Bridging gaps in health care

Pharmacists and their teams were pushed to the limit during COVID-19, and they proved their mettle. The achievements and sheer “stick-to-itiveness” of community pharmacies have served to cement their viability as community health hubs.

“The pandemic has really highlighted the importance of equitable access for patients to health services for both acute concerns and continuity of care to manage chronic health conditions,” says Angeline Ng, Vice-President, Professional Affairs, at the Ontario Pharmacists Association (OPA).

New or accelerated expansions to scope of practice for pharmacists—and for pharmacy technicians in some provinces—were essential to help set the stage. For example, “the administration of COVID-19 vaccines and tests was very impactful to increasing capacity, providing access and keeping patients healthy and safe,” says Ng.

Outside of COVID-19, many of the additional authorities for pharmacists had to do with prescribing services, including the authority to renew and adapt prescriptions for controlled drugs and substances. These authorities not only helped ensure continuity of care for patients, but they’ve also put pharmacists on a new footing within the healthcare system.

Most of those new authorities are here to stay, or provincial and national pharmacy advocacy bodies are working hard to make them permanent (such as the exemptions to the Controlled Drugs and Substances Act [CDSA], set to expire on September 30, 2026). And provincial governments aren’t done yet. Expansions to scope continue to be announced and/or are in the works, such as the long-awaited minor ailments program in Ontario, announced this summer and set to begin in January 2023.

As COVID-19 slowly makes its way to endemic status in Canada and around the world, its catalyzing impact on systemic change in health care will be felt for some time to come. Community pharmacy appears set to further its pivotal role as a bridge between patients and an overburdened public system. In this article, the Canadian Foundation for Pharmacy (CFP) provides an overview of where pharmacy teams will likely be most active. CFP then explores the need for organizational change within pharmacy in “The post-pandemic workplace,” page 16.

Potential for immunizations

As summarized in the Canadian Pharmacists Association’s (CPhA’s) chart on injection authority, pharmacists in almost all provinces and territories (except Nunavut and Northwest Territories) have the authority to administer most if not all publicly funded vaccines in addition to influenza and COVID-19.

Couple that with results from the 2021 joint survey by 19 to Zero and Neighbourhood Pharmacies—which found that up to 25 per cent of adults and 35 per cent of children may have missed a routine vaccination during the first year of the pandemic—and pharmacy seems a natural solution to help close an important gap in preventative care.

“There’s a huge opportunity for incidental immunizations as people come into their community pharmacy for other reasons and interact with their pharmacist. Someone who needs a pneumonia or shingles vaccine, for instance, could be identified and offered a vaccination right away,” says Shelita Dattani, Vice-President, Pharmacy Affairs, at Neighbourhood Pharmacy Association of Canada (Neighbourhood Pharmacies).

But to take advantage of this opportunity to increase the healthcare system’s capacity for vaccinations, several enablers need to be put in place. “First, we have a whole team to leverage to support vaccination in pharmacy,” says Dattani. “We need broader scope for technicians to vaccinate against flu, COVID-19 and other routine immunizations as well across all Jurisdictions.”

The needle is beginning to move on that front, with pharmacy techs in New Brunswick and Nova Scotia able to administer other vaccines beyond flu and COVID-19, and techs in Ontario able to give flu shots. Techs in Saskatchewan, B.C. and Ontario also have temporary authority for COVID-19 vaccinations, and authorization is expected soon for techs in P.E.I.

In March 2022 in Quebec, several publicly funded vaccines were added to the list of those that can be administered at the pharmacy, not only by pharmacists but also by a nurse employed in a pharmacy, or a pharmacy student, notes Nathalie Asbar, pharmacist, Operations and Analysis Support at the Association québécoise des pharmaciens propriétaires (AQPP).

Yet still more is needed to enable pharmacies as immunization hubs. “We need funding models for routine vaccination administration to be a remunerated service in more jurisdictions, like it is for flu and COVID,” says Dattani.

Currently, despite their authority to inject publicly funded vaccines, pharmacies in most provinces cannot bill the government for the service of injecting. Only B.C. and Quebec currently cover the cost of injection fees in pharmacies for almost all publicly funded vaccines; Alberta and Manitoba also provide limited remuneration.

