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Community pharmacist as rural health practitioner

Patrick Mahony

The Australian Journal of Rural Health © Volume 2 Number 1, November 1993

C ommunity pharmacist as rural health practitioner by PATRICK MAHONY

Paper presented at the Australian Rural and Remote Allied Health Professionals’ Conference held in Toowoomba, 14-17 August 1993.

INTRODUCTION

The objective of this paper is to outline the various roles of the community pharmacist in the com- munity health team and covers:

accessibility of the pharmacist and pharmacy staff

resources of community pharmacies

coordination of existing services

advice and supply function

a plan for an integrated and coordinated community based health service.

There is first a need to define the role of the community pharmacist.

A community pharmacist is a multi-skilled health professional who manages and operates a retail pharmacy. The major service is the supply of medi- cines through the Pharmaceutical Benefits Scheme. This service is supplemented by a range of informal professional services: advising on medications, sale of and advice on non-prescription medicines, sale of and advice on various health products, as well as the sale of many health and beauty products.

Pharmacies and pharmacists operate in accordance with state-based pharmacy acts and

Patrick Mahony, B Pharm MPS APAIPM MACPP

JP, is a member of the Pharmacy Board of NSW; Vice President Isolated and Essential Pharmacists

Association; Committee Member, Pharmacy Guild of Australia (NSW Branch); owner/manager of pharmacies in Manilla and Bingara.

poison acts as well as the federal National Health

Act 1963.

ACCESSIBILITY 6F PHARMACISTS AND PHARMACY STAFF

The very diversification of the pharmacy creates a non-threatening, interesting, caring and pro- fessional environment which has a high visitation

rate by a large cross-section of the community. Community pharmacists have again been rated

by the general public in the Morgan poll as the most trusted professionals. This trust, along with the location of community pharmacies and the legislated requirement that a pharmacist be available at all times the pharmacy is open, makes the community pharmacist an important member of the health team.

The multidisciplined skills and practices of the pharmacist creates some conflict within the health system. However, this must be seen in light of the community need for services which are ‘filled’ by pharmacists in their informal, professional manner. The major objective of this conference, and this paper, is to replace conflict with coop- eration to maximise the health outcomes of the patient.

At the Toowoomba conference in 1992 the training of pharmacists in pharmacology and pharmacokinetics was discussed. When this training is combined with the pharmacist’s competence to diagnose at a primary health care level, and with a responsibility to make medical

and specialist referral as necessary, the community pharmacy offers a cost-effective ‘front line’ service for many minor conditions, particularly winter ills, minor pain: dermatitis and gastric problems.

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6 The Australian Tournal of Rural Health

Pharmacists and their staff are trained and experi- enced in providing advice and recommending products for baby care, skin care, sports injury and incontinence problems, to name just a few.

In 1990 and again in 1991, the Isolated and Essential Pharmacists Association surveyed the 480+ pharmacies in one-pharmacy towns. These pharmacies are on average 60km away from the next pharmacy. The key factors from the survey are that the pharmacy and the pharmacist, usually with extensive community involvement, provide a wide range of services for a large geographical area.

Community pharmacies provide cost-effective and accountable community health services in a regulated environment, with qualified and res- pected staff present at all times. It is important to

consider every health provider’s role in the development of any health project.

The corporate plan of NSW Health states that public health care service should be available to all groups in the community.

Community pharmacies are located in almost

all communities. The 1992 survey shows that on average the one-pharmacy towns have two doc- tors. Some 14 percent of these communities do not have a hospital, and if they do only 18 percent of the pharmacists provide any ‘in hospital’ service.

RESOURCES OF THE COMMUNITY PHARMACY

The Pharmaceutical Benefits Scheme requires that all prescription claims be made through a com- puterised system. This has resulted in the fully com- puterised prescription records being maintained not only for new prescriptions, but also repeat prescriptions and certain pharmacist-prescribed medication.

The advantage of this database is that it provides the pharmacist with the means to make medication reviews, study drug interaction and provide patient information. The database is also often used by local medical practitioners.

