Keep GP costs down to win fight against rich world’s biggest killer, OECD says

Decades of success in cutting deaths from heart attacks and strokes are at risk unless governments ensure patients have affordable access to primary health care, the Organisation for Economic Co-operation and Development has warned, adding to pressure on the Federal Government to dump its controversial freeze on Medicare rebates.

As the AMA intensifies its campaign against the four-year freeze, which is set to drive down GP bulk billing rates and force up patient out-of-pocket costs, the OECD has said that affordable and accessible primary care is essential if the world is to build upon a 60 per cent decline in the cardiovascular disease mortality rate in the past 50 years.

In a major report on cardiovascular disease and diabetes released overnight, the OECD said although massive strides had been taken in reducing deaths from cardiovascular disease (CVD), it still remained the most common cause of death in developed countries, and rising rates of obesity and diabetes threatened to slow or even reverse these gains without a greater focus on preventive health, accessible quality primary care and more effective hospital systems.

“The prospects for reducing the CVD disease burden are diminishing, and the pattern of declining mortality is coming to an end or even reversing amongst some population groups, particularly younger age groups,” the Cardiovascular Disease and Diabetes: Policies for Better Health and Quality of Care report said. “Rising levels of obesity and diabetes are reducing our ability to make further inroads into reducing the CVD burden.”

The OECD warned that, on current trends, almost 108 million adults across the OECD would have diabetes by 2030, while an extra 23 million would have greater health needs and a higher risk of complications.

The report paid much of the credit for the decline deaths from heart attacks and strokes in recent decades to public health campaigns, particularly on smoking.

All OECD countries have taken anti-tobacco measures including mass media campaigns, higher taxes, advertising bans and quit services, with the result that between 1997 and 2009 the proportion of adults lighting up daily fell from 28 to 20 per cent.

“Smoking policies have been shown to be highly effective. Tobacco control policies…have saved lives,” the OECD said.

It said that although evidence about the effectiveness of Australia’s world-leading tobacco plain packaging laws was still being gathered, the initiative “may provide the next set of policy instruments for governments to help further reduce the harmful impact of smoking”.

But governments have so far been much less successful in curbing rates of obesity and diabetes, which the OECD said would instead revolve around the strength of a country’s primary health care system.

“Primary care is the centre of the health care system, and is particularly so for CVD and diabetes,” it said, emphasising the importance of affordable and accessible quality care.

“A highly accessible primary care system has the capacity to reduce inequalities in health outcomes and deliver care to those who stand to benefit most,” the report said. “This is particularly important for diseases such as diabetes, which is far more prevalent among lower socio-economic groups.”

It is a timely warning as the AMA ramps up its campaign against the Federal Government’s plan to freeze Medicare rebates until mid-2018.

AMA President Professor Brian Owler has criticised the policy as a “co-payment by stealth” because rising practice costs will force many GPs to dump bulk billing and charge their patients out-of-pocket fees.

Professor Owler said this was concerning because it raised the risk that patients would put off seeing their GP until their health problem became so serious it required hospitalisation.

It is a concern shared by the OECD, which warned that how primary care was funded had “enormous implications” for access to care and health.

“Higher out-of-pocket costs will lead to a lower use of primary care services, particularly among the poor,” it said. “By foregoing routine visits…patients are exposed to greater risk leading to a worsening of health status.

“It is therefore essential that primary care remains highly accessible to all.

“Good access is a necessary requirement to enable primary care practitioners to have regular contacts with patients, assess patient risk, monitor progress, deliver care and adjust treatments when required.”

As part of its report, the OECD examined ways to improve the quality of primary and acute care, including using digital technology to share up-to-date patient information and monitoring their health, as well as pay-for-performance schemes, better hospital access and public reports on the relative performance of hospitals and other health services.

It found that although there was some evidence that pay-for-performance schemes, under which doctors are paid for outcomes – usually in chronic and preventive care – can achieve some improvements, this is often highly contingent on a range of other conditions being in place, meaning great care had to be exercised in implementing such a payment model.

While lauding the success of recent decades in curbing CVD mortality rates, the OECD nonetheless said that it remained the “number one killer” in most member countries, and there were concerns about riding rates of obesity and diabetes, and gaps between recommended health care and that which was actually provided.

The Organisation said it was not just a matter of more money.

