A few weeks ago the Belgian Royal Academy of Medicine published a remarkable advice, stating that nurses could vaccinate patients independently. MD’s should still ‘prescribe’ vaccines, but nurses could inject them without a doctor at their side. Why didn’t they extend the advice to pharmacists, certainly for flu shots ?
EPSA, the European Pharmacy Students Association, calls for flu vaccination in pharmacies, based on a number of advantages for both patients and general health. Canadian pharmacists have a useful guideline and have proven it’s perfectly feasible.
The most important argument in favour of flu vaccination onsite is probably the extremely low threshold pharmacies offer. People can walk in without appointment; vaccines are administered immediately. For EPSA it is evident this will help to increase the coverage of vaccination. In English pilots some 19% of patients said they otherwise wouldn’t have gotten a flu shot.
Selecting the right target population is also perfectly possible. Most indications (diabetes, lung- and heart conditions, etc.) can be linked to the use of certain medications and/or age. Pharmacists should propose vaccination upon checking the medication scheme or drug history (now available online).
Vaccination could even become an integral part of the role of the ‘family pharmacist’; a concept that is slowly making it’s way, a family pharmacist being the pharmacist ‘of first choice’ of the patient, a.o. responsible for keeping the patient’s pharmaceutical record up to date (without excluding the occasional possibility of seeing another pharmacist e.g. after hours, on holiday, on the road…).
Information on every vaccination that has been administered can be easily registered on systems like ‘Vaccinet’, containing the vaccination data of the complete Flemish population. Such platforms should also become the place where doctors indicate who should or shouldn’t be vaccinated. This allows the treating physician to stay in control of the vaccination regimen of his patients. And obviously authorities (respecting privacy) will know and be able to follow the general vaccination rate, online, 24/7.
The most important reasons “why” vaccination by pharmacists should get the green light are benefits for the health of patients and the ease with which enough of them can get their flu shot, year after year.
Why Not ?
Obviously the most important red light is the legal ban, prohibiting pharmacists sticking little holes in their patients. Why shouldn’t or couldn’t this be changed ?
The medical risk- and precaution arguments the Royal Academy developed for nurses, are perfectly applicable for pharmacists. Just look at the guidelines Canadian pharmacists have been using for some time (CLICK HERE) and you will recognise all the same elements: necessary preliminary training, safety precautions, good practice guidelines…
The biggest obstacles are certainly not of a ‘medical’ kind. An unfortunate lack of mutual trust between doctors and pharmacists is often translated in a lot of scientific, practical and legal arguments. In the end, the reasons ‘why not’ are mostly of an ‘emotional’ and ‘financial’ kind.
I recently put myself up for evaluating a number of master proof theses of pharmacy students. One was about the way doctors perceive “BNM” (Begeleiding Nieuwe Medicatie = Training New Medication). This is a service pharmacists in Belgium since last year are supposed to propose to patients who get a 'first time' asthma treatment with a cortisone inhaler. They can get two times twenty minutes of specific training in optimal use of their treatment. I was appalled reading how petty and negatively doctors (both GP’s and specialists) reacted to the competence and the additional remuneration of pharmacists. The only positive thing was the fact that the more doctors and pharmacists knew and trusted each other locally, the better the new service was accepted.
The most important reason “why not”, rather than anything else, is simply the lack of trust between the medical and pharmaceutical profession.
Pay for outcome
The key to get over these obstacles is the way vaccination in pharmacies is positioned.
If the different stakeholders perceive it as a means for pharmacists to sell more products or steal work and income from doctors, it will never succeed. A whole new ‘marketing approach’ is required, far away form the typical ‘payment for delivering products’ pharmacists are known for.
I don’t know how much Canadian pharmacists make on a vaccine they deliver. They get an additional fee for the vaccination between 10 and 20$. Is this cheaper or more expensive than the fee doctors (or nurses) get ?
I don’t know and I don’t care: why not completely abandon the ‘product’ and even the ‘service’ as source of payment and simply go for ‘pay for outcome’ ?
Let’s get Out of the Box
Let’s think along some new lines. Modern entrepreneurs should take some risks. And they should collaborate ('net-work'). Forget ‘product’ and ‘service’ and don’t make a benefit on the vaccine or even on the vaccination itself. A really disruptive remuneration system should be aimed at increasing the vaccination rate of the whole medical team around a number of patients. Don’t let GP’s and pharmacists work separately; give them common goals. How ?
In Belgium the majority of patients – certainly those of the target population for flu vaccination – have a “GMD” (Globaal Medisch Dossier = Comprehensive Medical Record). The health insurance pays GP’s a yearly capitation fee for keeping this file up to date and keeps a record of which patient has a GMD with which doctor.
Now let’s suppose you would link these data to the vaccination data of Vacinnet (see above) on a common digital platform. Each spring both professions (together or separately) use the platform to tag those patients that should get a flu vaccination (something we already do, but separately; not on a common platform).
In the summer of each year, the platform calculates (and communicates) targets for each individually, but also for each ‘team’ of a doctor and family pharmacist together. The platform proposes their possible remuneration if they would vaccinate 30, 40, 50, 60, 70, 80, 90% of their patients. The amount could be a remuneration ‘per patient’, but only payable when the next percentage threshold is reached. The payment should be slightly less if they reach their objective alone and slightly more if they work together. In this last case, the remuneration can be fairly split between the team (doctor and pharmacist).
See what happens. Perceptions will all of a sudden change. To start with, both individuals are ‘in the same boat’. They don’t have to look at individual interventions or patients any more. Reaching targets can still be done separately, but the chances of success (and their remuneration) can be substantially bigger if they start working together.
Basically it means caretakers would get paid for shared data on results. The focus of remuneration and administration is no longer on individual vaccinations or delivering certain products. Mainly the outcome counts: reaching the highest possible threshold. The better the results, the more they benefit.
Seems logical, certainly if you have no problems letting go of the old ways of thinking; what I propose to do…
Dirk BROECKX – August 21th 2015
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EPSA article on Pharmacists (Dutch article):
Royal Academy of Medicine advice on Nurses (Dutch article):
Canadian Guidelines (English pdf):