Pharmacists too are upgrading their computer databases by installing either CD-ROMs or modems to extend the medication review service and to monitor adverse reactions, pharmacokinetics and drug interactions. The most up-to-date reference library on these matters is already available in pharmacies.

The pharmacist is also a resource. Often it is a medical practitioner or community nurse who is approached to speak about medication, when in fact, the most appropriate person is the pharmacist. A number of ‘specialist’ pharmacists are now employed in various health regions. These are community-based pharmacists who will speak with and train other health professionals in the most appropriate use of medications. The Pharmaceutical Society of Australia has developed a large range of resource materials for pharmacists in these areas. The Pharmacy Self Care and Discover Better Health programs are widely recognised as well- targeted information for the community.

Here is a recent example of this resource role: a pharmacist was working in a large private nursing home where the elderly female patients had a high incidence of breaking hips. The major controllable contributing factor was the use of CNS sedatives and hypnotics. This pharmacist intervened to eliminate CNS drugs and, where appropriate, to use shorter-acting hypnotics. The outcome was very successful for the patients and for the hospital,

but resulted in reduced income for the pharmacist. The pharmacist is not the only qualified staff

member available in community pharmacies. Many pharmacies employ other variously qualified and registered people. Pharmacy assistants have completed recognised training courses in, for example, skin care and general product know- ledge.

The community pharmacy has an efficient and cost-effective distribution network and includes deliveries within each community. The distribution network is not only for the supply of medicine, but also of medical appliances, non-prescription goods and health information pamphlets and reading material.

COORDINATION OF SERVICES TO THE COMMUNITY

Community pharmacists have traditionally held many important positions in their communities. The most recent survey revealed significant representation in local government, on hospital boards and in service and sporting organisations. Such involvement has led to the coordination of many voluntary health services in rural Australia such as the annual Rotary bowel screening

program.

Volume 2. Number 1 - November 199.7 7

In small communities where full-time pro- fessional services are not always available in disciplines such as audiometry, optometry and

chiropody, it is the community pharmacist who is often responsible for providing and coordinating these services. Mobile members of the community are able to travel to major centres for these services, but the aged, the financially disadvantaged and the home bound all rely on having the services coordinated by their community nurse, their general practitioner and their pharmacist.

Pharmacists have played and are playing a major role in a number of health screening programs. The info-test program run by Diabetes Australia in association with a number of accredited Self Care pharmacists is probably the largest in scale.

Many pharmacists provide blood pressure

screening and monitoring, as well as blood cholesterol screening, at a local community level. Where a full-time early childhood centre is not available, the pharmacy provides growth chart recording and monitoring, as well as counselling.

ADVICE AND SUPPLY FUNCTION

The major role of the pharmacist is to supply prescription medication and other pharmaceutical products to patients and to provide information and advice on their appropriate use.

It was interesting to note in Ross Harris’ paper in 1992, that nurses are seeking more information on the Pharmaceutical Benefits Scheme because of the enquiries they receive.

Pharmacists provide a more significant function than one solely of supply. Due to their training and record systems, pharmacists monitor pre- scriptions, identify drug-drug interactions, offer counselling on dosage regimen and advice on side effects. This all happens so automatically that often many people do not recognise the service.

Communications experts tell us that when patients visit a general practitioner, they are concentrating on the symptoms and diagnoses, but when they visit the pharmacy, they concentrate on their medication and getting better. Even if the pharmacist only reinforces the statements of the general practitioner, it is important.

With government policy increasingly shifting the costs of the Pharmaceutical Benefits Scheme onto the patients by greater emphasis on user- pays, pharmacists are being called on more and

more to answer questions about the pricing of pharmaceuticals and about the various safety nets that apply. The government’s minimum pricing

policy, for example, requires patients to pay a price premium whenever the doctor prescribes a brand item rather than the benchmark generic alternative. This can cause confusion for patients and carers which the pharmacist is often called upon to explain.

Improved compliance leads to better patient outcomes. Pharmacists can and do provide a number of compliance aids including dosage units.

