Collaboration between doctors and pharmacists in the community

The role of pharmacists is expanding in primary care.There is evidence that greater collaboration between general practitioners and pharmacists can improve patient care. Medication reviews are an example of how pharmacists can assist general practitioners. Joint training and co-location of practices should encourage increased collaboration between the professions.

Teamwork, communication and collaboration between health professionals are important for the safe and effective delivery of health care.¹ Australia's ageing population and the increasing burden of chronic disease present opportunities and imperatives for health professionals to practise collaboratively.

A literature review by the National Prescribing Service has identified significant problems associated with medication misadventure. Approximately 6% of hospital admissions are associated with adverse drug events and high error rates during transfer of care. Poor communication was the most important common factor contributing to medication errors.² Increased interprofessional collaboration between doctors and pharmacists could therefore reduce the considerable medication-related morbidity and mortality.

Pharmacy practice in Australia now involves patient-centred care including counselling, providing drug information, monitoring drug therapy and patient adherence, as well as the supply of medicines. Over the last decade, the role of pharmacists in the community has expanded with the provision of many professional services including medication reviews, diabetes and asthma management programs, and patient medication profiles.

It is in the additional role of managing medication therapy, in collaboration with prescribers, that pharmacists can now make a vital contribution to patient care. To do so, the role of the pharmacist needs to be redefined and reorientated. The traditional relationship between the doctor as prescriber, and pharmacist as dispenser, is no longer appropriate to ensure safety, effectiveness and adherence to therapy. Pharmacists need to pay more attention to patient-centred, outcomes-focused care to optimise the safe and effective use of medicines. Dispensing is, and must remain, a responsibility of the pharmacy profession, but prescribing and dispensing should not be done by the same person. By taking direct responsibility for individual patients' medication-related needs, pharmacists can make a unique contribution to the outcome of medication therapy and to their patients' quality of life.³

Australian and international studies have shown the benefits pharmacists can make to direct patient care and better medication management.^4,5 In the UK and New Zealand, reviews of medicine use have contributed to professional integration and patient care.^6,7 In Canada, early concerns about collaborative practice have been resolved as general practitioners discovered the benefits of working with pharmacists.^8,9 General practitioners are more likely to accept a pharmacist's recommendations if they have personal contact in case conferences than they are if they are sent written recommendations.¹⁰ General practitioners may be reluctant to use a service led by a pharmacist who they do not personally know.¹¹

The TEAMCare coordinated care trial demonstrated that pharmacists and general practitioners can work together in a primary care environment, although a greater degree of trust and collaboration is required.¹²Trust appears to grow over time. When pharmacists are co-located with general practitioners there is a greater opportunity for trust to develop.¹³ However, the full effect of pharmacist integration may take longer than one year to perceive clearly.¹⁴

Studies that have integrated pharmacists into primary care practices have shown improved patient outcomes.¹⁵ Collaborative models have improved the treatment of hypertension.¹⁶ Pharmacists have the potential to optimise drug therapy by identifying medication-therapy problems and recommending solutions.¹⁷ Prescribers are receptive to such recommendations.¹⁸ Pharmacist–patient consultations in relation to medication management within general practitioners' surgeries and in patients' homes have high acceptability to patients.¹⁹

A role for a pharmacist within a general practice has been proposed to provide multiple risk management strategies to improve medication safety. The role would focus on interventions to high-risk patient groups and disease states, and would use practice information technology systems to detect potential safety problems.²⁰

Interdisciplinary teaching of pharmacotherapeutics provides health professionals with greater insight into their respective roles. This could improve the quality use of medicines and reduce medication errors.²¹

Medication reviews

Medication reviews show the benefits of cooperation. Government remuneration for medication reviews by pharmacists began in 1997 in residential aged care facilities and in 2001 for community patients. Collaborative medication reviews are included in many general practitioner and pharmacist practices, clinical practice guidelines and decision support tools. Several randomised trials have shown improvements in prescribing, and reduced healthcare use and medication costs following medication reviews in patients with hypertension, hyperlipidaemia and diabetes.^22-4

The evidence supporting the benefits of home medicines reviews continues to expand. They can be effective in delaying the time to next hospitalisation for heart failure,²⁵identifying drug-related problems among people receiving treatment for mental illnesses,²⁶and assisting in the resolution of medication-related problems.²⁷Medication reviews after discharge from hospital have reduced morbidity and mortality in patients with heart failure.²⁸

Despite this evidence and considerable support by the Pharmacy Guild and Divisions of General Practice, home medicine reviews are still underused. For example, they are not used enough in the detection and prevention of medication-related problems in cardiovascular disease.²⁹

The dichotomous nature of community pharmacy practice is a critical dilemma for the profession. The role of community pharmacists has been traditionally characterised by dispensing prescription medicines, selling over-the-counter medication and offering healthcare advice. Community pharmacists are often not viewed as a core part of the primary healthcare team. Perceptions around being a retailer and healthcare provider create uncertainty in the minds of the medical profession, funders and consumers. Pharmacy is the only health profession that is reimbursed for its sale of a product rather than provision of a service.

Currently community pharmacists have limited opportunity to see patients in a primary care setting as part of a multidisciplinary team. Direct contact between community pharmacists and general practitioners is often brief and can be perceived as adversarial.

In many cases geographical isolation and separate premises are barriers to the integration of community pharmacists into the primary healthcare team. Electronic health records will potentially overcome some of the barriers with shared access to medication profiles and secure transfer of information. Lack of a private consultation area in a community pharmacy is also a barrier. In addition, the attitudes of doctors towards pharmacists and their contribution to better medication management is another barrier to overcome.¹³

Some medical organisations have been critical of an expanded role for pharmacists in primary health care, opposing pharmacy as the first point of call for treating minor ailments, pharmacist prescribing, disease state management, immunisation and sick notes. However, pharmacists already play a valuable role in triaging minor conditions in the community. People will continue to consult pharmacists for minor health problems as they are a trusted and accessible source of information and advice.

The roles of the doctor and pharmacist are complementary. Good working relationships between all healthcare professionals are essential to the delivery of personalised and effective patient services. All health professions must show greater responsiveness to changing patient needs.

Pharmacists have the skills and knowledge to contribute to the quality use of medicines, to minimise medication misadventure and to help consumers better manage their medicines. Interdisciplinary clinical teaching, communication and relationships are the keys to improving collaboration to achieve optimal medication management. Interprofessional collaboration between general practitioners and pharmacists must continue to evolve to meet the medication management and healthcare needs of the community now and in the future.