Primary care – can pharmacists fix it?

The IPU held a seminar today, reported by Paul Cullen in the Irish Times. I wasn’t at it, but I found the report intriguing. Based on Paul’s report, and the press release on the IPU website, the general proposition was that ‘Pharmacists hold key to reducing pressure in GP’s surgeries’.

There were two main points, one that many minor ailments which could be dealt with elsewhere are managed by GPs, and the other that more generic prescribing could save the Irish health system a lot of money. The second is true, but only if we get our act together on generic drug prices, and enforce generic prescribing, as the NHS has done. Incidentally, there is reasonable evidence that pharmacists can make an important contributor to improving the quality and safety of prescribing (e.g. Chisholm-Burns MA, Kim Lee J, Spivey CA, Slack M, Herrier RN, Hall-Lipsy E, et al. US pharmacists’ effect as team members on patient care: systematic review and meta-analyses. Med Care. 2010 Oct;48(10):923–33). What about minor illness and pharmacists?

There is quite a bit of evidence that pharmacists can make a very useful contribution to healthcare. There are two relevant Cochrane reviews, one on the ‘Effect of outpatient pharmacists’ non-dispensing roles on patient outcomes and prescribing patterns, and one on’Community pharmacy personnel interventions for smoking cessation‘. There are over fifty other reviews, and several hundred studies on various outcomes, diabetes, asthma, mental health, and more. Most of the ones I have skimmed seem to look at the role of pharmacists as part of a larger system of integrated care, or the impact of pharmacists on prescribing. Based on the reviews, and on reading the abstracts of about twenty interesting sounding papers, there is reasopnable evidence that pharmacists can provide effective care to patients.

The key intervention at the conference came from Colin Bradley, the professor of General Practice in UCC. Paul Cullen reports him as saying ‘there were significant financial and other obstacles to be overcome before GPs agreed to the scheme.Family doctors could feel it would “take bread out of their mouths” and needed to be properly resourced to treat chronic diseases’. I think he’s right. Why?

Suppose that it was decided to switch care to pharmacists in the morning. What would happen? Pharmacists are cheaper than GPs, partly because they can subsidize their premises by selling drugs, perfumes, makeup and so on. Pharmacists would skim off some of the simpler end of the GP business, leaving GPs to deal with the more complex cases, and the sicker patients. These are the patients GPs lose money on. In the same way that private hospitals in the US cherry picked the less sick patients to treat leaving public hospitals to deal with the more costly, and less profitable, cases (e.g. Cram P et al. Insurance status of patients admitted to specialty cardiac and competing general hospitals: are accusations of cherry picking justified? Med Care. 2008 May;46(5):467–75), pharmacists would undermine general practice. I also suspect that if anything went awry, the patient would end up back at the GP very quickly.

I’m not arguing that the IPU are wrong. From my perspective we seriously under-use pharmacists. We are beginning to use them more effectively, for example in giving flu shots, but there’s a long way to go. If we are to make full use of community pharmacists, practice nurses, and all the other staff in primary care, we need a new primary care contract, covering GPS, their staff, pharmacists, and others. We need a contract which pays, properly, for managing chronic disease, and which pays, properly, for integrated care.

This will cost. My (really crude) estimate is about one billion euros extra to fully develop primary care. This money could come, mostly, from the current acute hospitals budget, along with many skilled staff, patients, and clinical responsibility. In such a system, community pharmacists could use their full range of skills, not just improving prescribing, and reducing drug errors, but also providing direct patient care, mainly for those chronic disease managed by drugs, such as diabetes, raised cholesterol, asthma, and high blood pressure. This care would be provided as part of a team, in my view a team led by GPs, sharing information, sharing responsibility, and sharing the resources provided.

Could this be done? I think it could. Irish GPs are very innovative, and they continue to do an amazing amount of good care, in a very difficult situation. Irish pharmacists, evidently, want to step up, and meet this challenge too. Will the HSE/DoH join in? I really hope so!

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