The Royal Australian College of General Practitioners (RACGP) recognises the important role that pharmacists have in supporting patient healthcare through procuring, advising and dispensing medicines to patients. Like all health professionals, pharmacists should be appropriately supported to undertake their core function within a coordinated primary healthcare system.
However, the RACGP has significant concerns with moves to expand the role of community pharmacies beyond their core role. This expansion includes the provision of ad hoc medical services such as health screening and prescribing. The RACGP also has concerns about the unique retail–health model of community pharmacy, which allows for the sale of non–evidence-based health products.
Due to their central care coordination role, skills and knowledge, specialist general practitioners (GPs) are best placed to provide health screening and prescribing services to patients.
2.1 The unique retail-health model of community pharmacy incentivises business needs over patient care
Community pharmacies in Australia operate in a unique environment in which they provide government-funded health services and retail products. This retail–health model does not occur in any other part of the Australian healthcare system.
Pharmacies apply commercial principles to the health environment, selling a number of products that are unnecessary and unrelated to health as a way to maintain a viable business. The Pharmaceutical Society of Australia recognised this important issue by recommending against the sale of homeopathic products and complementary medicines or therapies where there is no credible evidence for use in its recent submission as part of the Choosing Wisely Australia initiative.1
On average, prescription medicines make up only 61.5% of a pharmacy’s sales. The remainder is comprised of non-prescription medicine sales (16%) and the sale of general retail products (22.5%).2
The direct relationship between volume of sales and business sustainability generates a conflict of interest, whereby commercial interests can influence the health advice provided by pharmacists. Programs and initiatives that encourage the ‘upsell’ or ‘add on’ of over-the-counter products in place of, or in addition to, a prescribed medicine is evidence of this conflict.3
Patients should not be exposed to a commercial sales-driven environment when they are engaging with a pharmacist for their health needs. Patient interactions with pharmacies and pharmacists should only involve the procurement of, and advice on, medicines to ensure that they receive the best standard of care within this context.
2.2 The sale of non-evidence-based products in pharmacies poses a risk to patient health
The sale of vitamins, supplements and other non–evidence-based products is rapidly increasing, with the majority of sales occurring in the pharmacy setting.4 Where there is no evidence to support their use, these products must not be sold alongside, complementary to, or as an alternative for evidence-based medicines.
The sale of these products can have serious health implications for patients. It can encourage a patient to delay or dismiss a consultation with a registered medical practitioner or reject conventional medical approaches, resulting in serious and sometimes fatal consequences.
2.3 Community pharmacy location and ownership rules stifle competition in the sector
The community pharmacy sector is protected by location and ownership rules that allow businesses to operate a monopoly in a specified location. In general, the rules stipulate that pharmacies should not operate in close proximity to one another, and that they must be owned by a qualified pharmacist.
The location and ownership rules in community pharmacy are stated to be in place as a mechanism to improve access to, and quality use of, medicines. However, many other areas within the healthcare system are faced with similar challenges of providing a government-subsidised service, promoting patient access and maintaining business viability – yet similar rules are not applied. For example, general practice faces parallel challenges in ensuring access to healthcare, particularly for vulnerable patient groups and patients located in rural and remote areas.
The rules were established under the pretence of protecting the viability of smaller businesses at a time when small community pharmacies were the majority of practices. Since this time, there has been a significant change in the models of operation of community pharmacy. The majority of pharmacies are now divided into a handful of very large, effectively operated corporate businesses, located in major cities and rural areas.
Any visitor into these commercial establishments will see that the observed principle aim is the sale of retail products rather than the provision of healthcare. For example, prime marketing areas are often dedicated to retail products such as perfumes.
The continued enforcement of geographic exclusion zones has been bypassed by the development of pharmacy industry itself. If these rules were abolished, it would allow community pharmacies and pharmacists to co-exist within the same structures as general practices, enhancing the role of pharmacies.
The RACGP is opposed to ownership and location regulations in the pharmacy sector. These regulations stifle competition in the sector, which can result in increased pricing of non-prescription medicines, limited patient choice and slow sector improvements.
2.4 Expanding the role of retail pharmacy does not increase patient access to high-quality healthcare
Many community pharmacies have, or have attempted, to expand their role from medicine procuring, advising and dispensing to providing ad hoc medical services, including health screening, prescribing and chronic disease management.5–7 Many medical practitioners, and even pharmacists themselves, consider it inappropriate that pharmacists provide these types of services.8,9
When a patient receives health advice or screening in a retail pharmacy, they miss out on important medical services that would be offered by GPs, potentially leading to a delayed diagnosis or care.
Despite this risk, some pharmacy organisations have argued that allowing pharmacies to expand their role, and deliver what can be described as ad hoc partial medical services or tasks, will increase access for patients who may otherwise be overlooked within the health system. However, access to services alone will not benefit patients. Patients must have access to safe and high-quality health services, provided by an appropriately trained and informed medical professional. There is no reason to provide primary medical services in settings with no link to general practice.
General practice is highly accessible, with nearly 90% of the Australian population visiting their GP each year.10 There are more GPs in rural and remote locations than any other health professional, including pharmacists.11 When a patient presents to their regular GP for a planned or ad hoc consultation, the GP can provide a range of other opportunistic healthcare services. These services include assessment, preventive advice, health checks (eg for patients with diabetes) and health education, as well as other tailored services based on information held by the practice.
2.5 Ad hoc medical tasks offered in a pharmacy setting fragment care and duplicate services while directing patients away from the coordinated medical care provided by their GP
Some pharmacies offer ad hoc medical tasks, such as vaccinations and health screening. These tasks represent partial medical services and are not equal to the full medical services provided within a general practice as part of coordinated care. These tasks often have no formal connection to the patient’s regular GP and therefore can result in fragmentation of care and duplication of services.
There are also indications that pharmacies are seeking to broaden their role to include other partial medical services, such as ordering of pathology.4 The RACGP does not consider this appropriate. These medical tasks alone do not support patient health and must therefore only be provided as part of the full medical services offered in general practice.
Funding different primary health professionals to provide what could be perceived by patients as similar services will result in duplication of care, creating system inefficiencies and wasting valuable health resources. It removes the guarantee that patients are receiving complete care and that the most appropriate healthcare professionals are delivering health services, risking patient safety.
Patient care becomes fragmented when similar services are offered by multiple health professionals. GPs draw on a comprehensive patient medical history to ensure that patients are receiving the best treatment for their health issues. Patients’ medical records are jeopardised when they receive health services that have no connection to their regular GP.
2.6 Offering ad hoc medical tasks, such as those provided in pharmacy settings, will result in over-testing and over-treating of patients
Retail pharmacy has launched or proposed several health-screening programs to screen asymptomatic patients for various health conditions. Screening asymptomatic patients can lead to over-testing and over-treatment, causing needless anxiety and appointments, and may consequently leave the patient less healthy.12
Patients often present to a pharmacy with health issues that they have self-identified as minor. On these occasions, it is a pharmacist’s duty of care to triage to general practice for an appropriate assessment. When a patient presents to a pharmacy for medications prescribed to them by their GP, a pharmacist must counsel the patient on the appropriate use of these medications.
Poorly targeted screening conducted outside the general practice setting can trigger patient concerns, a situation that often requires GPs to repeat tests or conduct additional tests. Patients should therefore be directed to their GP for health screening or a health assessment if they present to a pharmacy with indications that screening or medical treatment is required. This will avoid over-testing and over-treatment, and ensure that the patient receives the appropriate level of care.