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| Journal of the New Zealand Medical Association,
25-June-2010, Vol 123 No 1317
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Health care policy and
community pharmacy: implications for the New Zealand primary health care
sector
Shane Scahill, Jeff Harrison, Peter Carswell, John
Shaw
The past decade has seen policy reform result in significant
challenges for community pharmacy. Internationally, policy is driving change in
community pharmacy, although ‘reprofessionalisation’ from within
pharmacy is a contributor.1 Policymakers and
professional pharmacy bodies are advocating significant change to ensure
community pharmacy contributes to primary health
care.2–5
In New Zealand community pharmacy is an integral part of
primary health care but has been an underachiever in terms of the expectations
of current policy. Pharmacists are highly trained however in many instances
community pharmacists spend their time counting tablets in a dispensary.
Pharmacists and their support staff undertake bureaucratic roles on behalf of
other agencies often with minimal access to
prescribers.6 This is in direct contrast to
where energies need to be directed to facilitate health gains.
New Zealand policymakers request integration and
collaboration between community pharmacy and other providers including general
practice.7 In part, these policies are
underpinned by increased demand for primary care services in the face of
declining numbers of general practitioners. This is an international trend and
professional bodies of pharmacy see opportunity through role extension. One
example of this role extension (or reprofessionalisation) is Medicines Use
Review and Adherence Support (MUR).
MUR is an enhanced service which involves assessment of
patients’ medication regimens, their understanding and concordance, and
recommendations being made to the patient and general practice
team.8 Tension characterises this position,
particularly with regard to the relationship between community pharmacy and
general practice based on the overlap of current and future roles and
professional boundaries.
The thrust of our paper is outlining the implications of
policy change for both community pharmacy and key stakeholders. General
practitioners, primary care nurses, health funding and planning groups including
DHBs and PHOs are all expected to collaborate with the community pharmacy
sector.7 In this context, we describe the
changes community pharmacy must make to deliver the expectations of primary
health care policy and reform.
We highlight the implications, challenges and opportunities
for both community pharmacy and external stakeholders. To this end, we aim to
create awareness and debate amongst the primary care sector.
Policy driversThe Governments of New Zealand and the United Kingdom have
implemented major reforms since the mid 1990s that impact on community
pharmacy.2,4,7 The UK Government has been
prolific in its commissioning of consultation
reports3, literature
reviews,9,10 and health
policy2,11,12 outlining current and future
roles for community pharmacy.
The NHS White Paper for Pharmacy released in April
20082 draws on what Galbraith describes as the
attributes of a good pharmaceutical service3,
and outlines the potential contribution of pharmacy at various levels. Galbraith
describes the distinguishing features of a world class pharmacy (Panel 1) which
provides a benchmark for New Zealand.
Panel 1. Distinguishing features of a world
class pharmacy
Galbraith suggests that the fundamental principles
underpinning a contractual model for community pharmacy practice include models
of practice which enhance patient experience, support wellbeing and promote the
safe use of medicines. Additionally, community pharmacy needs to develop an
integrated ‘pharmaceutical care management’ service. This approach
should include a greater clinical focus, be integrated with other providers,
have a quality focus and be underpinned by adequate incentives to drive best
practice.
In New Zealand, primary health care reform has followed much
the same model as in the UK. The main difference is that the community pharmacy
sector has been central to these reforms from the beginning in the UK by
representation through a Chief Pharmaceutical Officer. Since the 1990s, pharmacy
has gained the attention and respect of high level health policymakers and
advisors from other health professions. Despite the importance of medicines and
medicines provision in the modern health care system this post does not exist in
New Zealand, whilst medicine and nursing do have such representation.
