This month Pharma-goss concentrates on one subject which the author believes should be a paramount discussion topic for all members of the pharmacy profession and especially those young pharmacists who wonder where their training is leading them.
The foundation upon which pharmaceutical care is provided to the Australian community is in need of an overhaul and until there is a thorough review of the way pharmacy services are structured there should be no more Agreements entered into between the pharmacy profession and the Commonwealth Government.
$1 billion a year is paid to pharmacists by the PBS for professional services and a similar amount again by consumers for the dispensing of medicines not attracting a government payment.
Is the Australian public getting its money’s worth or is there room for improvement through an alternate infrastructure that links more closely the supply of pharmaceutical services with the way health services are delivered in the 21st Century.
“The basic infrastructure upon which pharmacy services are delivered to the community is in need of a drastic and urgent review.”
Submissions can be made to suggest improvements to the health system in Australia
This is a view being put to the National Health and Hospitals Reform Commission by this columnist who believes that the full contribution pharmacists can make to primary health care will not be achieved while “community” pharmacy is wedded to the retail shop model.
The Pharmaceutical Benefits Scheme was formed on the basis of a doctor in a surgery writing prescriptions for people who then attended a chemist shop down the road to have that prescription filled – invariably and in the majority of cases for a formulation that had to be made up according to the doctor’s formula or recipe.
Medicine has moved on.
Pharmaceutical manufacture has developed beyond recognition.
The range of pharmaceutical agents has sky-rocketed.
The place where medical services are provided has changed.
The “chemist shop” in the retail strip has gone.
The retailing environment has undergone a revolution.
The education of pharmacists has expanded dramatically.
The pharmacists’ contribution is under rated
The provision of extra professional services from the retail shop is limited.
The client of the pharmacy service is not the typically healthy middle class person it was 60 years ago
Chemist shop at Roselands, Sydney 1967
The retail pharmacy continues under the guise of a “community” pharmacy as if this gives it some measure of endorsement by the public it serves.
It is a competitive private sector retailing outlet in a shopping centre where the dominant players are keenly contesting possession of a larger and larger share of the shopping dollar.
The future does not rest in the past…
But the pharmacy hierarchy desperately clings to the coat tails of a profession that must move on in a changing and global world that no longer bears any resemblance to the world that existed when the PBS came in to being.
The future starts now…
The time has past for trying to determine which path pharmacy should be heading down while it is at “the crossroads”. The fact there has been little change over the past 30 years is indicative of leadership intent on maintaining the “status quo”. The future role is described as
“(a)new concept is a patient oriented approach aimed at providing drug therapy for the purpose of achieving outcomes, and is key to the effective, ratio nal and safe use of medicines.”
There is only one way – towards the primary health care multi-disciplinary model.
The 50th anniversary Conference of the Pharmacy Guild looked at
what Pharmacy would be in the Year 2000.
Not much has changed in 30 years.
This reluctance to change the model of pharmacy practice has resulted in:-
o The high rental cost of retail businesses cannot be justified to dispense PBS medicines to the community. o The pharmaceutical service is not integrated into the same location as the primary health care facility.
o The number of “Approved” pharmacies spreads the dispensing fee dollar too thinly across too many outlets.
o $1 billion was paid in dispensing fees to Approved Pharmacies in 2007/08 and yet there was still an underutilization of prescriptions written and only half of the repeat authorizations issues presented for refilling.
o A pharmacy is paid the same amount for dispensing an original supply as it does for a repeat supply that may only require six keystrokes on a computer keyboard.
o The number of people admitted to hospitals as a result of medication mismanagement is still causing concern to safety and quality experts.
o The number of Home Medication Reviews carried out through retail pharmacies was only half of the expected uptake in 2007.
“Until pharmacists are doing what they are trained to do, and doing it well, they should not contemplate taking on any additional roles such as prescribing rights.”
The foundation for the PBS service delivery is a privately owned business that is protected from competition by virtue of the owner having to be a registered pharmacist. This precludes investment from other sources that may be able to bring expansion in areas of potential return.
Competition does come from within the profession and in a location where there are multiple sites the competition becomes paramount for the owner to maintain market share. This in itself goes against the notion of providing a better professional service that may not add to the financial return on capital.
There is no evidence to show that the public is best served by 4,992 Approved (to dispense PBS) pharmacy businesses in Australia and whether it might not be better served by a significantly lesser number.
The Sydney suburb of Lindfield has seven pharmacies
within a 500 metres radius.
The accountability of the pharmacy owner for the money received from the PBS is negligible apart from the legal requirements in supplying Schedule Poisons under the relevant State/Territory poisons legislation.
