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THE pharmacy profession has been stuck at a “crossroads” since it began moving from compounding of recipes prescribed by doctors in the 1950s to selecting a manufactured product from the dispensary shelves.
Was the move to manufactured products the turning point for the profession to be recognised as pharmacotherapy advisers?
Or was the viability of a retail shop more important, requiring intensive efforts against supermarkets encroaching on the market for cosmetics, toiletries and personal hygiene products that were traditionally bought from the local chemist shop?
The role of pharmacists and their place in primary health care has been on the agenda at pharmacy conferences for the past 40 years — and still has not been resolved.
The profession reached the crossroads without knowing which way to go — professional or retail.
This remains unresolved, with the profession unable to separate sectional interests intent on making money (mainly the owners of pharmacy businesses, all of whom are pharmacists) from the clinical role in primary health care (always on the minds of young graduates).
The money-makers are well in front and little has been seen of the “clinical practice model” predicted in 1978 at the Pharmacy Guild’s 50th anniversary conference.
This is not in the best interests of health consumers.
Millions of dollars are spent each year on the education of pharmacy undergraduates who are then relegated to the role of shop assistant without the opportunity to put their hard-earned skills and knowledge into practice.
The PBS bill of $9 billion a year — and rising — includes about $2.5 billion going to approximately 5000 agents across the country.
Surely this makes the PBS a small business support mechanism.
Does Australia really need 5000 businesses owned by pharmacists to act as agents for the PBS?
Are there areas, especially in the cities, where pharmacy businesses are simply vying with each other for the PBS business?
The PBS is propping up pharmacies which would otherwise be ailing retail outlets.
There is no audit or contractual obligation on the part of the pharmacy businesses to provide the value-added services expected of them by the federal government and the taxpayer.
A tender process would pin this down and allow for an appropriate number of agents prepared to add value to be selected.
At a time when the future direction of health funding is undergoing change, it is appropriate to review the role of the pharmacist and resolve, once and for all, the vexed question as to when the crossroads lights should turn green and where the open road should lead — to the clinical consultant in pharmacotherapy or the shopkeeper.
It is more than 20 years since a comprehensive review of the PBS remuneration structure was conducted by the Pharmaceutical Benefits Remuneration Tribunal.
In that time health care delivery has fundamentally changed, with a concentration of effort towards multidisciplinary teams within super clinics.
Is there a place in that team for a pharmacist?
The case for pharmacists to play a recognised role in primary health care could be influenced by what other health practitioners — especially doctors — think.
Surveys show pharmacists are trusted by the public, but how do other health practitioners see them?
You can give your opinion on the future role of pharmacists in a survey I am conducting. Results of the survey will be published in MJA InSight.
Rollo Manning is a pharmacist and public relations consultant with 50 years’ experience in the pharmaceutical sector.
Posted 15 November 2010
The comment re GPs being propped up by the public funding system just as much as community pharmcies is spot-on. Here in Tassie a group of GP practices has been running a series of TV adverts for a while now highlighting how they offer same-day appointments for patients who need them, referring specifically to hay fever, sore throats, sun burn and insect bites! Most patients with these problems do not need to see a doctor, such advertising only medicalises what are invariably minor ailments, deters self care, and costs the taxpayer dearly. The health-system needs to use the skill mix available to it more efficiently and in a collaborative way to benefit the public, rather than continue to be a cash-cow self-serving certain professionals, be they doctors or pharmacists.
Thanks for the article Rollo. As a hospital doctor I very much appreciated the input from my hospital pharmacist on a daily basis. I miss that in general practice where we have only occasional input from a distant pharmacist – usually that we have forgotten to sign a script! By all means move pharmacists into big clinics – so they can be part of the team. I would love to be able to have the pharmacist advise the patient about their medications – I am sure they would be more likely to take them, and I do not have the time.
Why are homeopathic “remedies” and ear candles sold in pharmacies (along with lollies and handbags)? Are pharmacists unaware that these things are not therapeutic, in which case their professional competence is questioned, or are pharmacists unconcerned that they take patients’ money for a product they know has no effect beyond placebo, or are in fact dangerous in the case of ear-candling? In which case their very professionalism is at stake. How can patients trust a pharmacist to advise them correctly on real medicines when they willingly sell them fake medicines? It’s a simple question pharmacists.
Ohh… I am so pleased to read some of the doctors’ comments in here. These positive responses restore my belief in the health system that I work in.
No health system is perfect. Rollo may have a good reason to theoretically question the need for pharmacists in this day and age.
I have asked myself this question many times until I discovered that the answer is there everyday I go to work at a retail pharmacy.
I have been working for an owner pharmacist who specialises in opening pharmacies in small rural towns. As soon as we open, we get praise and thanks for opening. On a daily basis people come in with questions such as: What is the best medicine for this condition? Are these medicines OK with these? What herbal supplements work? What doesn’t? What is a waste of money?
