The general practitioner and the pharmacist: a policy enigma?

Integrating pharmacists into general practice, aged care, and hospital services will enhance the quality use of medicines

Integrating the skills of health care providers in a blended and integrated manner will deliver the best value care to the community. Achieving this goal commenced with the establishment and spread of integrated primary care practices that provide complete personal care by including general practitioners and practice nurses, allied health clinicians, and alternative health practitioners. One of the most important health care providers still needed is the community pharmacist.

The goal of domiciliary medication management reviews (or home medicines reviews) is to maximise the value and safety of a community‐dwelling patient’s medication regimen. The review is initiated by the patient’s GP, but also involves their preferred community pharmacy and, as appropriate, other relevant health care team members and carers. Medicare data indicate that only 70 000 domiciliary medication management reviews (item number 900) were claimed for patients living in the community during July 2019 ‒ June 2020, a national rate of 270 per 100 000 people.1 While this figure may be 15‒30% lower than the overall number of reviews undertaken (personal communication, Marcus Edwards, senior pharmacist, Pharmacy Regulation Authority SA, 21 October 2020), it is still depressingly small given the opportunity such reviews provide.

As the number of frail older people2 and the prevalence of chronic diseases both increase with the ageing of our population, there will be many opportunities for employing the skills of pharmacists in primary care teams. It is clear, however, that we have yet to settle on the best policy and funding framework for facilitating their integration.3 This is partly because of the gap in the evidence as to whether pharmacists working with GPs and other primary care practitioners improves patient outcomes and reduces health system costs.

The REMAIN HOME trial reported by Freeman and his colleagues in this issue of the MJA4 provides insights in this regard and suggests some interesting new options. This stepped wedge, cluster randomised controlled trial included adults discharged from seven south‐eastern Queensland hospitals who were either prescribed at least five long term medicines or had primary discharge diagnoses of congestive heart failure or exacerbation of chronic obstructive pulmonary disease. The intervention consisted of comprehensive medicine management consultations with integrated practice pharmacists within seven days of discharge, followed by consultations with the patients’ usual GPs. Freeman and colleagues found that the number of emergency department presentations over 12 months was 54% lower, that of unplanned hospital re‐admissions 21% lower, and the combined number of emergency department presentations and hospital re‐admissions 31% lower for patients who had received the intervention. The estimated incremental net monetary benefit of the intervention over 12 months was $5072 per patient (about 30 times its cost). Pharmacists identified a mean of four medication‐related problems per patient during the initial consultations, most related to medication choices, adherence, or conditions requiring additional management; GPs implemented at least one pharmacist recommendation for more than 80% of patients.4

The logic and benefits of integrating suitably skilled pharmacists into general practice cannot be disputed. Their skills in post‐hospital review, difficult medication regimens and their effect on disease states, quality use of medicine audits, face‐to‐face medication reviews, and independent prescribing complement those of the primary care team. The benefits for the pharmacist are also clear: increased professional autonomy, meaningful engagement in a health care team, and personal interactions with patients in an environment less constrained than the pharmacy. Further, general‐practice‐based pharmacists have greater flexibility in timing the delivery of services, important to the modern professional workforce.

Interest in more efficiently integrating pharmacists into general practice has increased overseas.5,6,7 In the United Kingdom, the integration process required time, space, and an increased understanding of the broad role of pharmacists;5 the authors of a small qualitative study argued that pharmacists’ medication expertise was valuable to the GP, but that individual practices needed greater flexibility in how pharmacists were integrated, with funding highlighted as critical to the sustainability of the model.6 An interview study in West London found that success required clear documentation of the pharmacist’s role, adequate time for building team cohesion, good communication channels, care in maintaining the skills of other primary care members, and thoughtful patient and practice staff education about the role of general practice‐based pharmacists.8

Medical Benefits Schedule support for medication management reviews is useful, but further uptake by GPs and pharmacists seems unlikely in the context of current business models. The REMAIN HOME intervention reduced the number of re‐admissions over 12 months by about 20%,4 just as the Independent Hospital Pricing Authority (IHPA) commenced finalising a pricing model for avoidable hospital re‐admissions, including those attributable to medication‐related problems.9 Under the IHPA initiative, to be implemented from July 2021, health networks will not receive payments for clinically defined avoidable hospital re‐admissions within specific time periods. This model provides opportunities for pharmacist partnerships between Local Health Networks and Primary Health Care Networks, and could well facilitate a greater degree of success than the current MBS‐linked model. Pharmacists could also be more effectively embedded into the health system, in general practices (as in recent programs in Western Australia, South Australia, and Melbourne10), aged care institutions,11 and palliative care.12

The Australian Medical Association has called for a Pharmacist in General Practice Incentive Program,13 and incorporating this model into the broader health system framework is worth exploring. Successfully integrating pharmacists into general practice, aged care, and hospital services will allow more efficient identification, prevention, and management of medication‐related problems, reduce polypharmacy, enhance the quality use of medicines, and avert re‐admissions linked to inappropriate medication use.