The New Zealand Primary Health care Strategy (NZPHCS) is
much more subtle in outlining roles for community pharmacists, simply as a
provider of education in addition to medication supply and distribution
activities.7 The NZHPCS calls for the delivery
of high quality care through improved access and equity. This is expected to be
facilitated by integration between service providers and development of
culturally competent multi-disciplinary primary health care
teams.7 The NZPHCS does not provide detail of
what community pharmacy needs to deliver in order to improve health
outcomes.
Medicines New Zealand (MedNZ) is a
strategy4 which provides more direction, citing
three objectives:
The MedNZ
strategy dictates increased roles for pharmacy and highlights the central
position of community pharmacy in assisting patients to understand their
medicines better, to use their medicines appropriately, to monitor side effects
and adverse reactions and to optimise therapeutic outcomes through medicines use
and adherence.
New Zealand and the UK do not stand alone, with governments
and professional pharmacy bodies in
Australia13,
Canada14 and the United
States15 generating policy and vision
documents. Along with the New Zealand and UK policies and vision, these
documents highlight themes of change (Panel 2) which need to be addressed by
community pharmacy and the rest of the primary care sector in order to deliver
expected health outcomes.
Themes of changeIf value is to be gained from community pharmacy, the wider
primary health care sector needs to understand the current model of care and
therefore the change that is required including professional, structural and
remuneration models.
Panel 2: Health care policy and challenges for
community pharmacy and stakeholders
A greater emphasis on integration and
collaboration—Community pharmacy will need to work towards
complete integration within the primary health care system. This will require
integration in terms of technology and patient flow to ensure population-based
health care delivery. There is a need for engagement between community pharmacy
and DHBs which undertake health funding and planning activities and ultimately
dictate the use of funding streams involving community
pharmacy.16 The same applies to PHOs which
implement coordinated health initiatives for general practice
teams.17
For some proprietors and managers this will require a
significant refocus on relationship management, and being aware of the
environmental situation outside of the ‘four walls’ of their
pharmacies. For DHBs and PHOs this may require an equal level of self-reflection
and pro-activity.
Collaboration with the wider primary health care team
including general practitioners and nurses is
expected.7 Pharmacists will need to demonstrate
that they are medicines experts who can effectively communicate not only with
their patients, but also with other health professionals and representatives
from health funding and planning organisations.
A focus on the provision of quality primary health
care—As with general practice, demonstrated evidence of the
delivery of quality primary health care by community pharmacy will be mandatory.
Clinical and process audits will become commonplace within community pharmacy.
There is a greater expectation that community pharmacies contribute to both
patient and population health outcomes as a result of increased
multidisciplinary teamwork and integration at both practitioner and
organisational levels.4,7
The requirement for standardisation and benchmarking across
pharmacies will impact on those delivering the services through increased
compliance costs. The need to integrate and collaborate in order to improve the
quality and seamless nature of primary health care delivery will require
up-skilling at all levels within community pharmacy.
A focus on ‘service provision’ versus
‘selling a product’—Like general practices, community
pharmacies are small to medium sized businesses in New Zealand and two key
issues prevail for proprietors. First, the delivery of value to key stakeholders
is important for sustainability.18 Second, a
level of financial viability is required when making changes to the way services
are delivered.
Shifting from the need to make a companion sale to the
delivery of a range of quality assured patient oriented services will require
two significant changes. First, workflows will need to be re-engineered and
staff trained accordingly. Second, adequate remuneration needs to be provided.
Pharmacists in New Zealand are generally positive about
adopting new enhanced services which require
collaboration19 which is in agreement with
findings from the UK.20,21 However, the
difference between New Zealand and the UK is that for too long community
pharmacy in New Zealand has been providing services to the public for which
there has been no reimbursement outside of the sale of a product. Enhanced and
collaborative roles require an adequate level of remuneration in New Zealand so
that this focus can be reversed.
Activities such as minor ailments programmes are a good
example. Historically these activities have involved assessment of and response
to patient symptoms with the sale of a product or direct referral to a general
practitioner as appropriate. Despite fears to the contrary, pharmacists do not
see this as diagnosis.
