MAY,Edition # 26, 2001

 

I was unpacking some papers from a box that had been stored in a lost and forgotten corner, the result of a move from a previous location.
One item caught my eye, which used to hang on my office wall.
It is about 20 years old, the author is anonymous, but it is still as fresh as the first day I came across it.
I recently restored it to my office wall, and would like to share it with newsletter subscribers.
It is entitled "Start Something".

	Throughout history most great civilisations that have declined were victims of stagnation rather than conquest. Apathy, indifference, detachment led to decay. In every country today we find more people who prefer the role of spectator rather than participant. Whenever a problem arises, the spectator asks, "Why don't they do something?"
Start Something!		They can't help the police to maintain law and order. You can! They are not responsible
	for the conditions of your schools. You are! They can't give your community good government. You can! Every civic group, every business, every sports club, every good tradition, every worthwhile institution began with a need, a vision turned into reality by someone alive, responsible and innovative. To the people who sit back and ask, "Why don't they do something?" we ask, "Why don't you?"

I have always endeavored to think "out of the square", to be creative and innovative.
Hence the reason for this newsletter, which provides a forum for pharmacists who would like to express an opinion, or share an idea.
It has also been a concern professionally, that pharmacy has not had a universal vision behind which to unify.
Certainly, there are a collection of ideas, motherhood statements and the like, that are scattered in various corners of pharmacy, but nothing with true cohesiveness.
There is a general movement towards consultant pharmacy, forward pharmacy and an effort to lift standards through concepts such as Quality Care.
However, pharmacists are becoming a little dispirited, because when they penetrate the "gloss" surrounding these concepts, the substance is minimal.
The authors writing for this newsletter are expressing these thoughts in their own style, and presenting their strategies and solutions. They are developing a common thread, which is reinforced and stimulated when subscribers, such as Ken Stafford, submit critical comments (see Letters to the Editor).
This is good and helps to expand the common debate.
Most pharmacists would agree that the way ahead is to sell a professional service that is proactive, and does not chain you to a reactive process, such as dispensing.
Rollo Manning makes this point in his article in this edition, and Roy Stevenson discusses the same problem he faced as a community pharmacy proprietor.
In Roy's case, he had to abandon his pharmacy, because the processes and ideas he was following, were leading him into an ever tangled web.
There were good parts, but they were overwhelmed by negative forces.
There are some very good ideas kicking around, and they are professionally rewarding.The problem is getting the time to think, the space to develop, the trained human resources to help you to implement, and a financial reward to live on.
The money to pay for these activities has to arise from dispensing, at the micro level within each pharmacy, or at the macro level through NHS payment manipulations, which are set aside for professional services.
No matter which way you look at it, there is a requirement for more dispensing to fund value-added clinical extensions.
So if the basis of funding for clinical services requires an ever expanding base of prescription dispensing, who is going to do the increased work of dispenser?
The pharmacist?

Rollo Manning says that pharmacy assistants should be upskilled with courses designed to give them qualifications, and the necessary competence to carry out the work of dispensing.
Most pharmacists I have spoken to recoil at this concept, but when they are challenged as to why they think this could or should not happen, they are unable to satisfactorily respond.
The real reason is that if you take away dispensing from a pharmacist, you take away the bulk of his/her income, and survival mechanisms kick in instinctively.
The reality is that if well structured courses were offered to people interested in becoming pharmacy technicians/dispensers, it could provide the boost that pharmacy is looking for.
It would certainly provide opportunity for local employment, particularly in rural areas. It would also provide the labour necessary for what has become, to a pharmacist, a menial and repetitive job.
Most importantly, it would give freedom to a pharmacist, who could leave the four walls of a community practice at will. He/she may even be able to develop a standalone clinical practice, demonstrating inventiveness and innovation.
Consultant or clinical services could then coexist with dispensing, because they are freed from the dispensary shackles.
Pharmacy assistants might also provide another source of pharmacist supply.
Modular courses designed so that each component could be credited towards an eventual degree course, if undertaken, might provide a better quality pharmacist. This "apprenticeship" approach would not only give a good grounding, plus a career path, but would also deliver a person with the "common touch" i.e. less professionally remote. Having a career path may also make it more attractive for males.

