A Former Community Pharmacist Now a Practice Pharmacist- We Have a Q & A With Him

Clinical service pharmacists basically find themselves as a “divided bunch” and have an unclear vision for the future.
Certainly they have been derailed by having their voice taken from them by the PGA/PSA controlled Australian Association of Consultant Pharmacy (AACP), which incidentally, had its named changed from the original which had “pharmacist” in the title.
As the PGA and the PSA hold 100 percent of the voting shares in that organisation, clinical pharmacists have been “derailed” from the moment that they looked like being able to earn income outside of a pharmacy environment.

I guess that more in frustration clinical pharmacists now see opportunity in GP environments, and limited opportunity through community pharmacy.
Yet it is in the latter environment that community pharmacy stands to benefit most with an environment embracing clinical services, building new clinical initiatives that could reinvent community pharmacy by expanding its central “core” and provide benefit to all – patients, pharmacy owners and clinical pharmacists.

I know of one clinical pharmacist who has embraced the GP practice environment so I decided to ask some basic questions from his perspective.
The pharmacist’s identity has been masked so that he is able to speak freely.

The following is a summary of our Q & A session:

Q. Although you are now successfully working from a GP clinical practice space, do you intend to try and link back to a community pharmacy that has a range of clinical activities and facilitate extended collaboration between the GP practice and the community pharmacy?

A. No I am not looking for clinical space in or a formal linkage with a community pharmacy, and there are several reasons for this.
The community pharmacy is physically and philosophically independent from the other health care providers in primary care.
Clinically focused pharmacists need to establish a therapeutic collegiality with the other health care providers and this would be extremely difficult to do from within a community pharmacy environment.

Q. Given that community pharmacy has always been involved with primary health care why would a linkage be so difficult?

A. The clinical pharmacy roles in primary care are new and both trust and respect need to be built between different practitioners before roles can be established.
This incidentally takes time.

Why is time such an issue when community pharmacy has always been involved in primary health care?

A. Pharmacists working clinically in primary care now need new skills and knowledge, a point not necessarily appreciated by pharmacists generally.

Q. The identified clinical streams for pharmacists to be involved with are hospital pharmacy, HMR activity practiced from various settings (including community pharmacy), and a GP practice setting.
Shouldn’t these streams be expanded and supported by all pharmacy organisations?

A. There is also more than a little hesitancy within the profession to recognise different practice models with a belief that all pharmacists are capable of working in any area of practice without up-skilling.

What are the impediments to up-skilling?

A. Virtually all funding for pharmacist provided services is currently via a community pharmacy.
We desperately need new funding streams for all new specialised roles.

Q. Government tends to want to negotiate with a single organisation in respect of all pharmacy grants for perceived efficiency and control.
That organisation is the PGA and it has found itself on many occasions to be in a conflict of interest – it can only see clinical services being provided through a pharmacy often owned by pharmacists not skilled in the delivery of such services.

A. Speaking of funding being associated with a community pharmacy only invites a clipping of the ticket, and thus reduces the value of the clinical service provided.

Q. Do you think that there is a future with a pharmacy model following a strong PBS core focus as has evolved over the last 20 years?

A. It will not be too long before dispensing will be a robotically controlled process and along with changes to the ownership regulations, the community pharmacy environment is going to be even more aligned with supply and distribution.

Q. What then is your view of the future for community pharmacy?

A. I am extremely sympathetic towards those individual pharmacist owners who try extremely hard to align themselves with the medical profession as per your example of the US community pharmacist who is attempting to be uniquely clinical.(see Clinical Pharmacy-a US Working Model)
Having owned a dispensary only pharmacy next to 75% of a small town’s doctors, I am only too well aware of the need to inter-relate  and work closely with them.
Having moved on to develop clinical roles for pharmacists – initially I tried to provide these from within the community pharmacy environment – I soon realised that:

a) community pharmacy couldn’t or wouldn’t (I’m really not sure which) embrace the medication management roles, and
b) when they were successful they realised that they really didn’t know their patients as they thought they did and
c) their ‘collegiality’ with their local GPs hadn’t really been collegial, but as friends.

The only success pharmacists have had developing these roles is within the general practice environment.
It is an international thing, and while I have researched all the barriers that a community pharmacy needs to overcome, none of them are of themselves insurmountable.
I guess in a community pharmacy environment the time pressures are so great, the salaries for employee pharmacists so low, that to pay a skilled clinician $75.00 an hour to research a problem for a patient and then spend time with that patient and the patient’s other health care providers, is not considered cost effective.
The benefits of the pharmacists’ care accrue to the funders, not the community pharmacy, and additionally the community pharmacy doesn’t appear to have the health status of the individual patient as a priority, while the value of the product supplied does.

Q. What perspective adjustment is required by community pharmacy to be able to bridge the gap in professionally providing clinical services?

