Leadership, Future Direction, Public Health and Triage Services

Most pharmacists recognise the need to expand their focus from dispensing to something wider.
Community pharmacy is the most visible “face” of pharmacy, but its leadership struggles to keep its members focused on creative pathways that utilise the natural advantages of a community pharmacy – convenient location, health professional availability and access, a “core” duality vested in dispensing and clinical advice, and a strong trust by communities.

Unfortunately pharmacy viability has been hijacked by the Department of Health under successive ministers through the Pharmaceutical Benefits Scheme (PBS) as negotiations for sustaining reasonable returns for pharmacies have continuously evolved in delivering more financial pressure for community pharmacists, and through a “ripple effect” a flow-on to all other sectors of pharmacy.

The leadership “spin” that follows each CPA negotiated is always designed to pat them on the back for having delivered a return on investment, and that other word “certainty”.
This is purely cosmetic because successive agreements have culminated in forcing pharmacists into bankruptcy to record levels, and because pharmacy leaders have not produced a strategy to balance out pharmacy revenue streams, the PBS remains the most dominant stream at a profitability level that is not sustainable for the future.

Strategic planning for community pharmacy is delegated at the macro level to the Pharmacy Guild of Australia (PGA) while each individual pharmacy owner is responsible for their own strategic planning at the micro level.
When strategy levels do not synchronise or balance out, then one of two actions must follow – bankruptcy when you have completed the bankruptcy documents preparation process or a conversion of a community pharmacy into a retail pharmacy.

A retail pharmacy relies on commoditising every product and service under a marketing philosophy of delivering at the absolute lowest price.
That approach requires a high sales volume that must increase at a high rate to provide the cash flow to fund expansion.
Dips in the economy, a too high a reliance on supplier credit and a focus on quantity rather than quality is not a sustainable equation.
At some point long-term finance has to be secured to underpin a future expansion and margins across the board have to be gradually increased to ensure a profitable cash flow to stabilise the business.
This is a business cycle that has appeared before within pharmacy where a clear retail leader emerges, and after a period of time, competitors alter their business models to become more retail-oriented and eventually catch up.
Thereafter both sides move towards the middle ground and a further period of time lapses before a new cycle begins once more with a new retail leader emerging.

Each cycle initially ensures that the consumers that patronise the retail pharmacies are more typified as “customers” rather than as “patients”.
It is also quite obvious that the retail approach does little to enhance the professional value of a pharmacy, the only legacy being that of lower retail prices for a specific period.

Leaders entrusted with developing the macro vision for community pharmacy need to always be looking towards the future shape of the profession and enhancing its perceived advantages, to be able to progress to a higher ground that is both sustainable and satisfying.
Leadership aspiration should always have a vision of moving away from discount retail activity, and investing all that energy and money into something that will create a legacy to be proud of.

So let us have an individual look at each of community pharmacy’s advantages and suggest some leadership strategies that enhance them.
These are the advantages of convenient location, health professional availability and access, a “core” duality vested in dispensing and clinical advice, and a strong trust by communities.

The advantage of convenient location has always existed, initially created by new pharmacists having a vision of early ownership.
However, convenient location spaces became fiercely contested, particularly as the new pharmacists did not have sufficient managerial experience or emotional maturity to select their sites appropriately.
With the advent of PBS, government had the aspiration of its “PBS product” being distributed over all of Australia, so as to ensure no patient disadvantage due to distance or isolation.
Thus was born the “Location Rules” governing where any pharmacy wishing to provide PBS dispensing had to conform to.

Location rules are hated by economic rationalist academics that see these regulations as a limitation of competition.
Newly registered pharmacists also see them as an impediment for being able to establish their own niche pharmacy at a low cost entry.