Pharmacists also provide a number of over-

the-counter and pharmacist-prescribed medicines. These are often potent medicines. The pharmacist has the right to diagnose and prescribe certain drugs. These include bronchodilators such as Ventolin. The sale of this product as an over-the- counter medicine has come under scrutiny in recent months with a strong call for Ventolin to return to prescription only. However, on balance, the view is that for the convenience of the patient, a committee of the National Health and Medical Research Council (NHMRC) decision will be for Ventolin to continue as a schedule 3 or pharmacist sale product.

In this role, the community pharmacist has the opportunity to interact with a large number of asthmatics. A pharmacy on the northern Sydney beaches has a large number of teenage asthmatics as customers. Over time, the pharmacist has developed a successful method to communicate with this group. His success includes getting them to monitor their own status with peak flow meters and working with general practitioners to develop an asthma management plan. Most of this group are unknown in the hospital system.

Another important area of supply and advice

is that of medical and surgical equipment. In a Pharmaceutical Society survey in 1992, the majority of pharmacists had a large range of regu- larly used equipment for sale or hire. One major role of the community pharmacy, particularly in small isolated communities, is the hire, instruction for use and service of nebuliser pumps. In 1992, all pharmacists in the New England Health Region

had on average six nebuliser pumps available for hire. Several pharmacies had more than fifteen for hire. It has become impractical for local hospitals to maintain their own rental stock. Once

8 The Australian Tournal of Rural Health

nebulisation is prescribed by the doctor, the patient

must visit the pharmacy for the medicine and pick up the nebuliser pump. The rental fees are minimal, but where there is hardship, a voucher system or direct charge to the hospital can be arranged.

This process also applies for the supply of diabetic syringes through Diabetes Australia, for peak flow meters and for incontinence aids, etc, which will now only be subsidised through a mail order scheme. This attempt to bypass the com- munity pharmacy has neither saved the government money nor improved patient access.

The Department of Veteran Affairs has neg-

otiated supply arrangements for an extensive range of wound care and other products through com- munity pharmacies. This involves the Pharmacy Guild as a clearing and billing house and the total cost of the scheme is much lower than the direct supply method.

The important comment here is that duplication of services should be avoided so that resources are not wasted. Governments and city-based administrators should be encouraged to use the existing distribution network of community pharmacies, rather than create alternative and expensive infrastructure to supply the same service.

A PLAN FOR A COORDINATED HEALTH SERVICE

In rural communities, a fair degree of parochialism exists and there is great reluctance to change. However, an ever increasing demand for services also exists.

These new services are driven not only by consumerism, but also by the various providers of the services. Commercial and practical reality indicates that in rural and remote areas of Australia, some modification of the service delivery system must be made.

In a city, the market potential is in multiples of thousands but this translates to single units in the country. It is therefore only practical for these services to be provided in rural areas through multi- skilling and cooperation.

To do this without infringing on the territory of other health professional practices requires cooperation. The subregionalisation process in rural

areas by NSW Health does have some problems, but the positive factor is that health decisions are to be made locally.

To optimise contact between allied health pro- fessionals in rural areas, each must be aware of how the others operate, what resources are available or required, which common patients have been seen, etc.

The community pharmacist, as the most access- ible member of the health team, is the ideal team member to start this cooperation.

This can be achieved by:

utilising the pharmacy to assist with appoint- ments for visiting health professionals;

establishing consultation facilities within the

pharmacy or in co-locating community health service areas;

developing a more formal referral system between pharmacists and other health pro- fessionals;

structuring a product advice and supply service by the pharmacy for health professionals;

exploring various funding options for health professional services through community

pharmacies;

instituting cross discipline education of all rural health professionals, either through jointly run training programs or by having one discipline

provide training for other groups.

CONCLUSION

Experience in many different rural communities shows that through cooperation, magnificent outcomes are possible. Rural communities have traditionally rallied behind their hospital. However, the extension from hospital-based services to community-based services means that it is not only this facility which must be supported, but also the local health providers. Community health services including health education services must also have a local ownership.

To achieve all this, cooperation, planning and training are essential. Community pharmacists stand ready to take their part in this process.