A. Clinical pharmacy services are totally patient focused, and because of this, there are inherent conflicts of interest between the activities of primary care based clinical pharmacists and community pharmacies.
For example I frequently tell my patients to throw their copious quantities of multivitamins away as there is virtually no evidence supporting their use.
This attitude is not viewed magnanimously by my community pharmacy colleagues.

Q. Given your sympathy with community pharmacy and its perceived inability to provide quality clinical services, can you point to activities of a professional nature that may prove to be a better direction to follow?

A. There are many opportunities for community pharmacy to embrace, without trying to climb to the top of the skills mountain in one easy step.
Vaccinations are now working well, and screening for hypertension, blood sugars etc, (which have been around a long time), have never been fully embraced by community pharmacy, and this is probably because there has never been a system developed to move on to the care platform for the people identified.
There are huge opportunities for community pharmacy to move into a funded prescribing role for minor ailments but no-one it seems is wishing to go there as yet.
Perhaps, because it is seen as a costly exercise by owners who try to maintain their profitability.
I know numerous community pharmacists who are more than a little piqued at finding their remuneration doesn’t automatically increase along with greater levels of responsibility and skill.
Maybe this is where the problem lies??

Q. You continually refer to a need for pharmacists to up-skill. With all the new pharmacy schools competing with each other, is the skill deficiency found in the quality of the education or the infrastructure through which it is delivered?

A. I have always worried about the disconnect between the university provided education, and the role the community pharmacists perform.
From all my discussions with educators, they have no idea what the role of the qualified pharmacist will actually be.
It seems to me that they are only interested in bums on seats.
The profession needs to address this.

Q. Can you summarise briefly the message that you hope will assist all pharmacists, particularly community pharmacists, to create some unified direction with clarity.
Do you have the answers?

A. And you will be pleased to note this is my last point, having moved on from a clearly defined role as the expert in the extemporaneous preparation of medicines and the application of same to the various medical conditions.
Pharmacy has lost its mojo.
None of us quite know where we fit in today’s health care environment.
Almost any other health care professional can embrace the roles we have carved out for ourselves with the basic underpinning role – dispensing – about to be relegated to a very simple technical occupation. Most of the work is already undertaken by technicians anyway, and there are future thoughts to develop checking technicians who like their colleagues in Scandinavia will completely supplant the pharmacist in the dispensary.

So you have evoked a rant!!
Born of a frustration and fear for our younger pharmacists who if we are not careful will have spent five years studying for a non existent role and will have nowhere to go.

Community pharmacy is a wonderfully successful and lucrative retail environment that needs the differentiation provided by a trained health care worker for its image and as an excuse for higher margins.
But it no longer has the dedication to the future of the professional role of the pharmacist that our forebears in their restrictive ‘one man one practice’ professional environment once had.

We, the profession, have an awful lot of very urgent work to do!

Our interview concluded at that point and for me evoked a pattern of emotion, frustration, exasperation….whatever!
I am sure most pharmacists have gone through the same gamut of feelings during a professional lifetime and we wonder what has happened to our once unified, interesting and well paid occupation.

i2P agrees with most of the above points made, but we still believe that it is possible to provide a quality clinical service from a community pharmacy environment.
We totally agree with the practice pharmacist’s comments above and we elaborate on three of them:

* “Clinical pharmacy services are totally patient focused, and because of this, there are inherent conflicts of interest between the activities of primary care based clinical pharmacists and community pharmacies.”

This has always been acknowledged by i2P and we believe that the clinical service function should be provided by clinical pharmacists in the form of an alliance partnership, with income separation similar to managed models of GP practice.
This allows for the patient focus needed and isolates the practice costs which is what most pharmacy proprietors fear.

* “Clinically focused pharmacists need to establish a therapeutic collegiality with the other health care providers and this would be extremely difficult to do from within a community pharmacy environment.”

This is indeed endorsed by i2P and we would assert that the practice pharmacist could assist in this process by liaising on a practice pharmacist to community clinical pharmacist basis and educating or assisting the community clinical pharmacist to extend their collegiality with other health care providers.

* “Pharmacists working clinically in primary care now need new skills and knowledge, a point not necessarily appreciated by pharmacists generally.”

i2P has always highlighted this fact and the need to have mobile, decentralised courses delivered to the region in which clinical pharmacists practice.
We are actually gearing up to support various education initiatives that are “over the horizon” initiatives for the moment, but which can roll out quickly because detailed business planning has been documented.

i2P has had a long association with clinical pharmacist development in a community pharmacy setting.
Recent developments in IT and associated electronic equipment has now made it possible to provide remote clinical services to home environments and even environments such as supermarkets.

Community pharmacy is at a “tipping point” because of disruptive technologies and unless it adjusts its business model quickly and attracts creative professional services alliances, it will be supplanted by other more efficient models that will not be “pharmacist friendly” in the format that most of us have collegially experienced at some time in the recent past.
Also, there is a possibility that these new models will not be “pharmacist owned”.

We ran out of evolution almost 12 years ago.
Time now for revolution!

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