terms with the GPs, communication tends to be intermittent and problem-focused. The community pharmacist does not play a major educational role for GPs or GP registrars. The current home medicines review model funds the consultant pharmacist to review a patient every 2 years; this is too infrequent for the consultant pharmacist and the patient to develop an ongoing therapeutic relationship. The consultant pharmacist usually needs to delegate home medicines review recommendations, such as ongoing patient education, to another health professional (e.g. the community pharmacist or GP). Medicare funds the GP to develop a written medication management plan with the patient and discuss this with the pharmacist: there is no budget for continued pharmacist follow-up with either GP or patient, so this rarely occurs. A non-prescribing, non-dispensing clinical pharmacist integrated into the multidisciplinary primary care team is an alternative model of care. An international meta-analysis of randomised controlled studies found improved medication concordance and reduced potential medication-related problems in general practices with an integrated pharmacist; however, it did not include any Australian studies.4 In an Australian retrospective analysis, pharmacist home medicines review recommendations were significantly more likely to be implemented (71 vs 53%) if the pharmacist was embedded in the practice.5 Our integrated multidisciplinary practice model is in accordance with the AMA suggestion that the practice pharmacist role should include a combination of patient services, physician-focused activities and systems-level interventions.1 Since the best outcomes for both practice staff and patients appear to result from the pharmacist working closely with GPs, the pharmacist (AP) works as an in-house specialist at the medical centre rather than as an external (ad hoc) consultant.5 GPs benefit in multiple ways from the pharmacist presence. Pharmacists’ support and input are provided in a timely manner in instances when they may not have previously been sought, from clinical meetings to incidental (‘corridor’) consultations. The practice pharmacist and GP relationship allows for advice tailored to the GP's preferred style and immediate needs and enables ongoing, long-term collaboration on more challenging cases. Further, GPs are more likely to enact advice from a trusted and respected colleague than recommendations from an external ‘contractor’.5 Patients benefit both directly and indirectly from the presence of a practice pharmacist. The pharmacist and patient can develop a therapeutic relationship, allowing regular and ongoing patient education and support. As practice pharmacists are able to access the patient's medical records and pathology results, they can more readily identify both underprescribing and overprescribing to support the GP in optimising the medication regime. The medical centre can potentially benefit, too. The practice is more capable of delivering integrated care since the multidisciplinary team encompasses a wider range of healthcare professionals. All staff members benefit from the opportunity to strengthen pharmacotherapeutic knowledge, while the simple presence of a pharmacist promotes increased medicine-based thinking. The practice pharmacist can support clinical governance through quality improvement activities across the practice, such as medication audits, drug usage evaluations and monitoring drug safety. Our practice pharmacist role includes a combination of patient, physician and systems-focused activities, with the services delivered tailored to local preferences and needs. Our embedded practice pharmacist has a continuous, ongoing role in the optimisation of medication use within the primary healthcare team. This reflects a valuable progression from an intermittent, reactive, problem-based model to a collaborative, integrated model of chronic disease care delivered by a multidisciplinary primary healthcare team. Whilst this is a positive move, further research into the effectiveness of this innovation in the Australian primary healthcare setting needs to be funded before this model can become accepted as the standard.