Pearls and Irritations

In last night’s budget the Government had been proposing to deliver cheaper medicines by doubling the number of medications that could be dispensed from a single prescription  for conditions such as high blood pressure and cholesterol. Taxpayers and patients would have benefitted but true to form the Pharmacy Guild lobbied the government and Minister Hunt ran for cover. It happens time and time again with the public interest ignored.

This proposal for the budget was recommended by the Pharmaceutical Benefits Advisory Committee, an independent and expert panel. The recommendation covered 143 of the most frequently prescribed medications.

Even the AMA accused the APG of putting profits before patients

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 37 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. A 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.

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 5,723  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. And be paid accordingly.

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? They let the APG lead them by the nose.

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 at least 1.5 km from each other? One consequence of this restriction of competition agreed to by the PGA and  Australian governments is that the number of community pharmacies has remained substantially unchanged  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 shopkeeping and more on earning income as health professionals.

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 stranglehold on the Department of Health in matters pharmaceutical.

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 ten 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. It is doing great national damage. We saw it again in the run up to yesterday’s budget.

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

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