Thus, there is an argument that now the PBS is a mature product that with the advent of Internet pharmacies, does not have to rely on a physical location to deliver its product, are they really necessary.
Community pharmacy renewal will occur quite naturally if younger pharmacists are given reasonable access to affordable practice ownership.

i2P would suggest that unless a new and different reason emerges that would require an Australia-wide pattern of community pharmacies supported by Location Rules, the existing PBS reason may be insufficient.
Change in community pharmacy is necessary and it is a clear requirement of leadership organisations to initiate that change and manage it for all of pharmacy benefit.

i2P has earlier suggested that location rules may exist as part of a public health initiative, having at its heart a triage service.
Read: The Opportunity for Pharmacist-Provided Triage Services

The suggestions contained in the triage article were positioned as futuristic suggestions that could be progressively worked at.
We now make an argument for triage that could be funded and established – and in a very short time-frame.

Recently, Malcolm Turnbull made an announcement and stated that Australia’s domestic violence level was now at a shocking level and that it is “Un-Australian” to disrespect women. People can check lawyers in New Jersey for domestic violence defense if they need the best domestic violence attorneys. 

He also said that gender inequality lies at the heart of violence against women and has called on parents, teachers and bosses to take part in a “big cultural shift” so that Australia becomes known as a country that respects women.

“Let me say this to you: disrespecting women does not always result in violence against women. But all violence against women begins with disrespecting women,” Mr Turnbull said.

Describing domestic violence levels as a “national disgrace,” he announced that $100 million in federal government funding would become available to tackle the issue.

But while welcoming the additional funds, community and advocacy groups were quick to criticise the package for not providing enough attention to critical areas such as crisis accommodation and community legal centres, which are vital to helping women escape violence.

For pharmacy the above issue of domestic violence can be viewed directly as a mental health issue for men, with health (physical and mental) risks arising for women and children as a result of domestic abuse.

i2P suggests that community pharmacy can use its convenient location and health professional accessibility advantages for abused women to make a first point of contact, and that it employs triage to enable a referral to a committed network of support groups or professionals.

One of the reasons that women do not make an early complaint is because of the fear that if they initially contact police, they may not necessarily be supported or that if action is taken to an insufficient level that it can lead to further and immediate abuse that can result in death.
Pharmacy represents a neutral and private contact point where a woman (and her children) can enter and not attract the type of attention that a visit to a police station may present.

Pharmacists can immediately provide counselling support and triage using predetermined police referrals, legal referrals, emergency accommodation and food provision services, also GP or other specialist counselling support.
These are all the obstacles that occur when a woman tries to escape a violent partner, and in that state she is often paralysed due to the trauma she may be experiencing.

Community pharmacy is in a position to organise a speedy exit from a violent home simply by creating a triage service – and there is government funding to underwrite the service.
Obviously, someone needs to be aware at the leadership level to put the infrastructure in place as a package and suggest it to government, pointing out that pharmacists can provide a discrete triage service and Location Rules may need to remain in place, even if slightly modified and divorced from PBS requirements.

And with the above architecture in place, other public health issues may be able to be partly or fully engaged using pharmacy triage.
At least this provides one future direction and creates a more rational argument for preserving Location Rules that currently exists.
The original article link above illustrated different forms of triage at different levels containing a suggestion that future pharmacy could be part of Australia’s emergency service platforms.
Recent media reports have indicated that some pharmacists may have a role already and be embedded in ambulance services forming part of the paramedic team, so the concept of linking some aspects to this development back to community pharmacies may be not so futuristic after all.

But always within a triage service there needs to be a pharmacy clinical service program which can also be a referral point within each triage, depending on competency.
Pharmacy is currently seeking to absorb mental health issues within its clinical offerings, so domestic violence may be one entry point, and is an issue that pharmacy can cope with discretely and efficiently.
Domestic violence can put community pharmacy “front and centre” in one of Australia’s worst ever crisis issues, making it a potential component of an essential service.
We do have a moral obligation to be involved wherever we can help as pharmacists.

There must be other similar opportunities that can be absorbed into a similar program.

This article is the first in a series that will build an argument for a future vision around each advantage attached to a community pharmacy.
Future articles will form up around the opportunities and development of community pharmacy advantages of:

* health professional availability and access,

* a “core” duality vested in dispensing and clinical advice, and

* a strong trust by communities.

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