“The evidence on what constitutes good quality care has been I the public domain for decades, but many OECD countries are still coming to terms with the changes that need to be made in their health systems to deliver such care,” it said.

The OECD said that one of the most significant challenges was to take evidence about best treatment and make it part of everyday practice.

Adrian Rollins

No crisis, but change is needed: Ley

Health system funding is not in crisis but there needs to be an overhaul of the way the Federal Government pays for GP and hospital services, Health Minister Sussan Ley told the AMA National Conference.

Setting out markers for the future direction of Government health policy, Ms Ley put doctors and state governments on notice that there will be changes to how the Commonwealth funds health care.

But, in a marked change of tone from her predecessor Peter Dutton, the Minister dropped warnings that health spending was unaffordable and embraced a collaborative approach to change.

“The Government is not claiming that we are in a health funding crisis,” Ms Ley said, though she added that, “we are saying that we have to be realistic. If we don’t make changes now, we will face a funding crisis.”

While the Government has dumped the idea of a GP co-payment, Ms Ley nevertheless said the current fee-for-service model of GP remuneration had to change.

“We need to shift from a fragmented system based on individual transactions, to a more integrated system that considers the whole of a person’s health care needs,” she said. “Innovative and blended funding models will be needed to provide appropriate care for patients with complex, ongoing conditions.”

In a warning for adherents of the current fee-for-service model, this is one area of health policy where there appears to be bipartisanship.

In her speech to the AMA Conference, Shadow Health Minister Catherine King said that, “I don’t for a moment suggest we abandon fee-for-service,” but warned there needed to be a “serious conversation” about whether it was best serving patients and rewarding good care.

Ms King said there were hundreds examples across the country of practices providing innovative and preventive care, often involving multidisciplinary teams led by GPs, but “the system as it works at the moment…does not provide incentives to reward this sort of activity. Nor does it reward outcomes”.

The issue of GP funding was the focus of a separate policy session at the Conference (see Providing high quality care doesn’t pay, px), where several presenters expressed concern of any change to funding arrangements that was not backed by sound evidence.

Among the speakers, AMA Victoria President Dr Tony Bartone said there was as yet no substantiated claim that alternative funding arrangements would deliver better patient outcomes than the fee-for-service model.

But Ms Ley said part of the change was aimed at ensuring better care for patient with complex and chronic conditions, as well as those with mental health problems.

She added that the Primary Health Networks being set up to replace Medicare Locals would be funded to “commission health and medical services to fill gaps”.

The Commonwealth has been heavily criticised for last year’s decision to axe the popular Prevocational General Practice Placements Program and abolish General Practice Education and Training, but at the Conference Ms Ley announced that competitive tenders for general practice training had opened. Successful bidders will receive funding to administer the Australian General Practice Training program, including co-ordinating and overseeing placements for GP registrars.

Tenders close on 10 July, and successful bidders will be funded from 1 October this year to the end of 2018.

Adrian Rollins

Providing high quality care doesn’t pay

Current funding arrangements for general practice do not reward quality care and must be overhauled, the AMA National Conference has been told.

While not calling for the current fee-for-service model to be scrapped, speakers at the policy session Funding quality general practice – is it time for change? said better patient outcomes could be achieved with changes to the way doctors are remunerated.

Former GP of the Year and Clinical Director of the Australian Primary Care Collaboratives Program Dr Tony Lembke told the Conference that although Australian practitioners provided high quality care, funding arrangements placed road blocks in their way.

Dr Lembke said there was a tension for general practitioners between their professional aspirations to provide quality care and the demands of running a business.

“The more I look after disadvantaged patients, those with chronic disease, or who are in aged care; the more time I spend training students, the less my income is,” he said. “That is a bizarre sort of system.”

Dr Tim Ross, National Medical Director for health insurer Bupa, said a shift was underway toward more team and community-based care, and the way GPs were remunerated needed to change to reflect and support a different model of providing care.

Bupa last year began trials of GP clinics where patients make a private payment for treatment which emphasises follow-up care and close co-ordination with specialists.

Dr Ross said he expected the Commonwealth to eventually adopt a capitation model of payment, where GPs are paid an annual fee to care for a patient, rather than be paid by service.

This would be part of a blended model including bundled payments from government, fees for services rendered and financial rewards for quality care, including outreach to patients.

