The Royal Flying Pharmacist? New Solutions in Rural Health Roy S Packer 4 th Year BPharm Student James Cook University School of Pharmacy Angus Smith Dr, James Cook University QLD 4811, Australia roy.packer@jcu.edu.au 0413 709 311 Keywords: Pharmacist, Royal Flying Doctor Service (RFDS), medication management, quality use of medicines (QUM), primary health care (PHC)
Page 2 of 6 Table of Contents Table of Contents... 2 Abstract... 2 Context... 3 Problem... 3 Solution... 4 Strategy for change... 5 Barriers to change... 5 Conclusion... 5 Acknowledgements... 5 References... 6 Abstract Problem: The RFDS (Royal Flying Doctor Service) currently comprises a mix of health professionals providing a crucial health service to rural and remote Australia. One vital health profession however, has remained relegated. Pharmacy Design: Literary review of existing settings in which pharmacists are integrated into interdisciplinary health care teams, supplemented with personal experience and collaboration with key Queensland RFDS medical staff via telephone interviews. Setting: Rural and Remote North Queensland. Key Measures for Improvement: These measures include ensuring QUM in RFDS patients and making this the role of the pharmacist in the team as the drug expert to increase compliance, understanding of medicines and health outcomes. Strategies for Change: A proposed method of integration is for pharmacists to initially join the allied health care team in their clinic services, which may initially only include the provision of medication reviews, and the Quality Use of Medicines (QUM). Effects of Change: The result will be improved efficiency and use of medicines leading to positive health outcomes for RFDS patients.
Page 3 of 6 Context For decades, pharmacists have played a valuable role in Australian primary health care, as one of the most accessible health care providers 1. Whilst there continues to be support for traditional pharmacy models, many challenges face the profession. As in many countries, the Australian pharmacy profession is shifting from a predominantly supply and distribution role to one of increased medicines management services within a retail environment 2. Pharmacists therefore need to adapt and embrace these new opportunities. The release of the Fifth Community Pharmacy Agreement (3 rd May 2010) 3 further endorses the delivery of quality patient-focused services in the context of community pharmacy. Medication management services, ensuring the quality use of medicines (QUM) in indigenous populations, and providing support to rural health care services are paramount to this agreement. This scheme remunerates pharmacists, enabling them to work collaboratively with physicians and other members of the primary health care team to achieve positive health outcomes for patients. Studies indicate that up to 40% of community pharmacists are comfortable in the traditional dispensing role ; however there are a growing number of pharmacists who seek change. This is especially true of recently graduated pharmacists, intern pharmacists and pharmacy student who realise the importance of embracing the clinical and primary health care (PHC) roles, for which they are trained 2. In rural and remote Australia, it is well known that access to quality health services is a major issue. To overcome the great tyranny of distance hindering access, in 1928 Reverend Dr. John Flynn founded the Royal Flying Doctor Service of Australia (RFDS), a telehealth and aeromedical retrieval service in order to provide a mantle of safety 4. As the most renowned health provider to rural and remote Australia, the RFDS services over 80% of the Australian continent with 53 aircraft at 21 bases employing 964 staff 5, 6. In 2009, the RFDS attended over 274,000 patients, travelling more than 23 million kilometres to some of the most remote areas of Australia 7. The RFDS has five main areas of operation: Remote Consultations (telehealth) Primary Response (aeromedical retrieval) Inter-hospital patient transfer Remote clinic services - allied health Medical chest program As a result, the RFDS provides an array of health care services from attending acute emergencies, to the diagnosis and treatment of chronic diseases. Utilising staff from a number of professions including physicians, nurses, dentists, physiotherapists, podiatrists, occupational therapists and diabetes educators, the RFDS provides a highly effective inter-disciplinary health care team to Australia s most remote communities 6. During this study, key RFDS medical officers were contacted, and with reference to the role of the above professions, a possible role for pharmacists was discussed. Problem While this mix of health professions provides a crucial service to rural and remote Australia, there remains one health profession that is not part of the team the PHARMACIST. A pharmacist s expertise in drug-therapy, ensuring QUM and medication management / education has been utilised worldwide in inter-disciplinary teams 8-12. As demonstrated in many hospitals, pharmacists play a significant role in ward rounds, medication reviews and prescribing protocols. Within the community, pharmacists often remain unrecognized for their PHC role and the triage referrals which they provide on a regular basis.
