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Culture clash: doctors vs pharmacists

While pharmacists and doctors generally work well together, there has been an underlying tension between their respective representative bodies, which came to a head recently when the President of the IMO made a number of provocative comments regarding the future role of pharmacists in healthcare.

Dr Ray Walley — speaking recently at a meeting of CPME, the European body for the medical profession which is considering the role of pharmacists with a view to reaching a common European position — fired a broadside, warning that enhanced powers for pharmacists could “create risks” for patients, with “no benefits”.

Dr Walley stated: “Pharmacists have a critical role to play in the health services but that is as a pharmacist and not as a doctor. The IMO is in favour of multidisciplinary teams where each professional adheres to the role for which they have trained and respects the roles of others. It appears that due to an economic imperative, pharmacists are now seeking to expand their role and act as doctor.  This is bad for patients. Shifting tasks from doctors to pharmacists will reduce quality of care and may well cost more for both the patient and the State in the long run.”

He maintained that pharmacy “is first and foremost a commercial enterprise and the patient has always been well served by having a clear distinction between the prescriber of medicines (the doctor) and the dispenser of medicines (the pharmacist)”. 

“The pharmacist gets paid to dispense and once you blur that distinction, you are at risk of a conflict of interest and of undermining the patient’s confidence in the medication they are being advised to take. The relationship between patient and doctor should not be undermined by anyone. It is a relationship based on the knowledge of the patient that their doctor has diagnosed their ailment and provided the best independent advice in terms of treatment and sometimes that treatment may not involve medication.”

Disconnect

Dr Walley’s comments are the most unequivocal statement yet by the IMO regarding its stance on the future of pharmacy in healthcare and exposes a wide disconnect in the way pharmacists’ and doctors’ organisations see the road ahead.

The Irish Pharmacy Union (IPU) responded with a statement defending the sector, stating “community pharmacists deliver a quality, accessible, personal and professional service that puts the patient first and has as its primary goal the optimisation of the health and wellbeing of society. Patient safety is at the core of everything pharmacists do”.

Speaking to the Medical Independent (MI), Dr Walley outlines his rationale for issuing the statement and expands on some of the issues he raised. “My approach to this matter is based on the nature of general practice and why it has been so successful in doing what it does,” he tells MI. “Many years ago, the World Health Organisation (WHO) employed Prof Barbara Starfield [US Professor of Public Health] to look into the importance of general practice. She advocated the importance of using the American terminology ‘primary care physician’ or ‘general practitioner’ to us… they don’t have many primary care physicians in the US. What she found was that the morbidity and mortality rates were down to two things: It was down to the number of general practitioners, and the personalised continuity of care provided by a GP. The more GPs providing personalised continuity of care, the less mortality. That is a WHO-espoused view.”

Dr Walley’s comments are the most unequivocal statement yet by the IMO regarding its stance on the future of pharmacy in healthcare and exposes a wide disconnect in the way pharmacists’ and doctors’ organisations see the road ahead

Dr Walley points out that some 15 years ago, former Minister for Health Micheál Martin promoted a similar point of view in the Primary Care Strategy. “Anything that reduces personalised continuity of care provided by the individual GP creates the danger of reducing the benefits of reduced morbidity and mortality,” he states.

Dr Walley references the Mid Staffordshire report in the UK, and said the report based on that healthcare scandal noted that loss of personalised continuity of care within the NHS should be reversed.

But considering the unprecedented pressure GPs are currently under, does Dr Walley not believe that the ground has shifted sufficiently since then, to warrant an expanded role for pharmacists to ease the chronic workload? “In fact, the ground has shifted to strengthen even more the role of the GP,” he responds. “Looking at the UK, there is evidence that general practice is underfunded and unfortunately, it is falling apart.

“The IMO has indicated that we want to do more chronic care; we’ve indicated that we want universal healthcare free at point of delivery, subject to resources. Ultimately, the problem here is, we have the Government advocating one approach but not providing the funding to support it. More than ever, we are finding that GPs can be dealing with more things, but on a personalised continuity of care basis.