In Alberta, for example, beyond COVID-19 vaccine and influenza vaccine, pharmacists can bill to administer two vaccines that they access through Public Health—DTaP (limited to pregnant women) and pneumococcal for people over 65. “Our biggest challenge right now is to try to get the attention of government to have conversations about access to their other vaccines supplied by Public Health,” says Margaret Wing, CEO at Alberta Pharmacists’ Association (RxA).

“It’s not that they don’t want us to participate in public health vaccinations, it’s just that

they have been so focused on the COVID pandemic that they don’t have the capacity

to engage us in these broader public-health vaccine conversations. But as pharmacists have become the number-one administrator of public health vaccines in the province, it will become easier to gain recognition for the profession and see more support for their role in this essential service in the future,” notes Wing, adding that community pharmacists in Alberta have administered 53 per cent of all COVID-19 vaccines.

Distribution is another important piece of the puzzle. “It would enhance vaccine access and uptake if vaccines could be distributed through wholesale, like flu and COVID are in many provinces, rather than having to go through Public Health,” explains Dattani.

Industry stakeholders say it’s not a question of if all the challenges will be addressed, but when and how. “With increased recognition of and demand for vaccinations in pharmacies, we need to think about how we support it and make it sustainable,” says Danielle Paes, CPhA’s Chief Pharmacist Officer. “That includes things like appropriate allocation of supply, better integration of pharmacy into public health planning, including pharmacy in discussions and promotions, and facilitating broader participation of the pharmacy sector within the harmonized vaccine authorities and funding.”

Minor ailments—and beyond

Following B.C.’s announcement in October, all provinces now have a program that authorizes pharmacists to assess and prescribe for minor ailments (or common ailments). Yukon is the first among the territories to have a program, with implementation expected in December.

In many of the provinces with established programs, the list of eligible minor ailments slowly but steadily grows. More public funding is also kicking in. For example, early this year Manitoba began to remunerate pharmacies for assessments for uncomplicated urinary tract infections.

Ontario’s program for pharmacist-led assessments and prescribing for 13 minor ailments takes effect January 1, 2023. Prior to its re-election in June, the Conservative government had agreed to discuss remuneration for pharmacies with OPA. As of early October, no further commitment has been announced.

OPA has proposed a $20 consultation fee for all 13 of the eligible conditions and that the program be available to all Ontarians to enable “equal and equitable access to this critical service; ensure pharmacy professionals are fairly paid for their work, time and expertise; and support service uptake and sustainability of the program while delivering an economic return on investment,” says Ng.

Looking ahead, Dattani predicts the pandemic has catalyzed opportunities for prescribing beyond minor ailments, for example, to help patients manage uncomplicated hypertension. “Allowing pharmacists to be more able to contribute to managing chronic disease through broader prescribing authority, like we have in Alberta, would be an important enabler to support patients and the health system in the management of chronic diseases in primary care.”

On another front in Ontario, the expanded scope for point-of-care testing (POCT) in the Province, which came into effect July 1, helps patients better manage chronic diseases and medications. While POCT in pharmacies is currently not publicly funded, OPA will continue to educate the Ministry of Health on the value of POCT by pharmacy professionals, especially now that its impact can be assessed in the real world. With real-world evidence in hand, the association will be able to make the case for funding and expansion of POCT that can be done, says Ng.

POCT offers significant potential for building capacity, echoes Dattani. “Whether it’s strep throat, HIV or screening for disease, there’s a huge opportunity for pharmacy to support population health and public health initiatives.”

Quebec pharmacists’ increased scope in treating minor ailments, which came into force in January 2021, “has really helped reduce pressure on the health system and on doctors,” notes Asbar. Although pharmacists in the province have had the authority to prescribe for minor ailments since June 2015, the list has been expanded, as has the scope in treating ailments that don’t require a previous diagnosis by a practitioner.

Asbar also cites the expansions in scope for the prophylaxis and treatment of coronavirus disease (Evusheld and Paxlovid). “We were the first pharmacists in the world to be able to prescribe the COVID-19 antiviral,” she says. Several other provinces have since followed suit for the prescribing of Paxlovid.

Lessons learned

Overworked pharmacy teams quickly realized that to implement expanded scope of practice and additional services sustainably, they needed government to step up its investment.

“I think the public has a real understanding now that pharmacists do much more than dispense medication,” says Dattani. “They can immunize, they can assess patients, they can prescribe, and they can be nimble in terms of how they can adjust their workflows. But we have to invest in this care.”

Remuneration from government, consistent with fees paid to other health professionals for the same services, enables pharmacies to invest in the resources required to consistently serve as a community health hub, she says.