Pharmacists recognise that diagnosis is not a core part of
their underlying training, whilst many have a good understanding of diagnostic
processes they are very well aware that this is not their primary role. In line
with the UK model, minor ailments programmes will be more formalised, have
restricted protocols for funded medications that can be dispensed, have
associated funding streams for pharmacists’ time, will require training
and accreditation and have standard deliverables.
The model of shop assistants providing triage and much of
the advice about minor ailment management may come under scrutiny and may
precipitate a reassessment of the roles and levels of work within community
pharmacy.
Looking after your patient...looking after your
population—The expected health gains through implementation of
the NZPHCS are underpinned by a population-based focus on health care provision.
Ten years ago this was a new phenomenon for general practice which now applies
to community pharmacy. Brief screening and intervention for alcohol consumption
is one example whereby integration and coordination with other health
professionals and with PHOs will be required.
It is not a matter of simply putting a poster on the wall or
having a product-based shop front display. Training, taking a wider view of
activities and the environment outside of the pharmacy and relationship
management of key collaborators will be important drivers of success.
The provision of enhanced pharmaceutical
services—Days are numbered for the handing out of ‘the
brown paper bag’ which contains a pile of medications for which little or
no advice is given and for which concordance is not supported or monitored. The
provision of value-added patient oriented services will become the norm.
Coordinated MUR, minor ailments programmes and public health screening will be
targeted at high risk patients for whom the most benefit will be gained.
Structural changes will be required to ensure private
consultation areas are available for assessment and counselling. Systems and
processes will need to be in place to ensure that general practitioners, primary
care nurses, nurse practitioners and receptionists are kept informed of the
actions which community pharmacy has taken or the recommendations that are made.
Changes in human activity will also be required to implement
enhanced services. Pharmacist confidence,21,22
an unwillingness to leave the comfort zone of the
dispensary,23 uni-professional
cultures24 and pharmacy’s inexperience of
the commissioning process23 have been cited as
barriers to change in the UK. Similarly in New Zealand the way pharmacists think
and act and their relationships with stakeholders has been cited as a barrier to
moving forward.25
Developing new models of pharmacy
practice—The old adage of ‘location, location,
location’ - or being near to a general practitioner, thereby ensuring high
prescription turnover will not be enough to deliver the wide range of services
that pharmacy is expected to undertake. Just as general practice has had to
change over the last thirty years, community pharmacies will need to develop and
implement new workflows and models of practice as well. Activities such as the
management of minor ailments that have been routine clinical practice will
become more formalised and require re-engineering in order to deliver services.
New services will require different models of practice and
the strengthening of relationships.8 MUR is a
service that will require substantial re-engineering. Many pharmacies now have
consulting rooms or private areas and there are a growing number of examples of
these services. To develop this widely, more pharmacists will need to be
trained, support staff will need to be aware of the process, private space
allocated, documentation systems put in place and there will need to be
increased liaison with general practitioners and nurses.
A defined agenda and processes for
change—The ability to think, develop vision, cement key
stakeholder relationships and adapt through strategic change are prerequisites
for the survival of community pharmacy. Tsuyuki and
Schindel26 have started thinking about this
process in a systematic way. Applying the well established model of change by
Kotter highlights the need for developing a sense of urgency, forming a guiding
coalition, achieving short-term gains toward longer-term goals and embedding a
focus on the future within the culture of community
pharmacy.26 To some extent policy is helping to
develop a sense of urgency. The rest must come from within the pharmacy
sector.