“That’s how you ensure that you have the records in one place, no duplication of effort… there is a greater need for more GPs now than ever existed previously. We have escalating healthcare costs internationally — why would you want to throw away 40 years of evidence showing that how you reduce morbidity and mortality, costs, ensuring compliance and ensuring best practice dealing with chronic care is through personalised continuity of care by a general practitioner?”

Training

“GPs have trained for four-to-six years at undergraduate/postgraduate level, followed by a one-year internship, followed by a four-year training programme. We are trained in history, examination, investigation, diagnosis and management and we are the only ones with that training in the primary care setting. I have an excellent relationship with my pharmacists and the predominant role of the pharmacist is, to me, medicines optimisation.”

Dr Walley also raises concern about the danger of “mixed messages” going to an increasingly elderly population. “Much of the vaccinations that we do include opportunistic reviews of other issues,” Dr Walley tells MI. “The potential loss of that opportunistic review is of great concern.”

On the question of how exactly the IMO intends to “strongly oppose” greater responsibilities for pharmacists, he states: “We are going to base our objections on evidence-based medicine. This is not about saying ‘pharmacists are not good at this or that’. What we at the IMO are stating is this — if you have a Rolls Royce and you decide not to put sufficient fuel in the car, or postpone maintenance work, to use that analogy, we argue that that’s bad medicine.

“Ultimately, it’s about putting the patient at the centre of this and ensuring that optimum care is maintained and you do that by properly funding general practice. This is not a criticism of pharmacy, this is a constructive review of what works best.”

He went on to challenge the research put forward by the IPU. “This is coming from three jurisdictions specifically — the corporate model in America, where there is massive conflict of interest; the model in the UK; and Canada, where they actually ran out of GPs in certain areas. In the UK, the GP was being given absolutely everything to do, not allowing them to do the job of a GP.

“So you have the UK, which is a model which was managed wrongly; a model in Canada, where there were no GPs; and a corporate model in the US. Just because these approaches came about doesn’t make them right.”

Conflict of interests

He went on to describe the “elephant in the room” — the issue of conflict of interests. “How can you be a purchaser of medicine and a provider too? I can’t do that… it has been found in studies that patients do not have the ability to differentiate between necessary and unnecessary treatments. The difficulty when there is a conflict of interests is, you are exposing people to types of commercial activity, which may further impoverish a susceptible cohort of the population, a vulnerable group, the elderly.

“We can’t afford to have mixed messages for people.”

Dr Walley concludes: “Again, I am not criticising pharmacists here; it’s about patient safety and patient continuity at all stages… there is a plethora of evidence internationally to show this. What the IMO is advocating at all times here is evidence-based medicine. In the past 40 to 50 years, the evidence is that you need to increase funding of general practice, increase the number of GPs and lengthen consultation times.

“The evidence provided by pharmacy to support expanding the role is short term; there is no long-term evidence to show the potential effects on morbidity and mortality due to a disruption in continuity of care.”

Responding

Also speaking to MI, IPU Secretary General Mr Darragh O’Loughlin responds to some of the comments Dr Walley made in his address to the CPME meeting.

“There is a lot of evidence to show that pharmacists playing a greater role in healthcare improves outcomes,” he tells MI. “For example, Canada achieves a higher ranking than Ireland in terms of measures of health outcomes, despite grappling with GP shortages. The availability and accessibility of primary care through pharmacies is not the only reason, but it is surely a contributory factor.

””
Mr Darragh O’Loughlin, IPU

“Pharmacists are involved in delivering patient care there as part of chronic disease management, in partnership with physicians. The physician and pharmacy organisations there have worked together and they have delivered. In January of 2014, we had the former Minister for Health for Alberta [Iris Evans] in Dublin speaking publicly [at the RCPI and on RTÉ] about how she grappled with a serious shortage of primary care physicians and how it became clear to her that she couldn’t deliver the acceptable quality of primary care that Alberta needed,” he continues.

“She made the decision to expand the role of pharmacists and the range of care they provide to give people access to primary care. As a result, patient outcomes were clearly improved. Subsequently, she became Minister for Finance and it also became clear to her how much money had also been saved with that initiative.”