Who will answer these questions with no pharmacists?
The supermarket manager? Surely the doctor can – but do they have the time?
Yes, this pharmacist is motivated by commercial ventures but this is his/her specialty: providing pharmaceutical services to the public and who is a better specialist in his field to do that than a pharmacist?
As some doctors mentioned in their comments, not all pharmacists are good or bad but it is the same in every other profession.
What people fail to remember is pharmacist-owned pharmacies makes the owner personally accountable for any errors. They therefore are legally liable for any danger inflicted knowingly or unknowingly upon the public.
To simply state that the PBS is nothing but a supportive mechanism to small businesses is not a well thought through and balanced view.
Patients I deal with are often prone to getting adverse reactions to excipients or to standard doses of specific medications, and I welcome the recent trend for pharmacists to do their own ‘compounding’. Congratulations to them for being part of the broader trend towards ‘personalised medicine’. I just wish so many of them didn’t have a blind spot for all the non-evidence-based megavitamins they have on their shelves. How many of them have the integrity to advise their clients not to waste their money on this stuff?
I recently received a lovely little card and some chocolates from two doctors we had on rotation at my hospital. It said “Dear Pharmacy, Thank you for help & support during our time here. Your advice has been invaluable and has saved lives!”. Thanks also to the other doctors who have expressed their appreciation of us here.
I see from both sides of the fence. I have seen compassion and caring of GPs and concern and dedication of pharmacists working in my centres. We need one another to provide quality primary care for patients. At times, pharmacists need to be more aware of their place and take more care with what they say to patients, and GPs need to use the knowledge and skills of the pharmacist more frequently.
I have witnessed a GP refuse to take a patient suffering from severe chest pain into his room for the consult because he was told that the patient didn’t have a Medicare card (and therefore would not have been paid). I have heard of pharmacists as they close a shop for the day refusing to serve young mothers in their endeavour to go home while the mother begged for Panadol for her feverish child. Neither of these people are employed by me any longer. Both professions can do a lot better.
I am a doctor and I really value services provided by pharmacists, be they hospital-based or community. Many a time have I prescribed wrongly or missed a drug interaction. I simply don’t have time to check the 20 drugs everyone seems to be on at the same time, ensure compliance, etc. Having a pharmacist to check my work is very valuable.
As a consultant pharmacist there is opportunity to have case conferences with GPs or have GPs fax back reports stating they are prepared to make changes to medications based on my recommendations. For those that take time to case conference they often express their gratitude, stating they have learnt something from the times spent discussing medications. There are great opportunities out there to be a “drug specialist” and make a difference to the quality of life of patients and to optimise the dollars spent on medications. Suggest avoid getting bogged down in retailing, Coles and Woollies do that quiet well.
Hospital pharmacists saved my bacon many times when I was a resident. I remember working ridiculous hours and never really being able to make sure my patient’s were on the right drugs and making sure the patient recieved their discharge drugs appropriately. They never rubbed my mistakes in my face and were consistently a pleasure to deal with, something that I cannot say for many allied health professionals. As a group they had the best work ethic amongst the allied health professions.
Not sure that doctors should be judging pharmacists for being commercially orientated. Most doctors also work in private practice and from what I’ve seen there seems to be plenty of doctors who are willing to subject patients to all sorts of procedures as long as they can perform the procedure themselves, particularly when the kid’s school fees are due. Many academic papers have shown that when doctors are given the ability to self refer it is quickly abused.
I am fairly certain that most doctors/GPs are working in businesses that are being propped up by the MBS as much as community pharmacies are being propped up by the PBS – the obvious does need stating every now and then – and the question “do we really need doctors ?” is already being asked as nurse practitioners gain PBS prescribing rights and optometrists already have them. . . go do med if you don’t like pharmacy!
It really saddens me to read these comments – and indeed the opinion article of Rollo Manning.
Let’s remember something – pharmacists, unlike any other health profession, are funded only from dispensing fees and merchandise in the shop. Anyone can come into a pharmacy at any time and request to speak with a pharmacist – without an appointment and without a payment. We don’t expect that from a GP, dentist, physio, etc – yet we expect pharmacists to spend time giving quality evidence-based, non-biased recommendations to anyone and everyone. And yes, I agree, it should be evidence-based, and include non-pharmacological options as well, but it’s unlikely to happen until we are remunerated in some way for these consults – not every interaction, but the complicated ones.
I am a hospital pharmacist, so I am more aware of the evidence in the hospital sector, showing how valuable these pharmacists are to the the healthcare team. A study published in 2004 showed that, based on the economical impact from the interventions made by a ward pharmacist, we earned our daily wage in about 42 minutes of our 8-hour day (Br J Clin Pharmacol. 2004 Apr;57(4):513-21).
