Is rural community pharmacy practice different?

\\(Introduction\\) With 5,665 community pharmacies in Australia, the nature and value of their services have been explored in some detail. However, the differences in practice between the 17% of rural pharmacies, compared to urban pharmacies, have not been investigated thoroughly. This thesis used several approaches to quantify and qualify the perceived and promoted differences in rural community pharmacy practice both in Australia and internationally. The following research questions were proposed. Primary questions: ‚Äö How and in what aspects does rural community pharmacy practice differ from that in urban areas? ‚Äö What are the implications and significance of these differences for development, support and implementation of new programs for rural community pharmacy practice? Secondary questions: ‚Äö What are the influences in rural pharmacy practice today? ‚Äö What knowledge and skills define rural pharmacy practice today? ‚Äö What are the implications on recruitment and retention of pharmacists in rural areas? ‚Äö What are the implications for undergraduate and postgraduate training? \\(Methods\\) An extensive literature review was conducted of academic papers, government reports, popular articles and professional documents, which examined rural Australia, health in Australia and pharmacy. A systematic literature review was then undertaken to find comparative studies of rural and urban community pharmacy practice internationally. Key opinion leaders were interviewed on two occasions to investigate potential changes in their views over time, about the profession and rural practice (2008‚Äö-2010, 2016). Pharmacists, who participated in a cardiovascular research pilot project, Pharmacist Assessment of Adherence, Risk and Treatment in Cardiovascular Disease (PAART CVD), were also interviewed (2009). A survey of pharmacists was undertaken to gauge their views on current and future practice (2014). Practitioner and consumer data, previously unpublished, was reviewed from the Third Community Pharmacy Agreement (3CPA) (2005) and the Fourth Community Pharmacy Agreement (4CPA) (2010) Quality Care Pharmacy Program (QCPP) evaluations, for differences between rural and urban practice. Finally, previously unpublished data from the Pharmacy Cardiovascular Health Care Model (PCHCM) (2005) examined differences in rural and urban community pharmacy practice from a consumer perspective. This then generated a body of work over a 13‚Äö-year period with relevant papers from the systematic literature review going back to the 1990s. \\(Results\\) \\(and\\) \\(conclusions\\) The systematic literature review and other investigations, showed there was a lack of comparative data between rural and urban pharmacy regarding day-to-day practice, both in Australia and internationally, over the investigated time-period. In two published studies, rural pharmacies had a larger regular patient cohort, and the pharmacist was more likely to proactively engage in health conversations with patients. While investigating data for practice differences, it was found that there was a lack of definition for what a 'professional service' entails, which caused confusion in the results obtained. Consumers and practitioners had quite different ideas on the extent of the availability of professional services within pharmacies. Rural consumers thought their pharmacy was capable of providing a service, but then they were unlikely to use it (2005). They also only had an idea of service based on what is currently available, or asked in the surveys conducted (2005, 2010). Using 3CPA and 4CPA data there was no significant differences in professional service provision by rural and urban pharmacies (2005, 2010) using pharmacists and customers views. Patients with cardiovascular disease in 2005, were more likely to use their pharmacy for lifestyle advice (p<0.00) or dispensing (p<0.00), but there was no statistical significance between patronage by rural and urban customers for other professional services at this time. Rural practitioners, who were interviewed, thought the pace of life and collaborations with local health practitioners were two distinctive aspects of their practice. During the systematic literature review, conducted until the end of July 2018, it was found that sometimes more professional services were conducted in rural areas, but this difference was then discounted by some authors, suggesting the geographical circumstances accounted for this difference. Other studies found that if a pharmacy was located in a rural area, it was not a significant factor for professional service delivery, but any difference depended more on pharmacy size, type and staff numbers. Pharmacists were concerned about a lack of improvement in wages or conditions over a number of years, yet there was an expectation to introduce new services within existing practice. Although some were ambivalent, pharmacists were interested, had confidence and enjoyed provision of new services, but were apprehensive about the time taken, given the other requirements of their current roles. However, this concern appeared not to be specific to rural community pharmacy. Overall, pharmacists were reticent to charge the patient for time taken to deliver professional services, and would instead prefer the Government to pay. Historically, many pharmacists have not charged for any additional professional services or advice. A lack of collaboration with other local health practitioners was shown by the degree of uncertainty about the practitioner relationships, expressed by pharmacists if professional services were introduced in the pharmacy. This sentiment was reflected by many practitioners, and this result was no different in rural practice, despite earlier suggestions that inter-professional collaborations were better. In 2014, pharmacists would like to change their practice in the future, but they thought this would not happen; they were uncertain about the future, and felt no real change would take place in the profession. While key opinion leaders were at the forefront of the profession, and were positive about change, this change appeared to be slower at the practitioner level. Many 'at-the-coal-face' pharmacists were despondent; however, again, this sentiment was not specific to rural practice. Examining policy reports over the past 20 years, the literature, and interview data, found that pharmacy as a profession does not 'have a seat at the table', when many national and state rural policies were, and are developed. Consequently, the profession was not mentioned as a significant 'player' in rural health. Community pharmacy was often only seen as a place where prescriptions could be dispensed, and some primary health care services were provided. Pharmacists were only viewed in their roles within a community pharmacy and not in any broader role. \\(Recommendations\\) More comprehensive research is required in all areas of practice, to dismiss or confirm the disparities found in practitioner and patient beliefs, of current community pharmacy practice. This is not just an Australian phenomenon or a rural one. The profession has clear guidelines for minimum standards for 'professional services' but these must be acknowledged and consistently adhered to in every community pharmacy. In Australia, there needs to be an acceptance of payment for professional services by practitioners, whether the service be in part paid by the Government, or as a service charge paid by patients. There is a strong case for better remuneration and conditions for all pharmacists to enable a competent and sustainable workforce. A new modelling of suggested pharmacist staff ratios should be undertaken to consider incorporation of multifaceted complex professional services into day-to-day business across rural and urban community pharmacy practice in Australia. The profession and its associated professional organisations should clearly articulate the skill set of pharmacists to promote relevant competent practice at the highest level. A review of the current rurality classification system is required, to allocate funding and enable those practicing in rural locations, to take advantage of the opportunities available. New funding models should be implemented to allow for those who travel from urban settings to practice in rural areas and are not covered by current funding models. Models of pharmacy practice in rural areas should be supported by long-term funding to attract pharmacist practitioners. Finally, as a profession, there needs to be more pharmacy/pharmacist involvement in rural health policy nationally by professional associations, and locally by practitioners improving their own links with other health professionals. There was little found to substantiate the assertion that rural pharmacy practice is overall different from that in urban areas. This lack of evidence, or at least documentation thereof, potentially jeopardises the profession, professional organisations, teaching institutions and the practitioners in attempting to lever off a 'difference' for funding, recruitment and retention in rural and remote areas of community pharmacy practice.