Extending the Role of Pharmacists



17 OCTOBER 2009




Extending the role of pharmacists;

How to get the right balance between the business and the professional model.

Are pharmacists ready for change?


In her address to the Pharmacy Guild of Australia (PGA) in October last year, Minister Roxon expressed the hope that ‘the government’s strong focus on front-line community care might allow you, as pharmacists, to more fully utilise your extensive training, knowledge and skills’. A year later, I wonder
what she now thinks about the response by pharmacists, particularly in sickness prevention.

I am a relative ‘outsider’ on health and pharmacy issues. Yet in the work I have done on healthcare over the last ten years I have felt an ‘outsider’ may have some advantages or at least a different perspective.

At the outset, I must say I have been surprised above all else by the concern of respected pharmacy professionals about the unwillingness of the profession to change.

The concerns expressed to me are clearly long standing. A former president of the Pharmaceutical Society of Australia, Beresford Stock, said 27 years ago ‘… we have stagnated professionally’. (3rd Commonwealth Pharmaceutical Conference, Trinidad, February 1982). He said that in 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.’ Professor
Sansom said much the same to your congress in Perth last year.

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. (I don’t call it a health system.)

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 about 300 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.

The government has announced prescribing rights for nurse practitioners and midwives – a useful beginning where nurses are showing pharmacists a clean pair of heels in extending their professional role.

The field of prevention beckons pharmacists. It is a field in which Australia have made good progress across a wide field – lung cancer, male heart disease, cervical cancer, vaccine preventable diseases, the road toll, HIV and SIDS – despite spending only about 2% of health funds on prevention and actions to
date have been mainly ad hoc and reactive.

We need a transformation of health care in Australia from our sickness model to one of prevention and wellness with an extended role for most health professionals. The case is clear-cut. In May 2007, the Australian Institute of Health and Welfare identified 14 preventable health risks. The top five were
tobacco smoking, high blood pressure, high body mass, physical inactivity and high blood cholesterol. These 14 preventable risks accounted for 32% of the total burden of illness and injury in 2003.

In focusing more on disease prevention, we must however be wary of the risk of continually redefining disease which increases medical services and prescribed pharmaceuticals, particularly in areas such as high cholesterol and high blood pressure. What cholesterol level is too high? When is blood pressure too high? The risk is that respected panels of medical experts will keep lowering the guidelines, eg cholesterol from 6 to 4, and so set new standards for the practice of medicine and prescribing. No doubt these new standards will produce health benefits, but all medication carries some risk and much higher costs.
This is particularly the case with statins which once we start we are likely to continue till the day we die.

Are pharmacists the most over-qualified and under-utilised of professionals?

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 pharmacies on high street are a highly accessible and high profile resource, more so than GPs’ surgeries. You attract HSC students with high academic scores. Excluding contact through dispensing, pharmacists in Australia had 20 million primary care consultations with patients in 2004/05, ranking behind doctors and dentists (Community Pharmacies Contribution to Health in Australia – Berbatis & Sunderland, Pharmacist, Vol 27, 2008).
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.

But it does not seem that pharmacists are fully responsive to needs and opportunities. The fourth agreement between the Australian Government and the Pharmacists’ Guild provides $560 m in ‘Part B’ for pharmacists to be more active in prevention, management of chronic conditions and self-management by
patients. This funding goes particularly to the elderly and chronically ill, aborigines and indigenous communities, pilot programs in diabetes, asthma, and communicable diseases.  The funding supports the e-health initiatives to facilitate the dissemination of information about medical entitlements. But do pharmacists really have their hearts in this extended role when this $560 m is 30% underspent?

Multidisciplinary primary healthcare clinics

At the Centre for Policy Development in June 2007, we proposed the roll out of about 200 primary healthcare centres across Australia serving an average population of about 100,000 each. Pharmacies would be an important feature of these centres.

These centres could ensure a focus on population health, prevention, keeping people out of hospital, professionals working as a team and focusing on local needs.

These services provide an excellent opportunity to address some of the major problems in our health services. It is difficult to introduce new governance arrangements and modern workforce practices for example, into an old and established system.
It is hard to teach old dogs new tricks. But a new architecture of primary health care centres offers new opportunities for better governance, a more flexible workforce, improved teamwork and more practice substitution. This possibility for real change in health practice through these new centres must be seized.

In these primary healthcare centres, or GP super clinics as the Australian Government calls them, it is important to see them as much more than an opportunity for co-location with doctors and pharmacists for example doing what they already do but being physically closer to each other. There needs to be active professional collaboration for both to be involved as partners in drug prescribing and with the pharmacist ensuring that the GP fully understands the risks of incorrect or over-prescribing which are a major cause of adverse events. But do pharmacists really want to collaborate with other health professionals or remain individual business entrepreneurs?

Unfortunately, the PGA opposes pharmacists working as consultant pharmacists within the GP super clinics. It insists instead that the only pharmacy participation must be via the establishment of a community pharmacy within the clinic. Using the internet, I found that the PGA is resisting any idea of consultant pharmacists in super clinics.

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, is there yet sufficient will amongst pharmacists generally to make the change that is necessary? Is there a clear mind set for pharmacists to be more professional and extend their role?

In an echo of what your former President said 27 years ago and at the PAC Conference in Perth last year, 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.’

In any reform there will need to be an appropriate balance between a business model that provides financial rewards and a professional model that provides professional satisfaction. Where do you want that balance?

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 to you last year.

‘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.’