There are also many practical considerations. “Pharmacy in general needs to look at how we maximize our efficiency and effectiveness using technology, work processes, and with appropriate staffing to ensure sustainability,” notes Paes. “Through this rapid evolution of our role, we also need to strive for and promote healthy, safe and inclusive practice environments, for both patients and pharmacy teams.”

In taking a “big picture” approach, greater attention must be put on design and workflow to allow for more of a primary care and health hub environment, adds Paes. “We need consultation rooms and the physical space to provide care with privacy, but also the technology that connects us to electronic health records and facilitates provision of services in a way that is collaborative, streamlined and has low administrative burden. We’re using a patchwork of systems and tools right now and should be much more cohesive.”

Given that pharmacies currently operate in silos, disconnected from the rest of the healthcare system, she says there is a lot of opportunity to open lines of communication with our interprofessional colleagues and to facilitate the exchange of patient information and details pertinent to funding, insurance coverage and administration.

Wing maintains that practitioners must also adapt to their new reality. “Status quo is no longer acceptable,” she says. “You have to be able to change and there has to be fluidity around the practice environment to be able to meet the changing needs of the patient.”

She adds that during COVID-19, the provincial government has shown its flexibility and there was a “sense of urgency” around the needs of patients and support for pharmacists able to readily adapt their practice environments. “We saw government’s ability to bend regulations and [show] leniency on policies to help meet those public expectations. As a profession, we need to have that same ability to provide the care that patients need without being stuck in those old models of care or traditional funding frameworks,” says Wing.

At the same time, says Wing, government needs to recognize and support the needs of healthcare providers—especially for their mental health. “It isn’t just the public that needs to be cared for; pharmacists as hard-working healthcare professionals need that same support.”

Lobbying for pharmacy resources

Provincial and national advocacy organizations are continuing to capitalize on pharmacy’s pandemic gains by lobbying for the necessary support to implement expanded scope and services sustainably.

Neighbourhood Pharmacies, for example, is sharing best practices between provinces to encourage their adoption and investments by government. “We bring those examples and illustrate them in other provinces so we can ensure that governments everywhere can understand the benefits and value of enabling pharmacy as a health hub to support the needs of Canadians in all communities across all jurisdictions,” says Dattani.

At CPhA, harmonization is a priority. “Our lobbying efforts have been focused on building a case and gathering evidence in key areas to show that we really do need a national harmonized scope, and we’ve been able to demonstrate that,” says Paes. The CDSA is a prime example: although the Act is national, under the control of Health Canada, application of the exemptions remains subject to the laws and regulations of the province or territory. As a result, not all jurisdictions have been able to take full advantage of the changes made at a national level.

“We are keeping a close eye on all provincial developments when it comes to pharmacist authorities, and we’re doing whatever we can to support our provincial partners so that we can advance the profession as a whole,” summarizes Paes.

Strengthening the profession from within is also a priority. “CPhA is focused on building on pandemic gains and ensuring that pharmacists have the support they need to carry forth our ever-evolving role in a sustainable way, from the perspectives of mental health and wellness as well as workforce planning, with proper funding for standard services,” says Paes.

“The long-term goal of pharmacists is to maximize their potential as healthcare professionals and drug experts, which is what they have been trained to do,” says Asbar of the AQPP. “This is what we must focus on to ensure the sustainability of their profession.” The association has been busier than ever providing tools and educational opportunities for its members, and she anticipates that negotiations with government will conclude in the near future. “The goal is always to alleviate pressure on pharmacy teams and offer them reasonable terms for them to be able to continue and expand their practice.”

With a United Conservative Party leadership race underway and a provincial election looming in Alberta (Spring 2023), RxA has reached out to build relationships with MLAs, legislative members and candidates who will be running in all the ridings—those who will eventually form the next government and support policy change within Alberta Health, when the current agreement with pharmacy expires in 2025.

While no one wants to experience another pandemic, there is no denying that COVID-19 precipitated the realization that pharmacy can serve as a community health hub. “Unless there’s a huge event like COVID that creates an environment where there’s this necessity to change to meet the public need, it requires lengthy, persistent advocacy efforts to have those pieces move,” notes Wing.

The crisis led government and the public to acknowledge pharmacists and their teams as important providers or facilitators of primary care and public health initiatives. Now it’s a matter of capitalizing on those gains.