There are an awful lot of fantastic, dedicated and knowlegable pharmacists out there, who would love to be involved in a super-clinic situation, be part of that healthcare team, and share our pharmacological expertise! Why don’t we do some qualitative and quantitative pilot research to see how beneficial that could be?
I see myself as someone that has better knowledge of drugs and formulations than doctors, and someone that supposedly has more time to investigate these issues than a doctor. We’re also an important second check that dispensing doctors cannot provide. Whilst these mistakes may only occur once or twice per week – I would hate it to be you or one of your relatives that is the receiver of that mistake. Doctors can also neglect to think of very simple practical things – just recently a doctor provided a prescription for 4mg tablets of a potent hormone and told the patient to take 7mg twice daily. It took a lot of arguing with the doctor to get her to provide a prescription for 0.5mg tablets as well – but I was happy to be persistent because it created a safer and easier outcome for the patient.
I don’t dispute that there are money-hungry pharmacists out there who have little regard for improving the health of their customers. As an employee pharmacist I also hate these people. I had a pharmacy student complain to me once that the hourly rate had decreased substantially since he started his pharmacy degree. This made me mad because we want people to enter pharmacy and be caring about their work – not to enter pharmacy because it’s a good way to get rich.
Unlike many pharmacists I believe that supermarkets could provide pharmacy services just as well as independent pharmacies – so long as there was a separate pharmacy section supervised by a pharmacist – similar to the segregation of supermarket liquor stores. I worked in the UK for a while where supermarkets have pharmacies – and found working for a money-hungry multi-national was the same as working for a money-hungry pharmacist. In fact, working for a supermarket was probably better because my customers paid less for their OTC items and there were many more employee benefits to being part of a large chain.
I believe that pharmacists are an anachronism of a past era, when real apothecaries existed and the real pharmacist made his own remedies. Now he is a retailer like any other. If Kmart is allowed to sell aspirin, why can’t a real doctor sell his own remedies. After all, they are prepared and prepackaged. The reason the public lovvvve pharmacists is because they have the time to be nice, they give “free medical” advice and have time to sound plausable after the poor ol’ GP has just done his after hours home calls, done his hospital rounds, and now faces a busy day at the coal face. The GP is barely surviving, whereas the pharmacist retails cosmetics, etc, has assistants do his work. Let’s level the playing field. If the pharmacist wants to be a doctor, let doctors dispense their own drugs.
Pharmacists are paid a dispensing fee to provide advice and a CMI [Consumer Medicine Information] to the patient. This is very rarely provided and, even when it is, a shop counter with no privacy is no place for providing disease state counselling. Cut out the middle man, let doctors do the dispensing and supermarkets sell the rest of the rubbish pharmacists deal in and cut an enormous cost to the taxpayer entirely out of the system.
In my consulting psychiatric practice I have had a lot of patients complain to me in recent years about the intrusiveness of many pharmacists who attempt to get the patients to give their psychiatric history to them in a public place (a retail pharmacy) and then sometimes give alarmist and incorrect advice when they know virtually nothing about the complexity of the patient, and are not being asked for their advice about psychiatry. it has become a real problem.
These are relevant comments. However, having just returned from the annual conference of the Society of Hospital Pharmacists of Australia in Melbourne with over 1000 delegates, the issues raised by Mr Manning do not reflect the plethora of clinical activities undertaken by pharmacists not working in the retail or community setting. The term pharmacist, like doctor, clearly needs to be clarified to the area of practice being discussed.
I think there should be a survey on the commonest diseases in ranking order that are non-hospital managed or based and the cost of medicines to the PBS used to treat these diseases. The diseases should then be separated and those that are lifestyle related or caused be identified and subject to a discussion at high levels on whether treatments should involve lifestyle changes and money targeted towards that management with regular evaluation of outcomes. There may be huge savings to be obtained I suspect and a much better outcome as well. Government-funded studies should be carried out to compare, properly funded lifestyle change treatments against drug treatments.
Both doctors and pharmacists could reinforce these treatments as a more valuable cost-benefit ratio than current treatments.
I fail to see why the public trusts pharmacists! They sold out their professional integrity years ago. They are nothing but businessmen and women with the bottom line overriding their concern for the public’s health. Why else would they be selling homeopathic products and other sham-ful and shameful nonsense with no evidence for efficacy? It’s time that pharmacists with integrity go back to being experts in proven medical treatments. As it is they present as dodgy witchcraft peddlers!
I think the way community pharmacy is remunerated is the main barrier to the lack of engagement and added services that pharmacists could be providing. There is no monetary value placed upon these added servcies therefore many owners actively encourge employee pharmacists not to bother. If pharmacy wants to show they are truly about patient care something other than dispensing fee-for-service needs to be negotiated