He said a team-based approach to care would mean patients seeing a physiotherapist, psychologist or other allied health professional would not need to see their GP in order for funding to occur.

But AMA President Dr Tony Bartone said that providers carried the risk in a system of bundled payments, and the funding model encouraged cherry picking of patients.

Dr Bartone said the fee-for-service model often got a bad rap for issues that had more to do inadequate indexation of Medicare rebates and poorly designed Medicare Benefits Schedule items.

He said there was no evidence that any alternative funding models were superior to fee-for-service, a point admitted to by former AMA Presdient Dr Steve Hambleton, who has been appointed by Health Minister Sussan Ley to lead the Primary Health Care Advisory Group.

The Group has been established to make recommendations on how to provide better care for chronically ill patients and those with mental health conditions, as well ways to improve the co-ordination between hospitals and primary care, and to look at “innovative care and funding models”.

Dr Hambleton told the Conference the work of the Group, which is due to report in November, would be evidence-based.

Currently, he said, “there is no clear winner in terms of which [payment] system is better for outcomes, but we all know there are places where we can do better, [where] we can align the business and professional imperatives better”.

“It does not mean we throw out fee-for-service, but is there a way to say that, if you spend longer [with a patient], if you think about it longer and spend time planning a bit longer, how do you reward that?

“At the moment, the short you spend [with a patient], the less time you spend, the less you think and the less you talk, the more you get paid,” Dr Hambleton said.

A video of the policy session can be viewed at: media/ama-national-conference-29-may-2015-session-2

Adrian Rollins

AMA National Conference 2015

More than 250 delegates and observers revelled in three days of high level health policy discussions, ceremonies and a lot of socialising at the AMA National Conference in Brisbane on 29 to 31 May.

The Conference which had as its theme, Medicare: midlife crisis?, drew together practitioners, academics, operators, students, trainee doctors and media from across the country and internationally, to discuss and debate the latest challenges in health, from climate change, family violence and the treatment of asylum seekers to general practice funding and training, the outlook for public hospitals and the pitfalls of defensive medicine.

Speakers included former Prime Minister Julia Gillard, who addressed the Leadership Development Dinner, Health Minister Sussan Ley, Shadow Health Minister Catherine King, Queensland Health Minister Cameron Dick and Aspen Medical CEO Bruce Armstrong, who detailed Australia’s response to the West Africa Ebola outbreak.

Participants had plenty of opportunity to socialise, including at the President’s Cocktail Reception, the Leadership Development Dinner and the Gala Dinner.

To see more details of the Conference, including video of each of the Conference sessions and policy debates, go to: nationalconference

Adrian Rollins

Size counts as incentive change helps some, costs others

GPs working in some of the nation’s smallest towns and most remote communities are set to receive a hefty increase in Commonwealth subsidies, while around 5000 working in major regional cities will lose thousands of dollars in incentives under changes to a program intended to attract doctors to work in rural areas.

Assistant Health Minister Fiona Nash has announced that incentives for doctors to live and work in 450 small towns across the country will be raised under changes to the GP Rural Incentives Program (GPRIP).

Under the changes, the annual incentive for doctors working in towns with fewer than 5000 residents will increase from $12,000 to up to $23,000, and the incentive for practitioners working in remote areas will be increased from $47,000 to as much as $60,000.

But the qualifying time to receive the incentive has been increased from six months to two years for doctors in rural and regional areas, while doctors in remote locations will have to wait 12 months.

And an estimated 5000 doctors working in regional centres with a population of more than 50,000 will lose their incentive payments under the changes, which come into effect from 1 July.

The change is being implemented as the AMA lobbies the Federal Government to establish a training program to give junior doctors experience in a rural general practice.

The AMA has urged the Commonwealth to adopt the recommendation of the Independent Expert Panel – which it established to advise on the redesign of the GPRIP – for the introduction of “a program that provides a high quality community medicine and general practice training in rural and remote areas through extended placements for junior doctors”.

The recommendation follows the Government’s decision last year to scrap the Prevocational General Practice Placements Program, which left general practice as the only major specialty without a program for prevocational training experience – something AMA President Associate Professor Brian Owler said was vital to sustaining and building the GP workforce.

“This sort of experience can influence junior doctors to pursue a career in general practice, and it can also give doctors who choose other specialties a valuable insight into how general practice works,” A/Professor Owler said. “A carefully targeted prevocational GP training program can also help boost rural and remote workforce numbers”.

