Editorial

Neil Johnston

Welcome to the March edition of i2P – Information to Pharmacists.

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So how are pharmacists unique?

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Linda Bryant articles by this author...

Linda is a New Zealand Clinical Advisory Pharmacist working as part of a team with GP's and nurses, in a medication advisory role. New Zealand clinical pharmacists get some encouragement to work independently in a variety of settings not necessarily tied to a community pharmacy. Through her company, Comprehensive Pharmaceutical Solutions, she contracts to Primary Health Organisations, lecturing postgraduate students in Clinical Pharmacy and undertaking evaluations of services. Linda's PhD thesis involved investigation into the barriers of implementing Comprehensive Pharmaceutical Care (clinical medication reviews) in primary care.

Five things set me thinking about what the role of a pharmacist really is?
Are we heading in the right direction – one that will provide a sustainable future for the profession?
Firstly, of the 20 general practices in our Primary Health Organisation (like the Australian Divisions of General Practice), there are about 60 practice nurses (not all working full time).
While in a practice late last year, one practice nurse was telling me how great it was that she had almost finished her postgraduate certificate in Long Term Conditions – a relatively new university-based 600 hour certificate.
She was really enjoying working with the people with long term conditions (cardiovascular, respiratory) in her clinics within the practice, helping with education, lifestyle choices, motivation etc.
In particular she had had great success with helping a patient understand her medicines better and be more compliant.
Of our 60 or so nurses, 10 have completed this certificate, and more are enrolled for this year.
Some have moved on to undertaking their postgraduate diploma.

Secondly, I was asked to provide a two-hour session on medicines at one of the monthly Continuing Nurse Education sessions we run. Apparently, for the last three years, in the survey the nurses have said that they need to know more about medicines, “because the patients always ask us about them”.

Thirdly, to assist ‘high needs’ patients we have community health workers (no formal qualifications) who are culturally appropriate and able to work with patients ‘at their level’. These community health workers are being taught the basics about medicines to pass on to the patients in the community, and have been taught how to complete the medication cards.

Fourthly, the primary care nurse leaders group is finalising region-wide standing orders for practice nurses – enabling practice nurses to diagnosis and provide, according to criteria, certain medicines – antibiotics, vaginal antifungals, analgesia medicines, and medicines for sexual health (azithromycin, emergency oral contraceptive etc)

Finally, with the terrible disaster in Haiti, I wondered where pharmacists would be in a catastrophe. How important are we? Would we be a profession that was needed in the front line with the doctors and nurses?

Ah – such depressing thoughts for the new year, but we do need to be honest about where we sit in the health care environment, and what unique skills and knowledge we are able to bring to the table at a time when others appear to have similar skills. We can strut around and say, “we are the medicines experts” and ‘we control the dispensing so we should give the advice” – but is this really our uniqueness – at this level?. I could not say that the practice nurses with their postgraduate certificates are not as good as pharmacists at imparting basic medicines knowledge that should have been given at the time of dispensing, or helping people with improved compliance. The nurses have a relationship with the patient already. They are accessible in what we now term the patient’s ‘medical home’. They are perceived to be in the team, with direct contact with the general practitioner. They already work with the patients on adherence to lifestyle choices such as increasing activity and better food selection – without the perceived conflict of retailing a weight loss product etc. And, yes – I can believe that patients ask their practice nurse about medicines, even if I may not think the nurses have the purported extensive knowledge of pharmacists.

As for the community health workers – I’ve been told by some pharmacists that these cards take too long to fill out. I guess community health workers have a different focus time-wise …. But I know that hospitals have these medication cards automated – so why isn’t this happening in community pharmacy?

So – what can pharmacists do that is unique and would give us a sustainable future? Being in a very overcrowdd middle ground is not the place to be!! The continual dumbing down of our professional service roles to a level that other health care providers can also undertake with ease, is not the answer.

° At one level, we need to take on public health roles with what we do have that is unique – a professional shop environment … so actively look towards extending pharmacist-only medicines – and make sure the pharmacist is seen to be involved. i.e. do not down grade them to pharmacy-only medicines – perceived as just another retail item. Note how the nurses are already moving into the area of providing prescription only and pharmacist only medicines through standing orders. And don’t forget the great involvement they develop with the patient by doing so.

° At another level of practice altogether, we need to utilise our higher levels of knowledge and understanding by providing real clinical advice, such as happens in hospital pharmacy where generally the clinical pharmacists are independent of supply and distribution. This is their focus for over 50% of their time. This clinical role should be undertaken in the general practice, just like the practice nurses (where it can be recognised and respected)

° We need to push for collaborative prescribing privileges – and this can really only happen if we are a part of general practice team, and completely independent of the dispensing role removing ourselves from all the potential conflicts of interest. We need our independent clinical pharmacists there NOW to build up the clinical role so that we are already entrenched when prescribing privileges become available to pharmacists. In Australia this would see Home Medication Reviews taking place within the general practice. If anyone should be working under standing orders for providing medicines – should it not be the clinical pharmacist in the practice?

So – what is the future of the pharmacy profession – we need to push our (hopefully) extensive clinical skills as an entire package, and not get into territorial fights by focusing on only a small aspect that can, and in some cases already is being done by nurses and others.

The principles of business say that you don’t want to be stuck in the middle – being neither a large cheap warehouse type business, nor a smaller, expensive boutique business.

As the song goes … “Don’t mess around with Mr In-between”.

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