Robert Haua was awarded the Future Pharmacist of the Year Award for 2015 at the latest Pharmacy Awards.
The topic given was:
How and what are you going to do to enhance the role of pharmacy in the primary care setting? Explain how and why your suggested changes will be acceptable to other members of the primary care team, and possibly to funders.
Collaboration and integration: the way forward for pharmacy – by Robert Haua
Pharmacy is a dynamic profession that is continually evolving to better contribute to patient care, in the face of the escalating complexity of health technology and healthcare services.[1] Over the past 10 to 15 years, policy reform has resulted in significant challenges for community pharmacy.
Community pharmacy has consistently been identified as a crucial aspect of primary healthcare; however, it often underperforms with regards to the expectations of existing policy.[2]
Pharmacists are cited as being “medicine experts”, yet current practice frequently demands they act as distributors of medicines who operate as the final step of a patient’s journey, as opposed to being an essential component of the medication-use system.[1]
Strategic documents aim for multidisciplinary teamwork
The New Zealand Primary Health Care Strategy, although somewhat dated, insists on the provision of high quality care using a collaborative, multidisciplinary and culturally competent approach.[2,3]
In response to the Primary Health Care Strategy, the Ten Year Vision for Pharmacists in New Zealand was commissioned and presented a clear vision of where the pharmacy profession needed to be by 2014.[1,4]
The vision document including goals such as “pharmacists will work collaboratively with doctors, nurses and other healthcare professionals as integral members of the healthcare team” and “pharmacists’ knowledge and expertise in medicine management will be respected and sought after by other healthcare professionals, as well as patients”.[4]
The 2014 deadline has passed and, while there has been some development regarding pharmacists’ advancement in the area of clinical expertise, pharmacists are generally still not thought of as full members of the primary healthcare team.[5]
This is despite evidence suggesting that pharmacists are among the most accessible and trustworthy health professionals.[6,7]
Pharmacists need to demonstrate their skills
In order to align with the Government’s aim of improved integration and collaboration, pharmacists need to engage with other health professionals and demonstrate that they have the pharmacological expertise to benefit the primary care team.[2]
The increasing number of pharmacist initiatives, such as Medicine Use Reviews, the Community Pharmacy Anticoagulation Monitoring Service, Medicines Therapy Assessments and pharmacist prescribing, promote collaboration between pharmacists and general practitioners.[8,9]
However, some community pharmacists believe that there is a resistance by GPs to expanded roles for pharmacists, due to the ideology that pharmacists may be usurping the GP’s role in the healthcare system.[1]
It is through ongoing initiative and determination that pharmacists will be able to alter this mindset and promote a primary healthcare system that acknowledges the importance and worth of each healthcare professional.
More faith in hospital pharmacists
Research suggests that doctors have different perceptions regarding the roles of hospital pharmacists compared with community pharmacists.[9-11]
Smith et al. found 51% of physician respondents believed that hospital pharmacists should be involved in developing a treatment plan, whereas only 17% believed a community pharmacist should be included.[10]
This disparity possibly reflects the lack of integration between GPs and community pharmacists and the fact this is more common in the secondary care environment.1 Ironically, literature shows that GPs are more likely to be accepting of pharmacist clinical roles if undertaken in close collaboration with GPs.[8]
Yet the lack of a multidisciplinary approach, which the Primacy Health Care Strategy called for in 2001, remains one of the foremost issues in primary care.
I aim to help overcome this barrier between GPs and pharmacists by attempting to have a large level of engagement with general practices. GPs have highlighted that having a pharmacist who worked independently in the GP practice would be advantageous because they would be separate from the local pharmacy and have a greater level of integration within the GP team.[11]
I strongly identify with such a clinical position and believe it could be the gateway to improved collaboration In the future. This would also allow me to help alter the view of some GPs who have an incomplete understanding of new pharmacist initiatives and the benefits that pharmacists can have in the primary care setting.
The end goal would be creation of more clinical roles for pharmacists, widespread integration with general practices and improved health outcomes for patients.
Teamwork leads to better health outcomes
Despite the issue of role encroachment, GPs and other members of the primary care team should find the partnership with pharmacists to be beneficial and acceptable because research has consistently identified that implementing a broader approach to primary healthcare could facilitate a reduction in health inequalities and improve health outcomes.[12-14]
On the other hand, funding remains a major issue for the implementation of such interprofessional initiatives. GPs have voiced some concern that reviewing a pharmacist’s recommendations could result in an increased workload without sufficient remuneration.[8]
This viewpoint extends beyond general practitioners. There is an almost unanimous stance among pharmacists that the Government lacks a clear vision for pharmacy and does not equally represent pharmacy at a senior policy level.[1]
Despite adjustments to the organisation of primary care in recent years, existing service provision funding models are perceived to only partially support interprofessional teamwork.[15]
Pharmacists, in particular, acknowledge that current funding models are not compatible with the evolving role of pharmacy.[1] Therefore, the Government and other professional bodies need to allow pharmacists to contribute to policy-making decisions.
Although I acknowledge that my involvement in such issues may take place in the distant future, I believe that my tenacity, determination and passion for the profession would be well placed in working with policy-makers to ensure pharmacy is properly represented at the senior level.
Pharmacists worry about change
A further limitation to the utilisation of pharmacist services stems from the fact some pharmacists are less amenable to change. Both Australian and New Zealand research has identified that some community pharmacists may be anxious about change and instead support the more traditional model of pharmacy.[16-18]
Strong adherence to the traditional supervision and supply of medicine seems to be a principal barrier to envisioning and advancing the role of the pharmacist in the primary care setting.[17] It is therefore imperative that newly registered pharmacists adopt a sense of eagerness and self-efficacy.
