THE proposal for a pharmacy-based Minor Ailments Scheme (MAS) should be seen for what it is — a push by the pharmaceutical industry and pharmacy business to increase drug sales under the guise of health innovation.
The government is correct to insist on a formal trial to investigate the feasibility of a pharmacy-based MAS, but should go further and investigate the industry to determine whether further regulatory measures are needed to protect patients. Unless integrity within the pharmacy industry is improved, MAS programs will simply become another mechanism to increase drug use in the community.
Touted as a cheaper solution to managing minor presentations in general practice, MAS programs have been developed and promoted in the UK and Canada. Despite availability for years, there is a paucity of high-quality evidence supporting or evaluating MAS programs.
A recent systematic review has shown that the quality of reporting in MAS evaluations is often poor, and the assessment of bias is often difficult. The authors concluded that there was some positive evidence for MAS programs, but that results needed to be interpreted with caution and may be unique to the UK system. Ominously, the broader issue of drug utilisation was not considered in any of the evaluations; for example, deregulating the use of the antibiotic chloramphenicol in the UK led to a 48% increase in its use through substantial prescribing by pharmacists.
Despite this, Australian pharmacy groups and drug company organisations have been advocating for an MAS in Australia. Submissions to the federal government and Victorian Government have led to commencement of MAS trials in Australia.
Publicly, the justification for an MAS is that it reduces pressure on GPs, provides GPs with time to care for patients with more serious illnesses and is a more efficient way to manage minor ailments. This is despite evidence that access to GPs is not a problem, and a lack of evidence on effectiveness of current advice and treatments given to patients by pharmacists.
Privately, within the industry, the arguments are quite different. Competition and perceived income loss from Pharmaceutical Benefits Scheme (PBS) changes has prompted a renewed focus on broadening pharmacy income streams. Despite the 6th Community Pharmacy Agreement providing an extra $3.2 billion to deliver PBS medications, the pharmacy sector is looking to broaden revenue streams through the provision of clinical services and increasing sales of S3 medications (pharmacist only) and S2 medications (over the counter [OTC]).
Profit from drug sales is the common goal of pharmacy groups and the pharmaceutical industry. Pharmaceutical companies and pharmacy banner groups are becoming increasingly involved in providing pharmacy-based services. The relationships between these groups in Australia are not well known, and certainly not well studied. The so-called “Coke and fries” arrangement between the Pharmacy Guild and Blackmores to coprescribe complementary medicines with routine medical prescriptions is a good example of agreements that arguably put profit before consumer benefit.
Drug companies are now delivering a wide range of clinical services in pharmacies. For example, Apotex uses nurses and nurse practitioners and advertises delivery of health services in more than 800 Australian pharmacies. Sigma Pharmaceuticals and Probiotec have different arrangements. These collaborative arrangements in the pharmacy sector have developed without critical oversight and examination. There is doubt that consumers would know of the implications of services delivered by drug companies.
The Australian Self Medication Industry (ASMI), a multiple drug company-based organisation, has acted with the Pharmacy Guild to change restrictions to access and advertising of S3 (pharmacist only) medications (pages 3 and 6) to promote S3 drug sales. ASMI believes increasing consumer self-care is a key driver of pharmacy growth. A different perspective would suggest a profit motive from sales of OTC medication.
Some pharmacists are following the Guild’s transformation scheme in broadening revenue streams by involvement in educational courses to boost profits by sales of S2 and S3 drugs. Training includes the promotion of sales tactics via “pick-up lines” to engage consumers in minor ailment consultations. Concerningly, this has also been associated with sales of pseudoephedrine, yet there has been no ethical challenge to this practice from within pharmacy groups. It appears sales tactics are being normalised as professional behaviour.
Technological tools to augment drug sales have also been developed and implemented. The Pharmacy Guild software “GuildSmart” actively promotes boosting profits from medication sales as a key function. It alerts pharmacists in real time to sales opportunities with OTC drugs, companion drugs (that’s Coke-and-fries again) and generic medication. It is only a small technological step to automate drug protocols to address minor ailments and further enhance profits for pharmacies.
Business arrangements and clinical practices that promote drug sales have flourished in the community pharmacy sector in the absence of regulatory oversight or clinical evaluation. Marketing and sales practices promoting drug sales are now common. OTC drug sales are big business in Australia, but OTC medicine misuse is also a problem well known in the literature.
From a patient safety perspective, this is a worrying trend, and arguably it is not an environ in which an MAS should be implemented. If an MAS is to be implemented, the government should also undertake a comprehensive review of drug company influence and business activity in the pharmacy sector, as well as examining the marketing practices within pharmacies that inappropriately promote sales of drugs and products rather than benefiting consumers.
At the very least, there should be regulatory change to provide transparency regarding arrangements between pharmacies and the pharmaceutical sector. There are transparency rules regarding relationships between the medical profession and pharmaceutical companies, so similar standards should apply to pharmacy.
In a period of health reform, innovations should be accepted only if they lead to global benefits in patient and population health. Unless there is integrity within the pharmacy sector, MAS programs will become just another mechanism for industry to increase drug use in the community.
Dr Evan Ackermann is a GP at the University Medical Centre, Southern Cross University, Gold Coast, Queensland, and the chair of the Royal Australian College of General Practitioners National Standing Committee – Quality Care.