"Extending Health Systems into the Community"

Deciding on a rational approach to develop a system of appropriate charges for consultancy services provided to patients.

To develop an appropriate fee for service, particularly when there are few models around to draw information from, a consultant may need to look at other forms of consultancy outside of pharmacy, to see if there are any parallels. Perhaps the largest consulting group in Australia is the management consultants, and it is from this group that some basic data is drawn.

The model, which may suit pharmacy consultants, is often referred to as "the rule of thirds". Basically, a consultancy practice can be broken down into three major segments;

*applied time
*research
*operations.

Applied time is time spent, which is visible to the client (patient).
One would expect that this time be at least equal in value to that paid to an experienced pharmacy manager.
Research time is time spent in preparing for a client/patient. The time may be generalized to cover material beneficial to all clients/patients or it may be specific for a particular client/patient. This time should be costed at the same rate as applied time.
Operations refers to the cost of actually running a practice infrastructure and covers the cost of staffing, general overheads, marketing costs, finance costs etc. plus administrative time incurred by the consultant/principal. The costs of running a practice can vary depending on type. It is this area that can be initially discounted if the practice is run by a sole operator with a primary office based at home.
To structure an hourly rate it is necessary to determine what will be a net income from applied time and to apportion this amount equally to the other two segments. Assuming that an experienced pharmacy manager may earn $30 per hour, this becomes the benchmark.
A consultancy rate is struck at $90 per hour with research and operations having to be budgeted within their respective apportionment of $30 each. Assuming that an average pharmacy consulting session may run to say, 30 minutes for one structured session, then the advertised cost per session would be $45. Variations can be made to this price depending on total consultancy time sold.

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Many opportunities are opening up for pharmacists to develop specialties and further provide consultation services for patients.

Traditionally, pharmacy has worked in the area of drug interaction and side effects and the opportunity exists to provide formal reviews in pharmacies and nursing homes for a fee. However, with the ageing population and the majority of illness being of the lifestyle variety, an enormous potential exists in preventive medicine, specifically the utilization of nutritional supplements. Other areas of specialty include wound management, intravenous infusion management in the home, asthma and diabetes and the list is sure to grow as competence emerges from within the ranks of practicing consultants.

It is obvious that to take advantage of the above opportunities (and they are only a handful) it is necessary to upgrade knowledge by formal education and personal research to provide a knowledge base that can be sold.
Another observation is that consultants may elect to become "generalists... or begin to develop specialties in a limited number of areas. If this line of thinking is developed, then it is apparent that the model utilized by the medical profession may need to be adapted for consultant pharmacist use i.e. the concept of a G.P with referral to a range of specialists. In developing a consultant pharmacist model, care would need to be taken in the form of language used to describe functions and activities.
Using identical terminology may draw the criticism from the medical profession that pharmacists are trying to be pseudo-doctors. Similarities will inevitably occur, for after all, we are all involved in a health profession in many instances servicing the same patient from a different perspective.
Consultant pharmacists have already experienced pressure while performing medication reviews in nursing homes, with some doctors being highly critical or simply refusing to acknowledge pharmacy input. This should not deter consultant pharmacists, for while they adhere to a code of ethics, and conduct their practices with a high degree of professionalism, they will eventually win out.
Further, if government funding is involved in any health service, then the agency controlling the money will insist on value. While such programs as the "Quality Use of Medicines" are government driven and directed, we will see a continuing and increased use of pharmacists, for they are economical in cost and are highly regarded by the community at large.

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HOSPITAL PHARMACY CONSULTANTS... HOW ARE THEY PROGRESSING?

Hospital pharmacists have formed their own set of measures for accreditation which have been recently formalized and recognized by government. To date, not a lot has been happening in the hospital area and it is difficult to see how and when developments will occur, given the "slash and burn " mentality which is starting to cripple hospital services generally.

Clinical ward pharmacists have been conducting medication reviews for many years and these can be equated to nursing home reviews conducted by community pharmacy consultants. The larger hospitals are better able to make available an expanded clinical pathway for pharmacists, which involves a teaching role for nurses and other allied health staff, interaction with RMO's (resident medical officers) at ward level with extensions into medical rounds with VMO'S.

Apart from developing specialties in oncology, cardiology, renal pharmacy, psychiatry, clinical nutrition etc. most clinical pharmacists with about three years experience, would tend to have a wider skill range compared with a community accredited consultant pharmacists
It is a pity that hospital pharmacists and community pharmacists have not come together under the umbrella of AACP, for this is where a true liaison could occur, with much valuable input being available from the hospital sector. Hospital pharmacy departments have not only had their budgets curtailed in recent times, but they are suffering from a reduction in actual numbers of pharmacists, with most departments reporting personnel shortages ranging from 12% to 55%.
This has further meant that to provide basic dispensing and distributive services, clinical pharmacists have had to be recalled "in-house" to avoid a collapse of the system. Hospital pharmacists are poorly paid compared to their community counterparts and given the philosophy driving most state government budgets, it is difficult to see where any extra money may come from to fund hospital consultant pharmacists.
With current lack of incentive it is hard to see any growth in this segment in the short term However, it would be fair to say that all experienced clinical pharmacists in a hospital would already be performing a consultative role in that setting. It is a pity that these skills cannot be transferred to community pharmacists in an organized fashion, but with governments beginning to look at privatization of hospital pharmacies, opportunities will become available for community pharmacists and perhaps a seamless and mutual transfer of skills will commence.