Ireland is clearly facing similar challenges in terms of access to primary care, Mr O’Loughlin tells MI. “GP organisations here say that according to their research, waiting times for GP appointments have gone up from 10 hours [in 2010] to 34 hours; GPs will also be swamped due to the under-sixes scheme, among other such Government initiatives.

“The pressure on GPs will be enormous and the people of Ireland deserve the same kind of solution that has been brought into play in Canada and other countries. Patients don’t get ‘better faster’ by going to more complex and costly sources of healthcare.”

Prescribing

Responding to the content and tone of the statements by the IMO, Mr O’Loughlin tells MI: “Some of it just doesn’t make sense… and seems rather like a very poorly-considered statement, which is not backed-up by evidence, and is actually offensive to the professionalism of pharmacists.

“Pharmacists are already prescribing in the UK and Canada, where they can adjust medications and order lab tests, and so on, according to a treatment plan, which has been agreed by the diagnosing physician, so it is all in line with best practice. Pharmacists are accountable to the Pharmaceutical Society of Ireland (PSI) for all of their professional activities and operate to the highest standards.

“When the statement talks about a ‘conflict of interests’ [for pharmacists providing a broader range of healthcare], there is no evidence for anything like that occurring elsewhere before. For example, the proposal we have made on minor ailments is based on giving medical cardholders the same level of access to non-prescription medicines that private patients already have. Obviously, if there is an ongoing problem, pharmacists will of course refer that patient to a GP, who will make a decision based on that referral and advice.”

‘The pressure on GPs will be enormous and the people of Ireland deserve the same kind of solution that has been brought into play in Canada and other countries’ — IPU

The statement by the IMO also runs contrary to stated Government policy of its intention to provide for a greater role for pharmacists, Mr O’Loughlin points out. “Kathleen Lynch [Minister of State at the Department of Health with special responsibility for Disability, Mental Health and Primary Care] has stated in the Oireachtas several times that we need to explore ways to expand the role of pharmacists, and treating minor ailments is a part of that,” he
explains.

Recently, the Oireachtas Joint Committee on Health and Children issued its report on the cost of prescription drugs and its recommendations include that pharmacists should be involved in delivering more primary care, performing medications usage reviews and potentially prescribing medicines, Mr O’Loughlin notes. “That is the way health systems are going in other countries — they are not developing a GP-centric structure of healthcare, but a patient-centred structure, where we all treat the same patients and we should be doing it collaboratively.”

The ‘prize’

Describing himself as being “taken aback” by the content and tone of the IMO statement, Mr O’Loughlin stresses: “The patient is not a ‘prize’ and there should not be some kind of ‘turf war’ between pharmacists and doctors. Our job as health professionals — all of us — is to treat patients to the best of our ability and within the scope of our practice.

“That should be front-and-centre of our thinking, as well as treating patients in the most cost-effective way possible and it’s really very clear that allowing somebody to pop into a pharmacy and be treated for a minor ailment, or for advice, information and support in managing a chronic illness is the most cost-effective way of doing this.”

The IMO maintains that pharmacy is “first and foremost a commercial enterprise” and that the profession is seeking to expand its scope of practice “due to economic reasons”. Mr O’Loughlin alludes to this statement as being contradictory.

“The IMO itself has regularly said that GPs are effectively businesses, with all the associated overheads, and so on, and as a result, the fees they are paid by the PCRS and HSE are not going directly to the doctors, but rather are going towards the costs of running that practice,” he tells MI.

“I agree — GPs are indeed running a small business. If they were not doing that, they would not be in business and we would not have doctors. Part of the pressure they are under is the obvious need to maintain a viable practice so that they can provide the medical care necessary. For the pharmacist, the aim is to provide pharmaceutical care and pharmacy care. Pharmacy is certainly not primarily a commercial enterprise; pharmacy is primarily a healthcare profession that practices within a commercial context.”

Relationship

The IMO’s statement also refers to the doctor-patient relationship being potentially “undermined” and Mr O’Loughlin is quick to dispel this suggestion. “When pharmacists deliver services such as health screening, for example, as well as asthma and diabetes screening, they refer people who might not otherwise have gone to the doctor. We’re not making a diagnosis; we are simply advising some people that they may need medical care.