The GPRIP has been overhauled following the Government’s decision late last year to dump the discredited Australian Standard Geographical Classification – Remoteness Area (ASGC-RA) classification system and instead use the Modified Monash Model (MMM) to guide the allocation of resources.

While doctors in large regional centres will lose incentives payments under the revamped incentives system, Senator Nash said the new arrangements were much better aligned with community need.

The Minister said under the current system, around $50 million was being paid out each year to doctors working in 14 large regional centres, including Townsville and Cairns.

The scheme created incentives for doctors to remain in well-serviced cities which had little trouble attracting doctors, she said.

“The new GPRIP system will deliver a fairer system for smaller towns; redirecting money to attract more doctors to smaller towns that have genuine difficulty attracting and retaining doctors,” Senator Nash said. “It makes more sense to use that money to attract doctors to where the greatest shortages are – small rural and remote communities, not big regional cities. This means bigger incentive payments will go to doctors who choose to work in the areas of greatest need.”

The AMA was among several health groups that welcomed the move to dump the ASGC-RA classification system and replace it with the Modified Monash Model, but had urged the Government to include transition arrangements for any changes to incentive payments.

The Association said it would assess the impact of the Government’s decision to cut incentive payments to GPs in large regional centres from the beginning of next month.

Adrian Rollins

Knowing when to stop antibiotic therapy

In reply: Thompson and colleagues make an important point: contradicting dogma about the need to complete an antibiotic course is risky and potentially confusing.

My article1 was not written for patients, but it attracted media interest and public comment.2,3 I did not suggest that patients stop taking antibiotics as soon as they feel better, as some assumed2 — although I suspect many do.

Clearly whether they can do so safely, depends on the indication. It would be reasonable for a patient to ask, if the doctor has not explained, whether completing the course is necessary. If, as I suspect is still common, the antibiotic was prescribed for an acute respiratory infection, it is certainly sensible to stop when symptoms improve — albeit better not to have started.

Even when there is a good indication for taking antibiotics, pack sizes often do not correspond with recommended course durations,4 and both are often based on limited evidence. Shorter courses are likely to be just as effective for many infections.5 We need more evidence and more common sense, because unnecessary or unnecessarily long antibiotic courses promote resistance.6

5000 doctors caught out by rural incentive change

Around 5000 GPs working in major regional cities will lose thousands of dollars in Commonwealth payments while doctors serving isolated and remote communities will get increased incentives under changes to a program intended to attract doctors to work in rural areas.

But an estimated 5000 doctors working in regional centres with a population of more than 50,000 will lose their incentive payments under the changes, which come into effect from 1 July.

The change is being implemented as the AMA lobbies the Federal Government to establish a training program to give junior doctors experience in a rural general practice.

While doctors in large regional centres will lose incentives payments under the revamped incentives system, Senator Nash said the new arrangements were much better aligned with community need.

The Minister said under the current system, around $50 million was being paid out each year to doctors working in 14 large regional centres, including Townsville and Cairns.

The scheme created incentives for doctors to remain in well-serviced cities which had little trouble attracting doctors, she said.

The Association said it would assess the impact of the Government’s decision to cut incentive payments to GPs in large regional centres from the beginning of next month.

Adrian Rollins

Incentives hold out promise of better after hours care

The Federal Government has promised patients will find it simpler and easier to see a GP at night or on weekends following the reinstatement of incentives for medical practices to provide after hours services.

In a move strongly supported by the AMA, Health Minister Sussan Ley has announced that almost $99 million will be provided next financial year to pay practices that operate extended hours or make arrangements for their patients to receive after hours care.

Ms Ley said access to after hours GP care was an issue that was raised consistently during her consultations with the medical profession and the community since becoming Minister, and the incentive would give “positive support” to practices that ensured their patients had access to after hours care.

The reinstatement of the incentive was a key recommendation of the review of after hours primary health services led by Professor Claire Jackson, and followed widespread dissatisfaction with the arrangement under the previous Labor Government to give Medicare Locals responsibility for co-ordinating and funding after hours services.

AMA President Associate Professor Brian Owler applauded the Minister for moving so swiftly to reinstate the Practice Incentives Program After Hours Incentive.

