Pearls and Irritations

Pharmacists are the most under-utilised health professionals in the country. The Australian Pharmacy Guild is happy to keep  it that way.  

Concerns expressed about the ‘dumbing down’ pharmacists are long standing. A former president of the Pharmaceutical Society of Australia, Beresford Stock, said 36 years ago ‘… we have stagnated professionally’. (3^rd Commonwealth Pharmaceutical Conference, Trinidad, February 1982). Eight years later, in 1990, in a paper prepared for the PSA, he said ‘For too long the conscientious practitioners have been financially supporting those who have been avoiding their professional responsibilities to the community.’

We need pharmacists to do more in their professional capacity. To improve services and contain costs, we need multi skilling, up skilling and greater professional cooperation through interdisciplinary teams across the whole health sector. Pharmacist must take an active role in health prevention in areas such as tobacco smoking, high blood pressure, obesity and overweight, physical inactivity and high blood cholesterol. These constitute over 30% of the total burden of illness and injury.

Let me just mention a few examples of the workforce problems in our health sector.

• Not only pharmacists but also ambulance officers are not effectively integrated into health care.
• In Australia only 10% of normal births are delivered by midwives, (and 90% by obstetricians). In New Zealand 95% of normal births are delivered by midwives. In the United Kingdom it is 50% and in the Netherlands 70%.
• We have several hundred nurse practitioners in Australia when there should be thousands.
• The AMA is unwilling to share territory with other highly skilled but under-utilised health professionals. There are widespread demarcations, restrictive practices and closed shops.

In the national interest and in their professional interest, pharmacists must participate in the transformation of our health sector from a sickness to a wellness model. The 5,000 or so pharmacies on high street are a highly accessible and high profile resource, more so than GPs’ surgeries. Pharmacy attracts HSC students with high academic scores but many young pharmacists are frustrated.

Standing at the boundary of self care and primary care, pharmacists provide a range of often-unpaid services on an ad hoc basis to customers – advice on medications, advice to see the GP, aches and pains, colds and flu, burns, rashes and abrasions. But it is unsustainable for pharmacists to cross-subsidise their free services from paid services. Professional services must be paid for appropriately. I cannot see why pharmacists for example shouldn’t almost immediately undertake blood tests, as well as flu injections and managing repeat prescriptions.

Funding has been allocated by the federal government for pharmacists to assist the elderly and chronically ill, aborigines and indigenous communities and for pilot programs in diabetes, asthma, and communicable diseases. But do pharmacists really have their hearts in this extended role when there is under spending of these funds.

Some pharmacists have expressed to me their dissatisfaction that their professional skills are not fully utilised and extended. It is not surprising that many find dispensing medications and running what sometimes seem like gift shops, to be mind-numbing.

But despite the interest in increased professionalisation of many pharmacists there is not yet sufficient will amongst pharmacists generally to make the change that is necessary?

In an echo of what the former President said 36 years ago and at the PAC Conference in Perth in 2008 Professor Sansom, described as Australia’s ‘pre-eminent pharmacist’, the Chair of the PBAC, and the Australian Pharmacy Examining Council, put it bluntly.

‘The profession would miss out on inclusion in future healthcare models unless it changed its current structure.’ He added ‘the current structure which is heavily structured on drug distribution and projected images and performance of certain banner groups … all of those things together and independently restrict the innovation and development in pharmacy practice which will promote this profession as a legitimate partner in new primary healthcare delivery models rather than being seen simply as a distributor.’

Andrew Gilbert, Professor and Director of the Quality Use of Medicines and Pharmacy Research Centre at the University of South Australia, described the problem very graphically ten years ago.

I know from the many telephone calls I get from disgruntled young pharmacists who are expected to dispense over 300 prescription items a day. They say that they are instructed that their primary duty is to supply the product, correctly labelled to the right person and that this type of professional performance measure limits any attempt to work with patients, to use Consumer Medicines Information Sheets as part of the patient consultation process and to provide a primary healthcare service. … These [supply] requirements leave no time for patient-centred healthcare, primary healthcare services, patient education and training, professional development through mentoring by experienced pharmacists and discussions with other health professionals regarding the care of complex patients.

The evidence is compelling that the highly protected pharmacy business model which is comfortable and financially rewarding for owners up to this point is going to come under challenge. The history of protection in Australia is that protected sectors are very vulnerable and risk not fully appreciating their vulnerability until it is too late. Why is it that so much effort goes into political lobbying in Canberra and comparatively little effort into utilising more effectively the enormous professional talents within pharmacy?

