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Recently, I attended a meeting of a Clinical Council of a NSW Regional Rural Health Service.
Clinical Councils are a NSW State Government initiative to involve clinicians of all disciplines to have a say in how monies are to be dispersed throughout a region, from state government budget allocations for hospitals.
The prospect for a front line clinician to embrace high finance and economics is a daunting one, so many revert to playing politics as a means of covering their deficiencies. Being a hospital setting, doctors and nurses have the strongest political sway, allied health and pharmacy are away in the distance.
Basically, clinicians propose new or enhanced programs for the entire region, endeavour to prepare a two to five year budget, and have it debated by all clinicians. The project is then voted on, and many hundreds of thousands of dollars go into a specific "bucket" for that regional service.
The problem is that for the pharmacist representative, there is not the intimate background knowledge of what happens minute by minute in an emergency department or an operating theatre, so he/she is unable to pick up on the various nuances that may be expressed.
Being a single vote, the pharmacist is intimidated by the 10 plus doctor votes on the Council together with an equal number of nurse votes.
With nurses and doctors having the "hands on" experience, the pharmacist is quickly out of his/her depth.
Community pharmacists may experience frustration at having to justify their existence and explain to people what they do and how they do it, but believe me, there is just as much ignorance in the hospital setting.
For example, a project was discussed to set up a Pain Management Clinic, a facility which was regarded by most as an essential service for the region.
The Clinical Nurse Consultant who was developing the program, consulted a similar project in a Sydney teaching hospital, and came up with a preliminary budget.
One item, "Pharmacologicals" stood out for me, as it was noted at around $10,000 for the first year. No discussion had taken place with the local area chief pharmacist in regard to the range of drugs required to be stocked, the quantities of each or whether there was, in fact, sufficient human resource to dispense the anticipated number of prescriptions.
The project was voted on and was passed by a majority of clinicians present.
It was only after this had taken place (some weeks later) was it realised that the drug budget for this clinic would be closer to $100,000 (Gabapentin was involved in large quantities) and that the hospital pharmacy had no capacity for any further outpatient dispensing, as it was operating with only two full time pharmacists (out of a normal strength of five) plus a few casuals.
There was no capacity to offer clinical counselling services or patient/staff education to this clinic, which ought to have been a vital consideration at the budget planning stage.
No doubt the clinicians involved will become more financially and managerially proficient with the passage of time, and look to plugging holes in existing systems (such as the pharmacy dept), before venturing into new activities.

I was not so concerned that clinicians had got their financial numbers wrong, but more that the pharmacoeconomics could have been easily obtained from the pharmacy department and there had been no thought to include pharmacists in the planning of the Pain Clinic, even though it would obviously not work without pharmacy support and interest.
Pharmacy had once more been overlooked!
This is not an isolated instance as nearly all new hospital services are introduced without reference to pharmacy needs, so that as hospital dispensaries garner ever increasing workloads on one hand, they meet a brick wall on the other when they ask for additional staff.
Just do more with less, they are told.

Why is this so?
Our Roundup columnist, in this edition, reports on the very same situation occurring at a diabetic seminar. No presenter talked about drugs in diabetes because there were no pharmacists invited to participate.

Well, it has to get down to perception and the promotion of image.
Jon Aldous reports in his article in this edition on two matters: one, that pharmacy has slipped in the professional rankings down to fourth position in the annual poll taken across various professional traits; the other is that he complains of inadequate advertising and promotion of new pharmacy services, such as Domiciliary Medication Management Review (DMMR).
We, as pharmacists, know what we are doing and how valuable we are.
Why don't they know?
Think about it.

At the same Clinical Council meeting I had the opportunity to observe the local Division of General Practice putting their case for an IT interface with the hospital, to smooth out the rough passages for patient discharges.
Believe it or not, the state health services do not have secure e-mail systems or other Internet method for talking to community GPs.
But local pathology services (Mayne Health) do have a solution in their field of activity, and are actively reporting pathology results, and interpretation of the results, direct to GP desktops.

What interested me was the extent that the hospital system was cooperating with the GPs, including the funding of a GP liaison officer for three days per week within the hospital, the other two days being spent in the community at the Division's expense.
Funding for the Division's IT project was not immediately available, but I was surprised at the CEO's comments, which followed along the lines that he would scavenge monies from each of the existing approved projects to accommodate the GPs.
I guess what impressed me most was the smooth efficiency of the planning that the GPs were involved with, their clear (and local) lines of communication between members, the community projects they were involved with and actively promoting and the reciprocal support they were receiving from community groups and the hospital system.
Obviously the area CEO could not pass up a well planned GP initiative by promising funding one way or another.

I had that sinking feeling in the pit of my stomach as I mentally ticked off pharmacy's efforts in that same region for similar projects.
The silence was deafening!

And it struck me how organisationally fragmented we are within our profession and how there is an almost total lack of local organisation to deal with local and regional issues for pharmacy.
Rollo Manning, in this edition, talks about John Bronger's comments on amalgamating the Pharmacy Guild and the Pharmaceutical Society.
Is John Bronger noticing this same fragmentation at a national level?
In the global economy, of which we are just engaging (if only indirectly at this point in time), do our political structures need to be reexamined for future resilience?
Rollo postulates that our political bodies should be more state oriented, but I would go one step further and say that they should be regionally oriented.
The GP successes, with their Divisions of General Practice, have demonstrated this superbly.
For me, to attend a forum where pharmacy owners, consultant pharmacists, hospital pharmacists, locums and employee pharmacists can come together in one amalgam, and share experiences within the region they practice in, might just be a stimulating experience.
So why not a Division of Pharmacy Practice with support from the hospital system (even permanently chaired by the hospital pharmacists) where local issues and representation can occur, fully supported by the Pharmacy Guild and the Pharmaceutical Society?

Hospitals are beginning to enter a new phase where they are looking to partner community practitioners in a number of activities. A Division of Pharmacy Practice would ensure that Pharmacy received a fair share of this activity.

New pharmacy services, promoted from their own local Division, would command more attention, because they are directed to a general public and a professional community, which is familiar with the various pharmacists involved. It takes on a more intimate flavour when dealing with a local community, and more in line with the promotion of care concepts.
This is more difficult to achieve at a national level.

In particular, a local Division, properly supported by the Guild and the Society, could deal with local political issues such as a lack of cooperation with the DMMR and other new services. Having an organisation that can go "toe-to-toe" with the GP Division would solve a lot of introductory problems, and address any imbalances which are showing through.

This article commenced with practical examples of health professionals and planners, seeming to ignore pharmacists in the overall scheme of events.
While it hurts, the reason is that we are not organised at the local ground level to capitalise on events as they occur.
I would venture to say that there is not a single community pharmacist who is aware of the activities and expenditure on clinical services within the region I am describing. Area health services determine the focus of clinical services and are intimately involved in training clinicians.
If you are out of the loop, how can you expect to be noticed?

And perhaps a regional system of Divisions of Pharmacy Practice may be a more practical approach to John Bronger's suggestion of amalgamation.
Do it at the local level first and see what happens with a "bottom up" approach.

Ends
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