A/Professor Owler said the AMA had been calling for the return of the PIP funding “for some time” because of the benefit it would provide to both patients and practices.

“The new PIP payment structure will encourage and support general practices to provide after hours coverage for their patients, which will in turn ensure continuity of care,” the AMA President said. “Individual practices will now have greater control over after hours services for their patients, [and] patients will benefit.”

To pay for the reinstatement of the PIP incentive, the Government has scrapped the After Hours GP Helpline and redirected funds freed up by the abandonment of the Medicare Locals network.

Though some complained that the Helpline has provided a vital service, the Jackson review found there was little evidence it had reduced the pressure on rural doctors to attend after hours call-outs or improved continuity of care. It recommended that the service be scrapped and the funds instead directed into GP incentives.

While details of eligibility requirements for the incentives are yet to be released, the scheme –which commences on 1 July – will offer five payment levels depending on the degree of service provided.

They range from the very basic, level 1 service involving “formal” arrangements for patients to seek after hours care at another provider, through to a full service model where a practice has staff rostered on around the clock, seven days a week.

The incentive would rise from $1 for each Standardised Whole Patient Equivalent (an age-weighted measure based on GP and other non-referred consultation items in the MBS) at a level 1 practice, rising to $11 per SWPE at the top end.

The Minister said all practices would be required to inform patients of their after hours arrangements, and to ensure that correct details were provided in the National Health Service Directory.

“Under these new arrangements, patients will be able to easily find out what after-hours services are available, including services provided by arrangement outside of the patient’s usual general practice,” Ms Ley said.

The reintroduction of the after hours PIP has coincided with the Federal Government’s move to scrap Medicare Locals and replace them with larger Primary Health Networks.

Importantly, the Government has specified a different role for PHNs regarding the provision of after hours services than that fulfilled by the Medicare Locals.

Under the new arrangement, PHNs will be required to work with “key local stakeholders” to plan, co-ordinate and support after hours health services, with a particular focus on “addressing gaps in after hours service provision, ‘at risk’ populations and improved service integration”.

A/Professor Owler said the change in focus and function was welcome.

“The Government has listened and responded to AMA concerns about giving responsibility for after hours funding to Medicare Locals, which has proven to largely be a failure and simply increased red tape for practices,” the AMA President said. “While the new Primary Health Networks will still have a role to play in ensuring community access to after hours health services, their focus will be on gaps in service delivery.”

Adrian Rollins

Medibank abandons controversial GP trial

Giant insurer Medibank Private has abandoned a controversial scheme for preferential access to GPs for its members, but is pushing ahead with a pilot program for closer collaboration with doctors in the care of patients with chronic disease.

In a discreet announcement six months after its public float, the nation’s largest health fund revealed on 22 May that it had “redefined its involvement in primary care”, and would scrap the trial of its GP Access program on 31 July.

Under the program, trialled at 26 GP clinics in Queensland for the past 18 months, Medibank members were guaranteed same-day appointments and after hours GP home visits.

It was heavily criticised by the AMA and other health groups who said it undermined the universality of care and the principle that patients should be treated on the basis of need rather than income or affiliation.

Announcing the decision, the insurer’s Executive General Manager, Provider Networks and Integrated Care, Dr Andrew Wilson, said that although the 13,000 members who had used the service were pleased with it, “they did not feel it added additional value to their private health insurance”.

Dr Wilson said the fierce reaction of the AMA and other groups had also weighed on the decision to scrap the program.

“Disappointingly, it was clear from the feedback that this pilot was perceived as a first step towards the creation of a two-tier or exclusive health system,” he said. “Medibank is a strong supporter of universal health care, and we would certainly hate people to think that we were trying to do anything like this.”

Instead, the insurer is turning its focus to a scheme for closer collaboration with GPs in caring for members with chronic and complex conditions.

Last September it launched a pilot of its CareFirst chronic disease management scheme at six clinics in south-east Queensland, under which GPs receive payments to enrol patients with chronic health problems including heart failure, COPD, osteoarthritis and diabetes into a program that includes a care plan, health coaching and online education. Doctors are awarded incentives for improvements in patient health.

Medibank said that so far more than 200 patients had been enrolled, and early results were promising.

“Stakeholders also told us that GPs feel stretched and unable to provide the longitudinal care they’d like to be able to provide their patients battling chronic illnesses and complex health issues,” Dr Wilson said. “Through both our CareFirst and Care Point pilots we are now working closely with GPs so they can do more for their patients, particularly in tackling chronic disease and keeping people out of hospital.”

