Editor's Note: John Dunlop is a successful New Zealand Pharmacist who specialises in developing and marketing pharmacy clinical services.
He will be illustrating his model and his views of pharmacy in New Zealand, and making comparisons with the Australian version.
All references to the Pharmacy Guild and the Pharmaceutical Society contained within John's article refer to the New Zealand versions, unless otherwise specified.
To gain an insight into John's background and activities, please click the link found with the author's name above. We are very pleased to have someone of John's calibre to deliver a pharmacy clinical services perpective from a New Zealand base.
My background has provided me with some major opinion differences to those traditionally held by the Pharmacy Guild, and Pharmaceutical Society. I have also developed over time, many apprehensions about the attitudes and forward thinking capacities of those leading pharmacy organisations, many of which are not supported by research or reality.
Most pharmacists recognise that the dispensing process has now devolved to a very bureaucratically controlled technical function leaving retail pharmacists with the major problem of trying to provide justification for payment for perceived professional roles. Patient counselling; blister packaging; the “health professional you see most often”; etc, are terms bandied about as if they were proven entities that demonstrably added value to the patient’s health and well being. Unfortunately while most retail pharmacist can quote anecdotal commentary of providing some benefit to some patients, there is a paucity of good research to support their beliefs. More particularly one is obliged to ask if there is any evidence of cost-effectiveness in the current dispensing model.
It could be argued that the Pharmaceutical Societies were formed initially to enhance the interests of owners of pharmacies. In NZ, as in Great Britain and Australia, the Society’s Rules ensured that the majority of the governing body were owners. The creation of the Pharmacy Guilds, which are really trade unions of owners, cemented this bias.
Up to the 1950’s the bias and interest of the owners was probably very appropriate After this time the influence of the pharmaceutical companies began to impact negatively on the historical need for the pharmacists’ dispensing skills. Unfortunately the commercial bias of owners on the direction of the profession continued right up to the turn of the century in New Zealand. One might argue that this still continues in Australia given the inordinate power over pharmacy politics exerted by the Pharmacy Guild.
Owner’s understandable desires to protect their assets, has diminished opportunities to move into other areas of professional practice outside the confines of the retail pharmacy. Research moneys tend to be allocated to potential roles designed to be undertaken from within the retail pharmacy environment. Most of these pilot studies fail miserably. The research has shown; small numbers of patients enrolled for these services; high drop out rates; and the low priority given to these services compared to supply and distribution activity. It should be said however, that when these cognitive roles are undertaken, they are usually very successful – but uncommonly taken up.
In New Zealand and Australia in 1996, when the Hepler and Strands model of Comprehensive Pharmaceutical Care was first introduced, there was some 25% of the course devoted to changing the retail environment to accommodate the patient care model. Today, there is little retail pharmacy interest in this model. It was found, not surprisingly, impossible to promote intensive patient care from within the supply and distribution environment, which is geared to move as much product through the door in the shortest space of time for the maximum profit.
Consider the conflict between the urgency of retailing (making rapid contact with the customer) and working within the confines of health professional ethics where ’counselling’ the patient needs may take a minimum of 5-10 minutes. A consultation for the Emergency Contraceptive Pill is expected to take at least 20 minutes – but what happens when other customers are waiting? Similarly, profit is generated from a high turnover of prescription numbers – but leaves minimal time for ‘extra’ services.
The research shows very clearly that for pharmacists to realistically engage in the provision of those professional services designed to ameliorate the very costly problem of drug related morbidity and mortality, they must work in the same environment as the prescribers and other health care professionals. The development of trust; respect for each other’s knowledge and ability; access to patients; each other’s data; and interventions simply cannot occur when the pharmacist works from within the community pharmacy environment.
With an international environment promoting more self-management by patients; medicines availability on the Internet; nurses prescribing and managing medicines; there are good arguments for pharmacists to be proactive.
Perhaps it is time for those pharmacists who have a primary concern for the future of the profession and a real desire to provide patient care and take more control of the development of the profession.
There is certainly an urgent need for our professional bodies to focus on clinical pharmacist services unrelated to supply and distribution and OUTSIDE the retail pharmacy and INSIDE the practice and/or the Primary Health Organisations.
As this is the first column I have written for I2P, I thought it might be appropriate to provide a little of my background and the work I currently do. This may serve as a platform for some interesting discussions as time goes by.
I have spent 40 years in community pharmacy, mostly as an owner, but for the last 16 years have worked in the primary health care environment. Six of these years were as CEO of the College of Pharmacists. Currently I am part of a small company of pharmacists who work with patients and general practitioners in primary care (not attached to any retail pharmacy), involved in teaching postgraduate students, and contract to District Health Boards and Primary Health Organisations in New Zealand to determine the feasibility of pharmacist services. I am presently finishing my doctorate on exploring the feasibility of clinical pharmacist’s interventions of heart failure patients.