A challenge to community pharmacyWe have argued that the reform of New Zealand primary health
care is having, and will continue to have, significant implications for
community pharmacy and key stakeholders. All too often, Government policies are
seen by those working at the coal face as didactic, idealistic, unachievable and
non-sustainable and this appears to be the case with community
pharmacy.25
In moving forward, seven barriers need to be addressed by
community pharmacy including: the way pharmacists think and act, improved
systems of care and teamwork, improved funder relationships and remuneration,
appreciation of pharmacists knowledge and skills, support for research,
up-skilling current expertise and having a unified pharmacy
voice.25
Pharmacists themselves may have to make attitudinal changes
in order to take on new roles and integrate within the primary care team. Our
previous work reports pharmacists’ apathy, narrow and inward focus,
negativity of the current health care environment, silo thinking and taking a
subservient approach. This thought and behaviour needs to be replaced with a
level of outgoing confidence, underpinned by pharmacy placing
‘value’ on itself as a
profession.25
Lack of adequate remuneration has been cited as a
significant barrier to the adoption of enhanced
services.25 Whilst general practice has been
subject to the challenges and pressures of primary care reform, historically it
has developed a stronger negotiating position, is better supported by government
funded organisations such as PHOs and has had substantially more funding
reserves and remuneration policies such as Capitation and Services to Improve
Access (SIA).
These funding streams have provided sustainable revenue
outside of fee for service payment arrangements. To remain viable as a respected
health care professional, the community pharmacy sector as a whole needs to
demonstrate a willingness to adopt a “user pays” policy for services
that have historically been provided for free or subsidized by retail sales.
Tied in with the lack of adequate remuneration to provide
education, enhanced pharmaceutical services and public health initiatives, is
the historic relationship between community pharmacy, DHBs and the Ministry of
Health (MOH). New Zealand pharmacists perceive their relationship with DHBs and
the MOH and their bureaucratic processes to be a significant barrier to
community pharmacy moving forward.25
As a profession, community pharmacy has to become
indispensable, deliver value, and attempt to improve relationships with funder
stakeholders to assist in securing a funding model which enables the provision
of enhanced services to be sustainable. There is a need to decrease the reliance
on selling product to fund consultations. Pharmacists complete a four year
degree and a one year structured internship. Pharmacists need to utilise their
skills and demonstrate that a high level of clinical pharmacy is actually
practiced in their pharmacies.
Overseas experience suggests that pharmacists are generally
positive about the uptake of new roles27,
however this enthusiasm has not always occurred at the pace expected by
stakeholders8. In part this is due to the
barriers outlined by us previously. The New Zealand pharmacy sector will need to
take heed of these barriers and address them in a systematic fashion to enable
the change required to deliver these services. In order to demonstrate the value
expected by policymakers and other key stakeholders, the academic community
needs to implement a research agenda in conjunction with professional pharmacy
bodies.
Community pharmacy must fully commit to service evaluation
and actively participate in practice-based and organisational research. In this
manner pharmacists will demonstrate what they do achieve, rather than what they
could achieve.
Although significant, the above mentioned challenges are
not insurmountable and the pharmacy sector needs to rise to the challenge and
embrace opportunity.
Challenges and opportunities for the rest of primary health careThere will be significant value for general practice, DHBs
and PHOs when community pharmacy is more integrated with primary care and gains
traction in delivering enhanced pharmaceutical services. It is expected that
general practice will have patients who are better informed about their
medications, more likely to be concordant and who achieve the health targets
expected by the DHBs.
By engaging community pharmacy, PHOs will be seen not only
to contribute to population health outcomes, but also to the development of a
robust multi-disciplinary workforce and primary care infrastructure which is an
expectation of primary care policy.17 Community
pharmacy has been shown to contribute to positive health outcomes through
involvement in disease management programmes similar to those operating through
general practice in the United States.28
Disease management is a comprehensive approach to preventing
and treating disease that:
Disease management differs from
pharmaceutical care services in that pharmaceutical care targets not only
patients with specific diseases but also those with risk factors for
drug-related problems, a history of non-adherence, and frequent changes in
medication regimens.28 Smoking cessation is an
example of a successful disease management program implemented in community
pharmacy.