Adrian Rollins

AMA wants to recruit pharmacists to primary health team

Patients would suffer fewer adverse reactions to medicine and be almost $50 million better off while governments would save more than $500 million under an AMA plan to integrate pharmacists into general practice.

In a major pitch to improve patient care, reduce unnecessary hospitalisations, and boost cost-effective GP-led primary care, the AMA has developed a proposal to employ non-dispensing pharmacists in medical practices.

It is estimated that a quarter of a million hospital admissions each year are related to the use of prescription drugs, costing the country $1.2 billion, while around a third of patients fail to comply with directions for taking their medicines, undermining their health, causing adverse reactions and wasting taxpayer dollars.

AMA President Associate Professor Brian Owler said that integrating non-dispensing pharmacists within general practices as part of a GP-led multidisciplinary health team could go a long way to addressing these problems, improving patient health and cutting costs.

“Under this program, pharmacists within general practice would assist with things such as medication management, providing patient education on their medications, and supporting GP prescribing with advice on medication interactions and newly available medications,” A/Professor Owler said. “Evidence shows that the AMA plan would reduce fragmentation of patient care, improve prescribing and use of medicines, reduce hospital admissions from adverse drug events, and deliver better health outcomes for patients.”

The proposal, developed in consultation with the Pharmaceutical Society of Australia, could prove a game-changer in fostering closer collaboration between GPs and pharmacists.

It has come amid a concerted push by some in the pharmaceutical sector to encroach upon areas of medical practice in an effort to offset declining revenues from dispensing medicines, including authorising pharmacists to administer vaccines and conduct health checks.

The AMA has warned governments that allowing pharmacists to practise outside their field of expertise could put patients at risk, undermine continuity of care and increase health costs.

The AMA stressed that under its new proposal, pharmacists working within general practices would not dispense or prescribe drugs, nor issue repeat prescriptions, and would instead focus solely on medication management, including advising GPs on prescribing, drug interaction and new medicines, reviewing patient medications and monitoring compliance, improving coordination of care for patients being discharged from hospital with complex medication regimes, and ensuring the safe use and handling of drugs.

The proposal calls for medical practices to be awarded Pharmacist in General Practice Incentive Program (PGPIP) payments similar to those to support the employment of practice nurses.

The AMA has proposed that practices receive an incentive payment of $25,000 a year for each pharmacist employed for at least 12 hours 40 minutes a week, capped at no more than five pharmacists, meaning practices can receive no more than $125,000 a year – except those in rural and remote areas, which would be eligible for a loading of up to 50 per cent.

An independent analysis of the proposal commissioned by the AMA and conducted by consultancy Deloitte Access Economics estimated that if 3100 general practices joined the PGPIP program it would cost the Federal Government $969.5 million over four years.

The consultancy said that the average annual pharmacist salary was $67,000 plus on-costs, meaning only clinics treating 3000 or more standardised whole patient equivalents (an age-weighted measure based on GP and other non-referred consultation items in the MBS) would be likely to participate.

But the Deloitte report said the outlay would be more than offset by substantial savings in other areas of the health system, calculating that for every $1 invested in the PGPIP, taxpayers would save $1.56 in other areas of the health system.

In particular, Deloitte estimated that, as a result of the program:

a drop in the number of patients hospitalised because of adverse reactions to medications would save $1.266 billion;
fewer prescriptions subsidised through the PBS because of better use of medicines would save $180.6 million;
patients would save $49.8 million because of fewer prescriptions and the attached co-payments; and
Medicare would save $18.1 million because fewer patients would see their GP as a result of an adverse reaction to their medicine.

In all, Deloitte said the initiative would deliver a net saving of $544.8 million over four years for the health system, and the benefit-cost ratio improves with each year the scheme is in operation.

“The policy will likely to lead to improved compliance and persistence with medication regimens, which will result in improved health outcomes for patients,” the Deloitte report said. “This will result in significant avoided financial and economic costs for both the patient and the health system, as well as avoided broader economic costs such as lost productivity that arise when a health condition is treated and managed sub-optimally.”

The Deloitte report can be found at article/general-practice-pharmacists-improving-patient-care

Adrian Rollins