Increased role for pharmacists could improve rural GP access

Allowing pharmacists an increased scope of practice and the introduction of physician assistants are two suggestions for ending the most extreme shortages of GP services in certain parts of the country, according to a Grattan Institute report.

Written by health economist and the director of the Grattan Institute's health program, Stephen Duckett, and health fellow Peter Breadon, the Access all areas: new solutions for GP shortages in rural Australia report argues that there are several immediate, relatively inexpensive strategies that could help mitigate extreme shortages in seven areas identified as having the worst access to GP services.

Along with better sharing of information through shared health records and a continuation of the development of telehealth, the authors suggest that allowing pharmacists to administer vaccinations and provide repeat prescriptions to people with stable conditions and the introduction of physician assistants working under the supervision of doctors could help to end the most severe shortages in under-served areas.

They also write that trials to expand the role of paramedics in some aspects of primary care are underway, and this could provide another solution if they are successful.

Drs Duckett and Breadon have identified seven areas of severe GP shortages:

  • Kimberley-Pilbara in Western Australia, which covers most of the state’s north-east, including Broome, Kununurra, Karratha and Roebuck
  • The Northern Territory
  • Central and north west Queensland, which includes Mt Isa, Carpentaria and the Northern Highlands
  • Goldfields-Midwest in Western Australia, including Kalgoorlie, Exmouth, Carnarvon and Esperance
  • New England in northern NSW includes Armidale, Tamworth, Inverell and Scone
  • Southern NSW, including Queanbeyan, Goulburn, Bega and Cooma
  • South-west WA, including the southern population centres of Albany and Denmark

The authors emphasise that the report outlines a plan for the parts of rural Australia with the lowest access to GP services, where previous strategies have failed. “We don’t aim to bring these areas up to the national average, just to end the most extreme shortages,” they write.

“The problem has been around for generations. Successive policies have tried to fix it, but they have only solved the easiest problems by bringing GPs to inner regional centres, not to the areas with the greatest need.

“The three main strategies have been training more doctors, giving doctors and medical students financial incentives to go to areas of greatest need, and requiring overseas-trained doctors to do so.

“These policies have helped fix the easier problems – access gaps in inner regional areas. But for the most under-served areas, existing strategies need to be supplemented. We need new, more creative, solutions.”

The report provides figures showing the higher proportion of people who go to hospital for conditions that could have been treated by a GP in more remote areas, and that the rate of admissions for conditions that could have been prevented with vaccines is nearly four times higher in very remote areas than in major cities.

“For chronic conditions, it is nearly three times higher. Not all of this difference could be fixed by better access to primary care, but a significant proportion could be.”

The report also states previously reported figures showing how difficult it is to attract GPs to rural areas despite quite high subsidies on offer.

The authors write that it is essential to make the most of scarce resources while keeping GPs at the centre of the system.

“The first step is to make much better use of pharmacists’ skills. Pharmacists are highly trained, have deep expertise in medicines, and are located in communities throughout Australia.

“With the agreement of GPs and patients, pharmacists should be able to provide repeat prescriptions to people with simple, stable conditions. They should also be able to provide vaccinations and to work with GPs to help patients manage chronic conditions.

“We also need to increase access to other services, including diagnosis, which currently only GPs can provide. Australia should introduce physician assistants, health workers who practise medicine under the supervision of a doctor. There is good evidence that physician assistants could expand the care available in under-served areas, without compromising quality or safety, and at an affordable cost.

“The proposals in this report only apply to the seven rural areas with the worst shortages of GP services. They can be in place within five years. In 2011-12, they would have resolved the worst shortages for just $30 million. The costs would mostly have been offset by fewer, or less costly, hospitalisations as a result of better population health.”

One example they provide is of allowing a pharmacist to administer repeat prescriptions with previous authorisation provided through a patient's PCEHR or shared care plan.

“After a GP has made a diagnosis and created a treatment plan, they would be able to share the patient's record with the pharmacist, if the patient agrees. When a patient asked the pharmacist for a repeat script, the latter could look up the patient’s record, confirm the medication, and issue the script.

“Participation in these new arrangements might be limited to those with personally controlled electronic health records, subject to adequate roll out. This would facilitate both better communication between the three participants (GPs, pharmacists and patients) as well as allowing audit of pharmacist decisions.”

They suggest there are other solutions that should be kept, expanded or tested, including the use of practice nurses and specialist rural and remote nurses, Aboriginal health workers and rural medical training.

Solutions to develop and evaluate include an expansion of the role of paramedics and trials of access to specialist care using telehealth.

However, “telehealth may not be as suited to primary care, as physical tests are not as easily administered, and telehealth services don’t seem to reduce demand for traditional appointments,” the report states.

“Overseas, telehealth has not yet become a major part of primary care in other countries. Future developments, such as remote monitoring of health status, might work well once they are mature.”

The Australian Medical Association said the suggestions could result in rural Australians being “consigned to poorer quality health care than the rest of the population”.

AMA president Steve Hambleton said rural Australians should have access to the same high quality primary care as the rest of the population.

The AMA instead wants the government to look at its proposals, including providing a dedicated quality training pathway and to implement rural generalist training programs; to continue with financial incentives including those outlined in the AMA's rural rescue package, which it created in association with the Rural Doctors Association of Australia; and to do away with the districts of workforce shortage system.

It also wants the government to extend MBS video consultation items to GP consultations for remote indigenous Australians, aged care residents, people with mobility problems, and rural people who live some distance from GPs.

“This will considerably improve access to medical care for these groups and improve health outcomes,” the AMA said.

Pharmaceutical Society of Australia president Grant Kardachi said the report reinforced the message the PSA had been advocating for many years, that pharmacists must be more fully integrated into the health system as a whole.

“We have severe doctor shortages in many rural and regional areas, areas where there is often a pharmacist with the skills and knowledge to help resolve minor ailments that patients may present with,” Mr Kardachi said.

“Further, there are a range of professional services, including medication management, that a pharmacist can provide to ensure better health outcomes for the community.”

Posted in Allied Health

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