When the Galbally Report was first published, the issue of the orderly and sensible marketing of drugs was suddenly put at risk. The report imposed upon pharmacists the responsibility of providing proof that the information and value-added counseling available from a pharmacy environment was actually being done, and benefits were being provided for those patients/customers who were paying a premium for S2 and S3 medications.
It was immediately obvious to this writer that if the obligations stated in the report were to be imposed on a pharmacist, it would become physically impossible to develop a separate stream of clinical activity, such as consultant pharmacy.
The value analysis of Galbally was that if a patient/customer was not getting the full service, then they should not be obliged to pay the premium imposed through a higher margin. Other outlets e.g. supermarkets, should then be employed to deliver these products, and provide the necessary downward pressure on price, for consumer benefit.
This has left pharmacy the problem of having to justify and quantify the value-added benefits that are provided. The problem is how do you quantify a service that may need to be provided on the first sale of an S2 or S3 products, but which may diminish in scale as consumption increases?
One way to demonstrate this would be to delegate S2 and S3 sales completely to pharmacy assistants, who are competently trained and legally recognised, within the Poison's Act and Pharmacy Act, to provide this service outside of pharmacist direct personal supervision (i.e. only indirect pharmacist supervision required).
The pharmacist would still oversee internal policies for handling and selling of medications, and provide or develop approved forms of information, that could be suitably detailed to patients/customers by qualified assistants.

As manufacturers develop product managers to market and manage individual products, so should pharmacy focus on product categories (S2 and S3) that can be treated in a similar fashion. The technique is already employed in the wider retail sense (so called "killer" categories)
Education for an assistant could then develop in the form of an initial S2 certificate, progressing to an S3 advanced certificate and then on to a diploma for handling S4 and dispensing processes. The pharmacy technician diploma could then be credited towards a pharmacy degree course, if further progression is envisaged.

Ownership of pharmacies must always remain under the control of pharmacists in the development of this model. As future pharmacies will tend to be corporate in structure, provision should also be made in the various Pharmacy Acts to allow for qualified pharmacy assistants/technicians to be able to take up employee shares.
It is better to plan the model now, rather than have to change legislation later.
The benefits would be obvious

If the above processes were allowed to evolve, a pharmacist could take steps to increase his dispensing load and develop cost structures commensurate with the work to be completed (pharmacy technicians would be cheaper than pharmacists).
This would take the pharmacist out of his/her comfort zone, and would force a period of creative thought and rapid development into clinical services, stimulated by the urgent need to develop an income.
Using the cash flow generated by dispensing to fund clinical service development, a new pharmacy vision can begin to unfold.
Given the fact that there are many alternate practitioners providing an unsubsidised service to the community, and at an expanding rate, there is no doubt in my mind that pharmacy would be able to succeed in a similar venture.
There is a marketing need to differentiate the product that is currently on offer ( a counseling service with no fee charged) so that a fee could be charged for a service deemed valuable by a patient/customer
Don't look to the government to fund new clinical services.
Such services will always be bound to the existing NHS system, and payment will always be made by robbing one component of the NHS budget to pay for another.
Use government funded services to pay for the development of new private services.
The above model envisages that a pharmacy will be able to conduct its dispensing business without the need for a pharmacist to be present every part of the day, or even every day of the week.
Just to be there to provide clinical services, to be able to attend professional seminars and conferences (without importing locums to dispense), and to be able to meet formally or informally, with other professionals during the working day, would provide a professionally stimulating work environment.
Freedom from the shackles of having to "be there", has definite appeal.
Think "out of the square" and "Start Something"!

With the high cost of drugs, NHS will be under continuing pressures.
An ageing population exacerbates the problem.
The key is to develop models of preventive medicine and health promotion, which will delay or prevent many of the lifestyle conditions that progress to a defined illness.
As pharmacy is only concentrating its official clinical efforts around illness, it needs to refocus to include prevention.
Some years ago, Australian dentists did this most effectively promoting the use of fluoride and preventive maintenance. This was a good model for dentists, and they do not rely on a National Health System for payment of service.

As I started this article with the title "Where is the Vision?", I finish on the same note.
Creative thinkers and positive leadership need to be allowed to flourish.
This means abandoning many of the current and traditional work practices and structures, before it is possible to move forward.
We cannot absorb the good ideas without a major re-engineering process.
Let us get the basics right.
Put them in place.
Then give the space, time and nurturement to allow for growth.
But first, prepare the vision statement.
ends

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