Self-efficacy is imperative for change. If pharmacists do not believe that they have the knowledge and skills to change, they are unlikely to contemplate change.[17] I have a true passion for pharmacy and the evolution of the profession into a fundamental aspect of the primary healthcare team. Hopefully, entering the workforce with such enthusiasm will help to inspire others to embrace a similar disposition, eventually transpiring into increased acceptance of new pharmacist roles.
Additionally, in order to enhance the role of pharmacy in the primary care setting, it is crucial that the public understands the role of the community pharmacist and the clinical services that they can provide.
Despite the evolving role of the pharmacist in the care of chronic conditions, they are often an underutilised resource by the public.[19] The rationales for underutilisation are multifaceted; however, one core issue is the lack of consumer awareness regarding the breadth of a pharmacist’s knowledge.[20,21] Studies have illustrated many consumers believe that the pharmacist’s primary responsibility revolves around the provision of medication.[22,23] Thus, there is a clear misalignment between the public’s perceptions of the pharmacist’s role and what the profession can actually offer.[18]
With this in mind, I believe it is imperative that pharmacists actively strive to shift the public’s opinion of community pharmacy towards a viewpoint that pharmacists have definite and beneficial roles to play in the healthcare system. I believe that I will be able to contribute to this through actively participating in some of the new innovative services that pharmacists are able to undertake, upon appropriate accreditation. Increasing consumer exposure to these services will facilitate the public’s understanding of the potential of pharmacists. Subsequently, their services will become more widely used and accepted, thus enhancing the role of the pharmacist in the primary care setting.
Recruiting of Maori and Pacific pharmacists essential
In direct consequence to the misunderstanding of pharmacy as a career come issues with recruitment into the profession, which is especially prevalent with Maori and Pacific. In New Zealand, approximately 1.5% and 0.9% of practising pharmacists are of Maori or Pacific descent, respectively.[24]
Literature suggests that a lack of cultural concordance between patients and health professionals may reduce patient satisfaction, access and adherence to treatments.[25,26]
Indigenous people worldwide are subject to substantial inequities in healthcare access, healthcare quality and ultimately health outcomes, with long-lasting disparities in life expectancy, morbidity and mortality when compared with people of a nonindigenous descent.[27,28] Combating the underrepresentation of indigenous health professionals, including pharmacists, has been identified internationally as an essential approach to reducing indigenous health inequities.[29]
Therefore, it is imperative that the number of Maori and Pacific pharmacists increases to improve health outcomes for the Maori and Pacific population. I have personally taken part in many recruitment strategies for Maori and Pacific and the general consensus from secondary students is that they do not understand what it is that a pharmacist actually does and so often disregard it as a career choice.
Consequently, in order to increase the number of Maori and Pacific working in pharmacy, it is essential for secondary students to have an accurate and thorough understanding of the pharmacy profession.
New Zealand research has found early exposure is crucial to help overcome the educational, informational and access barriers to indigenous secondary students wishing to pursue a career in health.[30] Career advisors, while knowledgeable about the traditional roles of community pharmacy, often are less aware of the other pathways open to pharmacists and the more innovative services that pharmacies can now offer.[31]
It then falls upon tertiary institutions and the profession itself to take the initiative and change the general student perception of pharmacy. I have previously worked alongside Maori recruitment officers and visited schools in rural regions to help expose Maori students to the possibility of pursuing a career in health. I foresee myself continuing to be a part of such initiatives in the future, as I have seen first-hand the impact they can make on students.
Such interventions aim to reduce health inequities in New Zealand will be acceptable to policymakers and funders because there is the potential to combat the escalating cost of healthcare.[32-34]
The growing costs of healthcare can be partly attributed to the costs associated with conditions that are largely preventable through action on the social determinants of health.[35]
A 1998 study found that in Northland, if the number of avoidable hospitalisations within the lowest socioeconomic group was reduced to that of the middle groups, then approximately 950 admissions would be avoided, translating to potential savings of $2.2 million.[36] Therefore, reducing health inequities should be the foremost goal for policy-makers in New Zealand.
Conclusion – pharmacists ready for change and their role is likely to grow
Pharmacy in New Zealand is primed for change; however, that change has been slow.1 Pharmacists have the skills and expertise to become an invaluable asset to the primary healthcare team.
Although various barriers to integration exist at both interprofessional and bureaucratic levels, I am positive that the role of the pharmacist will continue to evolve and expand in the primary care setting.
I believe that the changes and influences I can make as a pharmacist will serve to help overcome these barriers and establish pharmacists as an indispensible part of a multidisciplinary primary healthcare team.
References
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2. Scahill S, Harrison J, Carswell P et al. Health care policy and community pharmacy: implications for the New Zealand primary health care sector. N Z Med J 2010;123(1317):41-51.
3. King A. The Primary Health Care Strategy. Wellington: Ministry of Health; 2001.
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23. Anderson C, Blenkinsopp A, Armstrong M. Feedback from community pharmacy users on the contribution of community pharmacy to improving the public’s health: a systematic review of the peer reviewed and non-peer reviewed literature 1990-2002. Health Expect 2004;7(3):191-202.
24. Pharmacy Council of New Zealand. Pharmacy Council of New Zealand Workforce Demographics as at 30 June 2014. Wellington: Pharmacy Council of New Zealand; 2014.
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