A contract requiring the provision of a range of services in return for the PBS dollar should be considered as a better way of ensuring that consumers obtain the information they need to take medicines wisely, safely and in the best attempt to adhere to the prescribing doctor’s regime.
The basis of one prescription for one item to be dispensed to an ambulatory person is an antiquated approach at a time when the clients that are recipients of PBS medicines may be in remote locations, in residential or aged care facilities, suffering from mental health complaints or aged under the care of a professional care agency.
A dump bin in a Melbourne pharmacy
While ever there are commercial pressures that require remedial retailing action the provision of a health professional service will take second place to money making strategies. It is often said that “pharmaceuticals are not ordinary items of commerce” and yet the evidence suggests this is not the case when turnover is chased at the expense of professional responsibility.
Extract from flyer distributed by
a pharmacy in Darwin
Each of the 4,992 pharmacies employs a registered pharmacist whose salary is paid for by the PBS. This same number of pharmacists may provide a superior health professional advisory service if concentrated in a fewer number of locations.
“Just as the profile of health service delivery has changed over the past 50 years so too does the profile of where pharmaceutical care services are operated from.”
The task ahead..
This is best summarized as “An expert outcome ... to develop a strategy for integrating pharmacists as team members with other health professionals, promote national health programmes, and improve patient care at all levels.”
For suburban residential areas
The will still be a place for the privately owned agency that successfully tenders for the provision of a pharmacy service to the population in the catchments area. The provisions of being a successful tenderer will be the delivery of a range of professional services that ensures consumers obtain maximum opportunity from the medicines supplied.
For Institutionalized patients
A pharmacy service can operate from premises within the institution and provide under contract a range of services as required by that institution. This applies to aged care, residential care and other specialty areas with the critical mass to support an “own pharmacy” service. The present arrangement of obtaining supplies from an outsourced retail pharmacy business is described as “…an administrative nightmare for doctors.”
Minority population group health organisations
A private pharmacy could operate from the precinct of an Aboriginal health or migrant health service or the health service could itself own the pharmacy that would then trade with the PBS to supply a service. The presence of an “in house” pharmacist will add value to the supply function.
For rural and remote towns
There is a need for a pharmacy service to be linked in with the primary health services. As the dollar available from the PBS makes more of the present day pharmacy businesses unsustainable there is a serious risk of towns being left without a pharmacy service. This is to be anticipated and a situation created where the service is not dependant on there being a pharmacist with the entrepreneurship to maintain an “own business”.
Emerging GP Super clinics
The incorporation of a pharmacy service with any government funded primary health care service is a must when it comes to a common sense approach to the supply of pharmaceutical care and advice to other clinicians. That there should be another alternative is to make a mockery of the whole notion of complete health care and disease management processes.
A classic case was presented during the National Competition Policy review of pharmacy regulation in 1999 when the Woodbridge Medical Centre was denied a PBS Approval because of its proximity to other pharmacies. This prompted the comment that “Retailers are product focused whereas we need to be patient and outcome focused” .
So where to from here…?
Flexibility will be a hallmark of the future with the laws that currently restrain trade in pharmaceuticals to a select group of registered pharmacists being loosened to allow health facilities, primary health services, town councils, and GP “super clinics” to have a pharmacy business on the premises.
The PBS is the boss
The real owner of a pharmacy business and the license to operate should be the PBS as it is where the Commonwealth dollars are spent to ensure an adequate, efficient and professional service. The PBS must be given the responsibility to conduct its affairs as it sees best in the interests of its consumers – the Australian public.
Where is the problem?
In 2008 the direction of the pharmacy profession is being dictated by a vested interest group of individuals who with a healthy bank balance provided by the same Australian public is able to bluster its way through the political processes and successfully convince the policy makers that it speaks for all sections of the profession. This is simply not true but in the modern day political climate “spin” and smooth talking seems to win the day even if it is stretching the truth beyond recognition.
The National Health and Hospitals Reform Commission states in its guiding Principle “Taking the long term view” that “A responsible forward-looking approach demands that we actively monitor and plan the health system of the future to respond to changing demographics and health needs, clinical practices and societal influences".
Pharmacy, pharmacists and all those that have been associated with the pharmacy profession across the years want to see it as an equal partner in designing the future. Without that someone else will be dispensing the medicines and it can be seen now how much that can cost other parts of the health system when not done well. It’s time for change – take us with you.
1. Dr S. J. Habayeb, WHO Representative to India. Challenge s& Opportunities for Pharmacists in Health Care in India. 30th November 2007
2. Kos Sclavos address to National Press Club Canberra 23rd July 2008
3. Menzies Centre for Health Policy 21st July 2007
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