Pharmacists could one day work in GP clinics. Here’s what’s in it for you

You’re discharged from hospital with some painkillers but aren’t sure if they’re safe to take with the heart medication you’ve been prescribed for years or the vitamins you take now and again. So you ask your GP. They recommend you see the pharmacist in the next consulting room for advice on how to safely manage all your medicines.

This is the future the Royal Australian College of General Practitioners (RACGP) wants to see. It wants the government to fund pharmacists to be a more permanent fixture in GP clinics – to be physically in the same building, as part of a multidisciplinary team.

The RACGP has made its case to the Productivity Commission inquiry into delivering quality care more efficiently. The commission’s interim report is due to be released this week.

But would this proposal really deliver more efficient health care? And how would it actually work?

We’ve just completed a large trial of pharmacists working in GP clinics in Queensland. Here’s what we think might work, and some of what we need to fix before this becomes reality.

Why would we want pharmacists in GP clinics?

Pharmacists are routinely co-located in GP clinics in the United States, United Kingdom, Canada, the Netherlands, Ireland, Brazil, New Zealand and Malaysia.

Their aim is to improve how patients manage their medicines. They can help clarify why a medicine is needed and how to take it. They can advise on more affordable medicine options. They can liaise between health professionals on issues related to medicines, say when a patient is discharged from hospital and needs care at home. They can also advise GPs on medicine issues, such as a recommendation to stop a particular medication or to prescribe one with more manageable side effects.

Under the Australian proposal these pharmacists would not dispense medicines while working in a GP clinic. The pharmacists would have a professional clinical role related to medicine management (which might also include activities such as giving vaccinations). However, a patient would still need to obtain their medicines in the usual way from a community pharmacy.

The RACGP proposes there would be cost savings from integrating pharmacists into general practice – a potential A$545 million in net savings over four years.

How would this be possible? Presumably by making it more likely patients take their medicines as directed (therefore staying healthier and using fewer health resources), reducing the level and severity of medicine problems (such as side effects that need to be managed), and potentially reducing the number of medicines people take.

While these benefits are broadly plausible, the magnitude of benefit is highly uncertain. This estimate is based on a report from ten years ago, which includes only small studies now almost 20 years old. Patient complexity and treatment options have changed over this time period, so more recent data and models should be considered.

Don’t pharmacists already do medication reviews?

Australian community pharmacists have been conducting medication reviews for more than 20 years. They can review a person’s medications in their home, in aged care, or in a community pharmacy.

But there are some clear advantages to pharmacists using their professional skills in GP clinics.

Having an on-site pharmacist may be convenient for patients who would like extra advice or to have their medicine reviewed outside their home or community pharmacy.

Having pharmacists and GPs work together in the same location also allows trusted relationships to form. This increases the likelihood of a GP responding to a pharmacist’s suggestion to change a patient’s medication compared to those made by pharmacists outside the practice.

But there are potential road blocks

While this sounds promising, it’s not clear if we have enough pharmacists to fill these roles. We need to maintain medication review services including those onsite in aged care and in community pharmacies, while supporting the expansion of pharmacists’ scope of practice (such as their ability to prescribe certain medicines).

Another issue relates to digital health records. Currently, a community pharmacist cannot easily add relevant information about medications purchased over the counter to a patient’s My Health record. It would often be impossible for a pharmacist working in a GP clinic to know what a patient has bought over the counter in a community pharmacy (such as aspirin as a blood thinner).

This means a pharmacist (or other health professional, including the GP) working in a GP clinic doesn’t necessarily have a complete picture of the patient’s medications. For the RACGP’s proposal to work well, the different digital systems used in the health sector need to be better integrated.

So, while the idea of general practice-based pharmacists is good in principle, details still need to be ironed out.

Could this work?

A recent Australian study has shown that when pharmacists worked with GPs to support patients discharged from hospital, this was cost effective. Patients were less likely to be re-admitted to hospital or go to the emergency department the following year.

However, other aspects of the implementation and benefits of this role require more specific evidence.

For example, our team has just completed a trial in Queensland to see if pharmacists in GP clinics can reduce the number of preventable medicine problems for key at-risk patient groups (for example, people with diabetes).

Through this unpublished research, we have already learnt that relationships and workflows between pharmacists and GPs must be negotiated on a practice-by-practice basis. This process takes time, support and additional funding.

Both GPs and pharmacists need to agree on their role, and pharmacists need to be trained and supported to work in this general practice setting.

Patients should also have a say in the type of services delivered in this model and the way they are offered.

Finally, while we can learn many lessons on how this works in other countries, we need more extensive implementation trials in Australia. They need to be appropriately supported to gather good evidence for evaluation. Then if successful, we could move to a staged roll-out to ensure value for money and better health outcomes.