Page 4 of 6 Solution Lately, there have been trends to include pharmacists in health care teams within community practice 2, 8, 9, 11, 13, 14. Examples include GP clinics in which a pharmacist works in collaboration with clinic staff to review high-risk patients, educate patients and staff on medications, identify adverse drug reactions / drug interactions, and promote compliance. Within these team settings, clinical skills are being used in an effective manner to increase the quality of health outcomes to patients, reduce the burden of disease and associated economic costs to the health system. It is therefore proposed that pharmacists should be part of the RFDS team. With disparity between rural and urban health, partially due to access to health services and education, pharmacists have the potential to offer essential health services to the community. Adapting the medicines counselling environment to a culturally sensitive and specific setting has shown to increase compliance and empower the patient 12. The frustration of practitioners in remote communities is exacerbated when, although medication is prescribed and disease states diagnosed, compliance remains poor due to the multitude of factors affecting rural health. Correspondingly, incomplete courses, and cessation of chronic medication regimens lead to patients continually returning for further acute treatment. Pharmacy interventions deal directly with QUM, adverse drug events, and dosage schemes. These interventions address many of the drug-related problems experienced, and demonstrate that the pharmacist has an important role within the team. In the current graduating pharmacy class from James Cook University, the first stage of accreditation for AACP (Australian Association of Consultant Pharmacists) has been completed, encouraging students to further become accredited to conduct Home Medication Reviews, and collaboratively work with GPs. Similar programs in Canada, the United Kingdom, and the United States have experimented with the integration of pharmacists into inter-disciplinary teams within the community setting 8-11, 15. These programs also utilise a common electronic medical record. The 08/09 Annual Report from the RFDS National Office indicates that ehealth for Remote Australia (an electronic medical record system) will go live in 2010 7. This will provide the platform for pharmacists and other allied health team members to work collaboratively as a true inter-disciplinary team, utilising this common medical record. Goals for successful integration include ensuring QUM (an underpinning role of pharmacy nationally) 1, 14 in RFDS patients. This task is the major focus of the pharmacist as the drug expert, and will increase compliance, understanding of medicines and appropriate dosing. Pharmacist interventions have also been proven to decrease the incidence of adverse drug reactions and medication misadventure 11, 12, 15. There is a financial incentive to be gained from a decrease in hospital admissions and acute emergencies due to drug-related issues. Studies indicate that the economic implications of preventable drug-related morbidity are so great that even expensive interventions to tackle the problem may be cost-effective 12. From a patient s perspective, the main benefits include better management of disease states (reaching therapeutic targets), a decrease in sick days (and subsequent loss of income), and general empowerment concerning their condition and related medications. Funding for the integration of pharmacists into the RFDS is an issue which would need to be suitably managed. A potential solution would be through appropriate programs within the Fifth Community Pharmacy Agreement 3 in order to encourage the employment of a pharmacist s services in this endeavour. Pharmacists are however not granted individual provider numbers such as those found in many allied health professions, presenting a challenge for remuneration. This policy currently makes it difficult for pharmacists to be utilised in PHC roles, and requires review in the future. The section 100 (s100) scheme, and Closing The Gap (Previously QUMAX) have constituted the major form of pharmaceutical support to indigenous and rural communities. However, there remains various discrepancies between the minimum support required by the community and that required by the service. Increased education provision and capacity building by pharmacists (as the drug experts ) is a vital necessity and rewarding opportunity in rural and remote Australia.
Page 5 of 6 Strategy for change A proposed method of integration is for pharmacists to initially join the allied health care team in their clinic services. This role may initially only include the provision of medication reviews, and QUM. As the role of the pharmacist within the team becomes understood and valued in terms of positive outcomes for the patient, there may be potential for expansion into other areas of the RFDS, including the medical chest program 4. Pharmacists therefore have a significant role in capacity building and supporting other professions, along with general health promotion in rural and remote practice. Naturally, integration will take time, and pilot programs are required to assess feasibility and economic viability. This endeavour has significant potential for improving health delivery to rural and remote Australia. Barriers to change There are also a number of barriers to integrating pharmacists into the RFDS team, including access to medical records, due to potential breaches of confidentiality with ensuing litigation, 2, 9. The existing perceptions of a pharmacist s shopkeeper role by other health professions 2, 11 have also been documented and may create barriers to the expansion of the clinical role of the pharmacist. However, research has indicated that much of this misperception has been overcome, and other professionals expressed surprise at the pharmacist s level of clinical knowledge and skills 9. Selecting suitable candidates for these PHC roles needs to be undertaken with clinical expertise, rural experience, willingness to be part of a team and cultural sensitivity playing an important role in the selection process. Conclusion Whilst many challenges face the integration of pharmacists into the Royal Flying Doctor Service, the health-related benefits that pharmacists can deliver as part of the team should predominate. The pharmacy profession as a whole is changing, with increased focus on clinical skills, which will allow Australian pharmacists to play a greater role as part of inter-disciplinary health care teams. A gap has been identified for QUM and medicine management to improve compliance with the potential for better health outcomes for the patients cared for by the RFDS. Pharmacists are able to fill the gap providing them with exciting opportunities to be part of the RFDS team in improving the health service to rural and remote Australia. Acknowledgements The Royal Flying Doctor Service (Queensland Section) James Cook University - School of Pharmacy (Townsville Campus) Professor Beverley Glass (Head of School School of Pharmacy and Molecular Sciences)
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