The primary care pharmacist

Community pharmacy practice is primary care. There, I said it. But many folks don’t agree. Community pharmacists are an important, but largely unrecognized, part of our primary health care system.

Recently, I was working on a team grant that contained a few different projects, including a community pharmacy‒based smoking cessation study. The team members (policy-makers and researchers) kept talking about “the primary care project” (the one with family physicians) and the “pharmacy project.” I objected to the terminology, insisting that pharmacy is primary care, so why don’t we present a broader view of primary care (one that includes pharmacy). Eventually, they agreed, but it was enlightening that getting that point across to a bunch of “primary care” researchers was so difficult. Part of the problem is that it is so entrenched that primary care = family physicians, and we just accept that as fact.

Indeed, most people equate primary care only with family physicians. Nothing against family physicians, but this ignores the much bigger picture of primary care. And, given that about a third of Canadians do not have or cannot easily see a family physician,¹ this places more importance on the “other” parts of primary care.

So, what is primary care?

The World Health Organization defines primary care as “the first level of contact of individuals, the family and community with the national health system bringing health care as close as possible to where people live and work.”² This was taken from their seminal Alma-Ata Declaration of 1978.

Health Canada defines primary health care as “an approach to health and a spectrum of services beyond the traditional health care system.” It goes on to say, “Primary health care [includes] direct provision of first-contact services (by providers such as family physicians, nurse practitioners, pharmacists and telephone advice lines).” Later, they state, however, that “at present, primary care services in Canada are delivered chiefly by family physicians.”³

Interestingly, the Canadian Institute for Health Information doesn’t mention pharmacists in their description of primary care.⁴

The University of Ottawa website, “Society, the Individual, and Medicine,” offers the following about primary care: “Primary care refers to first-contact care, in which the majority of health problems are treated. It is the foundation of any health care system, and nations with strong primary care seem to have better health than those without.”⁵ They also distinguish between primary care (“often describes a narrow concept of ‘family doctor-type’ services . . . but it can also apply to all first-contact care”) and primary health care (“a broader concept. . . . In addition to primary care services, it includes health promotion and disease prevention, and also population-level public health functions. It reflects the approach to service provision for a community proposed in the WHO 1978 Alma-Ata Declaration”).⁵

There are many other definitions. But the common key features are first point of contact and community. By these definitions, pharmacists are certainly primary care providers. In fact, given the greater accessibility of pharmacists to the public, one could even argue that we are a larger part of the primary care system than family physicians. Indeed, where does the public go first for headache, blood pressure checks, baby products, pregnancy tests, laxatives, cough and cold products, flu shots, allergies, fungal infections, as well as more acute conditions for which the pharmacist will triage and refer patients to other levels of care, such as an emergency department? This is all primary care.

Is this merely an academic argument? Absolutely not! (But then again, that’s what all academics say about academic arguments.) Government and health policy-makers recognize that with an increasing burden of chronic disease, gaps in care and an aging population, we need reform of primary health care. If everyone thinks only of family physicians in the discussions about improving primary health care, then we as a profession will be left in the dusty dark ages. This means you can forget about broadening of scope of practice or remuneration for clinical services or getting recognition for the primary health care role you already play. Simply put, we must be part of the discussion on primary care reform.

So what should we do?

Let’s start with ourselves. Let’s be unequivocal with our terminology. Pharmacists are primary care providers. Say it with me 10 times. Good. Let’s also (politely, because we’re pharmacists) correct folks who use the narrow physician-centric definition of primary care. Tell them that if we are to improve the health of Canadians, we must think about primary care in a broader sense. Inclusion of pharmacists can add more than 40,000 helping hands to the primary care arena.

Have a look at the provocative article by Dr. John Gums in The Conversation,⁶ which provides a cogent argument that pharmacists can help fill the gap in primary care access and quality in the United States.

We need to insist that the professional organizations that advocate for us start using this terminology—pharmacists are an important part of the primary care system.

Finally, is it too bold to suggest that we start to call ourselves “primary care pharmacists”? Because that’s who we are.

The paper by Gregory et al. (pages 90-98) deserves some sober reflection. In their exploratory study on community pharmacists’ decision-making they actually found that pharmacists have developed sophisticated methods (read, excuses) for avoiding decisions and responsibility. Cognitive dissonance was the term they used: inconsistent thoughts, beliefs or attitudes. Certainly, these findings are inconsistent with our aspiration to be responsible, independent, primary care practitioners. No more excuses! ■