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OPPORTUNITIES IN THE "HOSPITAL IN THE HOME" PROJECT

With the continuing pressure by governments to cut costs in the hospital system, schemes involving early discharge of patients with follow-up home treatment have been trialled around Australia.

Some of these schemes, particularly antibiotic home infusions, have proven to be a "win-win " solution for both patients and hospital budgets. The schemes also open up opportunities for clinical pharmacy in a consultant capacity. Initially, hospital pharmacists will fill these opportunities, but if we follow the American model, private services owned by pharmacists, will emerge to provide this expanding community activity.

Development of hospital in the home (HITH) services has been driven mainly in Victoria with other states still in their infancy. An opportunity exists to outsource this activity in the private sector, provided an investment is made in equipment to manufacture sterile products.
This investment would be at minimum $50,000, but would also act as a springboard to tender for other services such as chemotherapy. The opportunity here for consultant pharmacists to "value-add" to a community pharmacist practice is limitless.
Not all HITH dispensing is sterile work.
A large proportion involves ready prepared medications to support a number of medical conditions. A nurse with good clinical skills would be a necessary component to provide a team approach.
Pharmacy consultancy for HITH requires a skill in collaborative prescribing and innovation. Many of the treatments have to be tailored so that they can be utilized by the patient with minimal professional supervision (once or twice daily visits in the home). Medical practitioners rely heavily on pharmacist skills to recommend a variation of their hospital treatment and ensure it is dispensed in a manner that is both safe and convenient. For example, penicillin injections may be sent out as sterile, spring-loaded syringes that do not require a needle and will deliver medication at a set rate.
Medications prepared for HITH must be capable of being safely stored in the home, without any specialized storage facility other than the household refrigerator. Patient education is a strong factor in the success of any HITH program and this is the joint responsibility of the pharmacist, nurse and doctor on a continuing basis.
With consultant pharmacists being able to visit in the home setting, further opportunities exist to develop patient education and compliance, to counsel on all current medications and to clear out any unused drugs from the medicine cupboard.

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ARE THE NURSES AHEAD? A LOOK AT THE ROLE OF THE NURSE PRACTITIONER

With nurses displacing pharmacists in the Morgan Gallup Poll an awareness of the expansion of this discipline is occurring. Nurses have organized themselves industrially to become a potent political force and with the advent of clinical nurse consultants and nurse practitioners, an overlap into other disciplines is occurring.

This is certainly causing concern in some areas of the medical profession and pharmacists should also be concerned, as competition for new community services will be fierce. Only the most competent ( and perhaps the cheapest) services will be purchased by government and consumers. Nurses are already mobile in the community, pharmacists are not. However, pharmacists with their 5000 strong community network offer an ideal springboard to develop mobile community services.

In 1990 The NSW College of Nursing and the NSW Nurse's Association prepared a joint submission for the NSW Department of Health, to conduct a number of pilot projects. This was agreed to, and an expanded role for nurses was trialled within the health system depending on community need.
The venues were as diverse as Wagga Wagga hospital emergency department to the Mathew Talbot Hostel for Homeless Men, in Sydney. The final report on the project, based on ten separate pilots, was recently released, and highlighted the benefits of strong collaborative relationships between nurses working in a practitioner role with medical practitioners.
It concluded that nurse practitioners are feasible, safe, and effective in their roles and provide quality health services in the areas surveyed. The Australian Medical Association (NSW Branch) did not endorse the report.
Nurse practitioners are now able to write medication orders covering a restricted range of S3 and S4 substances, which are listed in a nurses' formulary. The order for medication must be appropriate to the context of care and the specialty area e.g. a contraceptive pill in a women's clinic. Nurses see this step as simply legitimizing what they are already doing. Is there a parallel here for pharmacy?

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To date, the AACP has completed some valuable development work in negotiation with the Federal Government and has succeeded in having a fee paid for medication reviews in a number of settings.This is a good beginning, because it gains recognition for the clinical aspects of a pharmacist's work, rather than the distributive elements involved in dispensing and general retailing.

Consultancy of any type always requires unstructured time.
Distributive services require highly structured time.
Thus, the two major elements involved in a pharmacy practice are directly at odds with each other, and because of time demands, the distributive activities have always gained ascendancy at the expense of the consultant elements.
As pure consultant pharmacy practices develop, a separation from the distributive element will occur and each will require separate management and marketing. It is foreseeable that consultancy practices will form up under independent ownership, leasing space in established pharmacies, in commercial offices or perhaps even in doctor's surgeries.
As the concept matures and consultant pharmacists begin to compete against each other for market share, new services will be developed and opportunities will become exciting. With all the predators encircling the distributive elements of pharmacy endeavoring to either secure components within their own environment, or actually own pharmacies outright, consultant pharmacy offers new hope.
Within the concept of this emerging discipline, newly graduated pharmacists can actually finance themselves into a practice, for the major capital required will be intellectual capital. The product of consultant pharmacy cannot be traded as supermarket merchandise and ownership definitely resides with the practitioner. Even if the proprietorship of distributive pharmacy changes direction into unqualified hands, the clinical component will always be safely ensconced within the pharmacy profession.
Consultancy offers new opportunity for a number of pharmacists.
For those nearing retirement and who wish an active retirement, consultancy eliminates the stress of running a large business and time can be structured to suit a more relaxed lifestyle.
Similarly, women in pharmacy with family demands may find consulting a suitable vocation for similar reasons, as time can be structured to suit a busy lifestyle. Experimentation is now required to develop varying and interesting models of consultant pharmacy practice. The information contained in this site may help in this process.

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