APRIL,Edition # 23, 2001
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NEIL JOHNSTON
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CONSULTANT
PHARMACY:
"HAVE WE GOT THE RIGHT STRUCTURES
IN PLACE?"
Consultant pharmacists have been slowly increasing in number since the formation of the Australian Association of Consultant Pharmacists (AACP), which has set basic guidelines and standards for this discipline.
We are now seeing the evolution of a clinical pharmacist emerging from within a practice setting that does not depend on the supply function to derive an income.
Some see this as the only future for pharmacy, others are simply not interested, being too busy within their existing environment to allow the time to become involved. Others see a happy mix of both models within the same community environment.
All models of pharmacy will be needed, accepted and interdependent.
The concept of consultant pharmacy has always been part of the pharmacy environment as a value-added extension of the normal supply function.
Pre-NHS times saw a considerable amount of this type of work being undertaken, with many pharmacists taking pride in patient education, diagnosing and prescribing for most minor ailments.
It was not uncommon for a skilled community pharmacist to have up to 80 percent of local prescribing activity, referring on to general practitioners, only after reaching the limits of his/her competence.
To ensure that they were the recipients of these referrals, astute local G.P's used to visit pharmacies regularly, in an informal manner, for an exchange of professional and social views.
Access to basic healthcare for patients was rarely a problem in these times, irrespective of income status. The local pharmacist and the local G.P used to carry people on their books for extended periods (sometimes years), asking people to pay what they could afford, and eventually writing off these debts against tax. It was not uncommon for G.P's and pharmacists to compare notes on the amount of annual debt written off, on the one hand boasting of the actual size of the debt, on the other, welcoming the deduction against a usually large provisional tax bill.
The system was like a micro tax system, with those that could afford their health care paying indirectly for those who could not afford.
The system worked well, and a tremendous amount of professional satisfaction was derived in the process. Patient's took delight in promoting "their pharmacist" to others, extolling his/her virtues as being "better than the doctor", and this aggravated some of the traditional divisions and jealousies, common between doctors and pharmacists, that have persisted to the present day.
With the advent of National Health, a three-pronged process emerged.
Patients initially were able to visit their doctor free of charge, have their medicines dispensed free of charge, and this meant that pharmacists immediately lost a goodly slice of their prescribing practice.
The process was actually encouraged by pharmacists, who saw their bad debts evaporate as they encouraged their poorer patients to embrace the system.
The federal government, for its part, promised faithfully that the Pharmaceutical Benefits Scheme would be limited to life saving drugs, and would never rise to be more than 25 percent of a pharmacist's prescription market.
The early days were a bonanza for all.
Doctors and pharmacists saw more use of their services ( with full margins) and the government gained kudos ( and votes at election time). This was the golden era for pharmacists and doctors, and was the primary cause of the rapid proliferation of community pharmacies.
It was inevitable that as greed took over in all the above sectors, it would become a tussle, with survival only of the fittest. Government saw an opportunity to expand the service ( and its popularity) by making the softest sector of the triad (pharmacy) pay for this expansion.
Thus began the slow, debilitating process that saw pharmacists having to hone their management skills to cope with the myriad of rules and regulations that were to define the Pharmaceutical Benefits Scheme. Pharmacists were also forced to expand their retail activities to compensate for income losses, and many saw this as subsidising public health, even to the extent of accusing the government of civil conscription.
There was a corresponding loss of clinical skills.
Doctors had a stronger political voice within the rules and regulations, which proclaimed the "doctors may", but always, "pharmacists will".
It also paralleled an erosion of the private prescription market held by pharmacists, from 75 percent approximately in 1960, down to four to six percent in current times, as the government deliberately broke its promise to pharmacy.
Some attribute this process as being the major cause of a current lack of practising pharmacists, because the working environment has become too stressful and demanding.
This deliberate process by government has seen the ownership of pharmacy, in real terms, pass from fiercely independent private community pharmacists, into a "back door" socialised system, no matter which flavour of government was in power. Control of professional direction was also manipulated, and pharmacy now finds itself a highly regulated instrument of public health policy with little flexibility for movement in its own right.
The loss of professional direction has cost pharmacy dearly as it has lagged behind the other professions in development. Diminishing "hands on" experiences with patients has meant that nurses have overtaken pharmacists in the Gallup Poll pecking order.