There are several features of pharmacies that are under challenge.

• How can the arrangement be sustained that pharmacies must generally, in urban areas, be 1.5 km from each other? One consequence of this restriction of competition agreed to by the PGA and previous Australian governments is that the number of community pharmacies has remained substantially unchanged at 5,000 since 1993 despite dramatic increases in population and PBS prescriptions. The consumer organization, Choice, in 2005 commissioned a study by the Allen Consulting Group on these location rules. Choice commented that ‘the location rules provide little consumer benefit and only advantage existing pharmacy operators’. (Choice, August 2009, p65)
• The PGA has successfully barred pharmacies from operating in supermarkets. Australians don’t have great love for the Coles/Woolworths oligopoly but they would love to see more competition. The PGA draws a red herring that supermarkets are purveyors of alcohol and tobacco, which many are. But a pharmacy in a supermarket would be headed by an accredited pharmacist, trained in the same way as other pharmacists, and subject to the same stringent accreditation and registration rules of states and the Australian government.
• The Pharmaceutical Benefits Advisory Committee has achieved some success in obtaining advantageous terms from suppliers, mainly US drug companies. It has shown clearly the benefits of a single payer or purchaser. Unfortunately, a lot of the advantage which the PBAC has secured has been lost in margins to pharmacists. But this is changing. Reduced margins will mean that the business model must change with less emphasis on shop keeping and more on earning income as health professions.

As margins are reduced, pharmacists will need to look at business alternatives. That is why the slowness of pharmacists to take up an expanded role, particularly in disease prevention, is of concern.

Perhaps pharmacists might consider two categories of registered pharmacists. One would compose many of the long-established pharmacists who are reluctant to move away from the distribution model. The second category could be younger and differently trained pharmacists who will respond to a new model of professional practice which substantially extends their role into disease prevention and enhanced therapies. It would seem a possible way to overcome the environment which new and highly motivated pharmacy graduates apparently find so discouraging and dampening.

It is quite remarkable that the PGA has consistently opposed direct relationships developing between GPs and accredited pharmacists. It insists that the relationship must be with the patient’s nominated community pharmacy. This is quite contrary to normal health referral practices. The PGA is a serious barrier to the advancement of professionalism in pharmacy. But as a powerful lobbyist against the public interest it has a strangle hold on the Department of Health in matters pharmaceutical.

But if pharmacists are not yet ready for real engagement in extended health care provision, I am not sure that governments are either. Our so-called ‘health ministers’ are really ministers for medical services. They do not have much influence on many key issues that are very important in population health and sickness prevention – poverty, low personal and group esteem, transport and isolation, tax, climate change and intellectual property, particularly in the pharmaceutical field. We have a medical model in healthcare based on the provision of medical services. It is not patient focused. It is provider-driven.

Further, health bureaucracies in recent years have significantly scaled down their expertise and resourcing of public health, prevention and wellness. The orientation is towards expertise in treating sickness rather than prevention which depends largely on collective action. Remember that the greatest contribution to public health in the last century has been clean water and sewerage – issues that require collective action.

Health policy is easy. Implementation is the hard part. Governments and their bureaucracies are not well prepared, quite the reverse.

We could learn from actions of governments and the pharmaceutical professions in the United Kingdom and in Canada in embracing an extended health role for pharmacists.. In France the local pharmacy is invariably the first port of call for persons seeking help or advice on health problems.

In a more extended form, I outlined the above to the Pharmacy Australia Congress nine years ago. The case was well received by many pharmacists, although not by all. It was particularly welcomed by younger pharmacists who felt their professional skills were not being effectively used. Shortly afterwards, I accepted an invitation to speak to the Australian College of Pharmacy dinner in Brisbane. It was described as a ‘must not miss’ event. But the invitation was withdrawn. Perhaps I did not have the pulling power I thought. But the real reason for the withdrawal was that the APG leaned on the Brisbane College. This is typically the way the APG works. It doesn’t engage in public debate but like all vested interests covertly lobbies ministers, members of parliament, senior officials and the media.

The PGA is still the major barrier to an enhanced professional health role for pharmacists. It is also in the front line protecting pharmacists from competition,

Do pharmacists really want to be professionals or are they content to be corralled by the PGA as shopkeepers?

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