Gaining traction and developing effective working
relationships between community pharmacy and general practice relies on both
parties being amenable to working together, respecting and valuing each other
and having a common goal of improved health outcomes. As such, responsibility
lies as much with general practitioners and nurses as it does with staff in
community pharmacies to ensure that this happens for the benefit of the patient.
Ongoing debate in The New Zealand Herald regarding
pharmacist involvement in the swine influenza pandemic highlights ignorance
about the training and skill-set of pharmacists at the time of graduation and
the services that pharmacists can offer. As it is, community pharmacists spend
significant amounts of time policing for other agencies such as The
Pharmaceutical Management Agency (PHARMAC), with poor access to
prescribers.6 The ill-informed comment in the
lay press does little to create a harmonious working environment where
collaboration prevails over ignorance, fear and patch protection.
Community pharmacy cannot be solely responsible for
integration within the primary health care infrastructure and teams. Although
some PHOs are taking a lead in developing relationships with community pharmacy
and there are small pockets of activity around the country, integration of
community pharmacy representation into PHO governance structures appears to be
slow. Involvement of community pharmacy in integrated primary care initiatives
also appears to be tardy.
DHBs have a role to play and significant responsibility in
the development of integrated community pharmacy services. In much the same way
as the PHOs, DHBs have been relatively slow to engage with community pharmacy.
The MedNZ strategy calls for increased involvement of
community pharmacy to ensure the optimal use of medicines and DHBs need to fully
support this strategy. In some regions this has occurred through the formation
of district wide advisory groups and project leaders who are assigned to
community pharmacy development portfolios. Involvement of community pharmacy in
integrated care projects has flowed from this approach but requires full
engagement by community pharmacy.
Last but not least, the policies of PHARMAC impact
significantly on the activities of community pharmacy in New Zealand.
Historically community pharmacy has spent considerable energy
‘policing’ PHARMAC policies rather than delivering the best possible
health care. The most recent example is the need for community pharmacists to
check the scope of practice of the prescriber for every prescription received.
This requirement for ‘PHARMAC policing’ needs to
stop and the considerable time and energy spent chasing insignificant and
distracting bureaucratic problems needs to be channelled back into patient care.
PHARMAC has considerable responsibility in ensuring that this transition
happens.
We suggest the entire primary health care sector within New
Zealand is made aware of and understands the ramifications of policy reform for
community pharmacy as a key partner in the delivery of primary health care.
Equally, we call for the community pharmacy sector to understand the challenges
ahead, to drive the change necessary to overcome barriers to moving forward
under current health policy reform.
There is a need to think about how the community pharmacy
workforce should evolve and how further integration of community pharmacy
services will be undertaken to ensure that pharmacy contributes to health
outcomes through coordinated approaches with other primary health care
providers. This cannot be undertaken by community pharmacy alone.
SummaryThe implications of primary health care reform are
significant for New Zealand community pharmacy and there is positive stakeholder
opinion of what community pharmacy should be able to achieve. However, there is
only so much that can be addressed through health policy, the rest needs to come
from change within the pharmacy sector with awareness, understanding and support
from key external stakeholders including health funders and planners and other
primary care providers.
Competing interests: None known.
Author information: Shane Scahill, PhD
candidate, School of Pharmacy, University of Auckland and Clinical Advisory
Pharmacist, Clinfotech Pharma Ltd; Dr Jeff Harrison and Dr Peter Carswell,
Senior Lecturers, School of Pharmacy and School of Population, University of
Auckland; Professor John Shaw Head of Department, School of Pharmacy, University
of Auckland
Acknowledgement: The lead author (SS) is
supported by a University of Auckland Senior Health Research Scholarship.
Correspondence: Shane L Scahill, School of
Pharmacy, Faculty of Medical and Health Sciences, University of Auckland. 93
Grafton Road, Grafton, Auckland, New Zealand. Fax: +64 (0)9 3677192; email s.scahill@auckland.ac.nz
References:
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