It is also ironic that governments (through the CoAG Review) have found that pharmacy practices are too homogenous and non-competitive, when they have been the defacto owners and generators of the rules, prices and available services, flowing through each pharmacy practice.
Government has reached the right conclusion, but has criticised pharmacists unfairly for a process that was totally government driven.
Now the system
has to be reengineered, because the total cost to government has become
a difficult budget item, as constituents regard subsidised health as a
natural right.
It has also left pharmacists as an underutilised, but highly educated
resource, that is only now becoming understood by government. The medically
dominated structures created by governments within the public health systems
are now seen to be out of balance and unnecessarily high in cost.
This belated recognition of pharmacists by government has seen some very
unusual public appointments.
The chairman of the recently reconstructed Pharmaceutical Benefits Advisory
Committee (PBAC) is now a pharmacist, and this is a highly significant
appointment. It is probably the reason for official pharmacy not opposing
the appointment of Mr Pat Clear, a manufacturer representative, on the
same committee.
Another recent appointment by the Federal Minister for Health, Dr Wooldridge,
has been that of Canberra-based Kate Carnell, Liberal politician and pharmacist,
to a board involved with doctor education and training, a move bitterly
contested by the Australian Medical Association (AMA).
Dr Wooldridge has publicly proclaimed the Pharmacy Guild as being the
most professional of any of the health organisations he has to deal with,
and it is obvious that the profile of pharmacy has increased as a result.
Whether the above movements are based on official pharmacy skills and
professionalism, or whether as a component of political expedience, only
time will tell.
Whatever the reason, the doors have opened for an expansion of pharmacy
structures, significantly corporate community pharmacy. These new structures
will be larger, fewer in number and will merge with other health professions
to form medical centres.
It is from this base that a permanent home will be found to nurture consultant
pharmacy, preferably through independent practices, subleasing space in
the corporate environment.
It is hoped that the models that emerge will not be like the current public
company medical centres, which have already shown to be promoting unprofessional
practices and over-utilising services, to the extent that they are seriously
affecting the Medicare budget.
One question
that has to be asked...
Have we got the structure of consultant pharmacy right?
The official organisation for consultant pharmacists is the Australian
Association of Consultant Pharmacists (AACP), a tightly controlled company
structure with two management voting shares, held by the Pharmacy Guild
and the Pharmaceutical Society respectively.
Each organisation appoints a number of delegates to the board of the company,
and it is this group that develops standards and opportunities for consultant
pharmacists.
To this point, the organisation has performed well, creating practice
guidelines, professional development, and identifying a range of clinical
activities which are reimbursed by government.
But it does need a boost.
It is time to open the company up to member shareholders so that they
can begin to plot their own destiny. Certainly, leave Guild and Society
representatives (one from each organisation) as permanent appointments
to the board, but let the members elect those people to represent them
who give best value.
And while we are about it, why not offer shareholdings to accredited hospital
pharmacists who would surely bring a valuable talent resource to the organisation.
There is a need to open and expand the points of view within the AACP
in a more creative and dynamic fashion, particularly in the area of non
government subsidised activities.
As was pointed out at the commencement of this article, consultant pharmacy
was flourishing in a private capacity well before the advent of the National
Health Scheme.
Here then, is an opportunity to think "out of the square".
There is also a need for regional groupings to provide a network of support
and share experiences. Perhaps this is the greatest need, because regional
groups can best configure educational requirements and delivery systems
for their own particular areas, and can configure liaison services between
public and private hospitals, also nursing homes, where appropriate.
One size does not fit all, and the achievements of regional groups, shared
nationally, will provide a continual input, generating the growth spurt
required.
It is my prediction that regional groups, promoting within their areas
of influence, could provide the stimulus for future pharmacy recruits,
as their profiles increase.
The mix and balance of government subsidised services and privately developed
services will provide enthusiasm,
increased morale and maybe, just maybe, a return to some of that fierce
independence and pride that this writer experienced at the commencement
of his career.
It would be great if this could really be our legacy to future pharmacists,
having lost our way in the recent past. The process appears to be under
way, but needs an injection to promote a bit more vigour.
In the article following this, an explanation of the new British system
is investigated.
The Brits are making great progress in the professional area, and while
some of our directions appear similar, they may be doing it better, faster,
more professionally and with better rational government support.
Read and compare
ends
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comments and views expressed in the above article are those of the author
and no other. The author welcomes any comment and interaction that may
result from this and future articles.
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