“Pharmacists refer people to GPs every day and the most effective way primary care is delivered in real communities is where pharmacists and GPs are working in partnership. It is ironic, in the context of the IMO’s statement, that in every community, the GP and pharmacist work together well and they each support each other in looking after the patient in the best way possible.”

He adds: “Today, and every day, you will find that there is a pharmacist quietly picking up the phone to a GP and saying something like, ‘I think there may be a mistake on this prescription’. Pharmacists do this every day and every GP will tell you that pharmacists pick up on errors from time to time… the statement from the IMO does not accurately reflect the good working relationship that most GPs and community pharmacists have.”

He also refutes the suggestion that there may be an increased risk for patients if pharmacists’ scope of practice is expanded.

“Every pharmacist who vaccinates is trained in the management of anaphylaxis, trained in how to use the EpiPen and CPR and the use of a defibrillator. That training is continually refreshed and the suggestion that there could be an increased risk to patients is simply not true.”

‘Sectoral concerns’

Mr O’Loughlin concludes: “As pharmacists, we don’t want an opportunity to improve healthcare to be lost or overlooked as a result of sectoral concerns, which can be easily addressed by looking at the international evidence.” 

For his part, Dr Walley is critical of recent moves to allow pharmacists administer vaccinations, such as the flu vaccine.  He says that the move had not brought any benefits and that take-up levels have not changed as a result. “Pharmacists have been allowed administer vaccinations for the flu virus since 2011 but there has been no increase in uptake levels as a result.  In fact, the vaccination rates for the flu vaccine in the key population of over-65s fell slightly from an average of 62 per cent in the years 2003 to 2010 to 57 per cent in 2011 and 2012 and 59 per cent in 2013,” he told the CPME meeting.

However, last April, during its AGM, the IPU said the number of people receiving the flu vaccination in pharmacies continued to grow exponentially, year-on-year, and during the 2014/2015 season, 51,560 flu vaccinations were carried out in pharmacies. The IPU added that its data showed that 23 per cent of patients vaccinated in pharmacies against the flu during the last flu season had never been vaccinated before and 83 per cent of these patients were in the ‘at-risk category’.

The IPU has called on the Minister for Health to allow pharmacists to provide additional vaccination services to patients to include pneumococcal diseases, hepatitis B, shingles and travel vaccines, which are delivered by pharmacists in the US.

Where the PSI stands

The Pharmaceutical Society of Ireland (PSI) provided MI with an outline of its position on the disjointed view of the future of the pharmacy profession in healthcare.

“The PSI welcomes an expanded role for pharmacists and pharmacy services that would benefit patients and also provide efficiencies to the wider healthcare system. There are a number of challenges currently facing Irish healthcare at the moment, including an ageing and changing population, the changing needs of patients who will require more future support in their homes, a significant increase in the incidence of chronic illnesses, new technologies, the development of more sophisticated and individualised medicines and the increasing cost burden of providing a good standard of healthcare to all in the future and pharmacists are well placed to take on expanded roles,” a PSI spokesperson told MI.

Education and continuing professional development for pharmacists are critical to any expanded role, the PSI added.  “Irish pharmacy education is transitioning to a new programme with increased clinical focus and practice placement opportunities and the newly-accredited integrated five-year MPharm programme, which began in 2015. This programme, as well as the recently-adopted CPD system for pharmacists, continues to promote a very high standard of pharmacist education and training in this country, and offers the possibility and flexibility to facilitate any expansion of the role of the pharmacist, as it may develop over time.

“The PSI is currently examining how the sector can most valuably and cost-effectively contribute to the health and wellbeing of patients in Irish healthcare through its ‘Future Pharmacy Practice Project’. The project builds on the work of the Interim Report of the Pharmacy Ireland 2020 working group, published in April 2008. As part of the project, the PSI has sought examples of innovations that have taken place in hospital or community settings aimed at improving patient care and safety through the better utilisation of pharmacists and pharmacy resources. A report from the project will be published early next year [2016] that will present international and national research findings and the outputs of multi-stakeholder engagement.”

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