He went on to add:

‘Professional services … [are] viewed as optional extras by many community pharmacists; services that may be provided if they are not too busy with the core business – supply. Even when a unique opportunity arose for pharmacists in the community setting to be paid a professional fee for services
unrelated to dispensing … the uptake of the service is low and the quality of the service is variable. Why is one of the most valuable professional services a pharmacist can offer, a pharmaceutical care focussed review in collaboration with the patient and their doctor only offered as an add on service in some
pharmacies that chose to participate.’

But change will inevitably come. Based on my discussions and reading the literature, 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?

You may well ask what has discussion of business prospects and protection got to do with extending the role of pharmacists in healthcare. I suggest it is a key issue.
An extended role of pharmacists will be essential, as future business prospects of pharmacists will be significantly influenced by contracting margins and increased competition.

There are several features of pharmacies today which will come 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 an increase of 25% in population and an increase in
    PBS prescriptions of 61%. In 1993, the average number of PBS prescriptions per
    pharmacy was 21,200. Last year it was 34,200. 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. This lack of competition
    may explain why paracetamol can vary in price from $10.95 for 100 Panadol to
    $3.95 for almost the same produce sold under the Chemmart brand. 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 remarkable
    success in obtaining advantageous terms from suppliers. It has shown clearly
    the benefits of a single payer or purchaser, something which the Rudd
    Government seems unable to comprehend with its subsidies to encourage
    multi-payers in private health insurance. Unfortunately, a lot of the advantage
    which the PBAC has secured has been lost in margins to pharmacists. But this is
    changing. Pharmacists may be able in the short term to achieve large markups on
    drugs like simvastatin, but a pincer movement is underway which will put great
    pressure on pharmacists’ margins. Over the next 10 years the patents on over
    100 drugs will expire. The margins available today on a drug such as
    simvastatin, one of the top 10 selling drugs in Australia with 5.5 m prescriptions
    per year, will come under pressure. The previous government and the PGA agreed
    to a mandatory price cut of 25% on medicines and a new system of price
    disclosure to the government by suppliers allowing the PBS price to be reduced
    to match the market in a situation where there is a significant difference
    between the government price and the market price. These arrangements will
    cover every generic drug by January 2011. I note that it is estimated that 75%
    of the bottom line of pharmacists comes from PBS dispensing items.

In an address to the National Press Club in July this year, the President of the PGA put the coming threat this way.

‘By the end of our agreement in 2015 [with the Australian Government] the burden [of these new arrangements] on community pharmacies will be a massive $1.2 b. This means a cost to each and every pharmacy in Australia of $249,000.’

It seems inevitable that the highly protected pharmacy sector is going to face major changes. The 2008 mechanism will eat inexorably into profit margins and the location rule must have a limited life.
The lesson of protection in Australia is that if you want to have a seat at the table when protection is being reduced, you must accept the need to change.

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. What do you want to do?

The Government is keen for greater emphasis on prevention and at the same time is keen to curb increases in health costs. It has announced that to bring government deficits and debt down to acceptable levels in future, it must cap the increase in real government spending to 2% pa. Over the last decade, Australian Government health spending has increased in real terms at 5% pa. In the 10 years to 2006/07, the PBS has increased at 8.4% pa in real terms, although in recent years it has been slower. Government outlays on medicine cannot escape significant change.

Commenting on the failure of pharmacists to respond to a new and more professional model of care based on the patient, the President of the PSA, Warwick Plunkett, said on 29 June 2009 (Financial Review)
that pharmacists were disinterested in innovation.  He added

‘A substantial slab of [the $560 m] (for professional programs and services) has not been spent and it is not clear how effective funded programs have been. There are a lot of things that have been done wrong. At the end of the day, there is going to be $100 m, about 30%, underspent from the current
agreement. It has taken too long to get things up and running. In some cases, they have given away incentives, but there has been no follow through and there are not huge numbers providing the new services.’

Charlie Benrimoj, Professor of Pharmacy Practice at the University of Sydney is quoted in the same Financial Review article as saying

‘What is required is an overall strategic positioning of community pharmacy in primary care that can be reflected in ongoing agreements.’

Professor Andrew Gilbert of the University of SA in an editorial in the Journal of Pharmacy Practice and Research (vol 39, No 1, 2009) also drew attention to the lack of interest in innovation of your two
peak organizations. He said

‘Attempts by some pharmacists to move towards a [patient-focused pharmaceutical care practice model as their primary role] have been stamped on by the PGA and the PSA.’

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.

But if pharmacists are not yet ready for real engagement in prevention, 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 all learn from actions of governments and the pharmaceutical profession in the United Kingdom and in Canada. The Canadian Pharmacists Association has developed over four years through extensive consultations, a new vision for pharmacy in Canada – ‘optimal drug therapy outcomes for Canadians through patient-centred care’. The Association has developed implementation plans and made a commitment to implement.

Last year, the United Kingdom Government released a White Paper which had been developed in cooperation with pharmacists and the community. In endorsing the white paper, the Minister for Public Health in April last year said that in time pharmacies will become ‘healthy living centres‘, offer treatment for minor ailments and in the area of disease-prevention offer more support for people entering on a new course of treatment such as high blood pressure or high cholesterol, offer screening for those at risk of vascular disease and other health service enhancements. In short, the minister was saying that the old dispensing model was inadequate for the future.

It seems clear to me that the increased professionalism and extension, particularly of disease prevention services which the government hopes for and many pharmacists desire, has problems in Australia. The distribution and supply model remains dominant. At the same time, the protected nature of the pharmacy sector will inevitably come under greater challenge and margins will be eroded. Can the PSA help pharmacists catch up the lost ground? How can the disconnect between how pharmacists are
trained and how most of them work, be remedied?

Despite the rhetoric about prevention, are governments, their bureaucracies and the professions ready to implement prevention policies. The answer to me seems to be ‘not yet’. Some hard thinking is required all round.