Phoctors and Docpharms

In these days of constant change or business disruption we often find ourselves in a constant state of anxiety.
This is not good for mental health and is probably the underlying reason why mental health issues have shown such a massive increase across the spectrum of entire populations, over the past five years
As a defence mechanism, many occupations, pharmacists included, have had to adapt –  or disappear as they become submerged and go “under the water”.
Constant tension can also cause people to lower standards of behaviour and fall between the cracks as disruptive change overwhelms them.

These issues also beset leaders as their tensions increase and they become unable to lead for the benefit of their “followers”.
This causes leaders to create a distance from their flock, causing a loss of direction.
It also sets the scene for a new set of leaders to emerge and generate the change required to adapt to the disruption already inflicted.

So what does change mean?
The formal definitions say that its meaning is to transform or convert;
to make the form, nature, content, future course, etc., of (something) different from what it is or from what it would be if left alone;
an act or process through which something becomes different; to become different or undergo alteration; to become altered or modified.

The major underlying reason for change in business is the Internet where new online businesses have created disruption through their expanded catchment reach and low overhead (discount) variants reaching invisibly into your own sphere of influence which has suddenly become static with a lower potential for growth.

Consider the high-end department stores and how they continue to be disrupted through other online, even offshore, retailers.

This has also happened to pharmacy where there is an enormous amount of online sale of pharmaceuticals, toiletries and cosmetics made through online pharmacies, which is a space some local pharmacies have earned success.

It has also forced some community pharmacies to change nature and try to become retail pharmacies.
Most pharmacy franchisers, including Chemist Warehouse and other Discount Pharmacies are all competing and trying to play in the same highly competitive space.

This form of competition is fierce, disruptive and at a high cost in trying to expand market share.

Government has also become disruptive and has cynically seized the opportunity to introduce a $1.00 discount for PBS scripts – and that comes straight off the bottom line.
There is no doubt that pharmacists will start going under in ever increasing numbers after June 2016, unless they succeed in replacing lost PBS revenue with alternative revenue flows, or build their internal market with a different product and services mix.
Quite a big ask, when pharmacy leaders are not leading efficiently at this time.

Because employment opportunities and low wages are creating an arid future for employee pharmacists, they are starting to mobilise and target GP – based roles through the creation of practice pharmacists – similar to that of practice nurses.
There is good overseas evidence that practice pharmacists are highly thought of and there is strong interest by GP’s to have them included in primary health care activities under GP supervision.

i2P supports any external clinical role by pharmacists and worries that the natural “home” for these pharmacists is not being fully supported through community pharmacies.
The claim for this not occurring is that funds do not exist.
This should be regarded as an opportunity to service the private market more extensively, rather than wait for public funding to catch up – usually at an inadequate rate.

In an interesting development in the UK, NHS England have made a dramatic increase in funds available for GP practices to employ 700 pharmacists.
In a recent media release it was stated:

“NHS England has doubled the funding available for its national pilot of clinical pharmacists in general practice, meaning 700 practices will benefit from a share of the £31m fund.

The significant expansion of the scheme, first announced in July, is due to ‘overwhelmingly positive responses’ from GPs, and recruitment of 403 clinical pharmacists is due to begin immediately for a spring 2016 launch.

The pilots, announced by NHS England today, will cover 83 practices in London, 230 in the south of England, 183 in the Midlands and 203 in the north, spanning a population of 7.6 million patients.

The scheme will run for three years and NHS England will contribute 60% of costs for the first 12 months – which will include a ‘training programme’ – dropping to 40% then 20%.”

A GP trainer from Bristol in the UK was moved to make the comment that he was unsure of how the range of non-doctors that were now surrounding doctors, would work in practice. He likened the professional mix as being like a cocktail without any alcohol – a “mocktail”.
He was trying to illustrate that while the surrounding support professionals were highly skilled within their own disciplines (and knew more about their subject than doctors did), and that they are not generalists and they were never trained to manage risk and uncertainty.
He gave all these support people titles, and from his personal perspective, these were all people trying to be doctors.
He gave the nurse the name of “Noctor”, the pharmacist the name “Phoctor”, and the physician assistant “Mocktor”- a mock doctor.

He further commented:

“We all know the impossible balancing act that is happening in primary care right now. Patient demand is escalating and GP numbers are dwindling.
We can do one of two things to put this right: manage demand or increase GP numbers.
As the former is political suicide and the latter entails cloning, the Government (supported by our college) has decided to increase the numbers of noctors, phoctors and mocktors (mock doctors).”

This GP’s misgivings are probably reflected in Australian GP’s and it is probably the reason that in the recent past, pharmacists have been accused by GP’s of generating turf warfare.
No doubt there are many community pharmacists who have been just as fearful of the emergence of “Docpharms” and “Nursepharms”, just two groups among many others that have aspirstion towards pharmacy ownership.

But if you think about it, pharmacists have always diagnosed and prescribed to the level of their competence, and referred the more complex patient to a GP.
Prior to the National Health Scheme, pharmacists held a very high market share of primary health care.
That market share rapidly eroded as patients were given the choice of attending doctors free of charge and then receiving their prescriptions free of charge.
Alteration of the patient flow meant that doctors treated many ailments that were treated competently and economically by a pharmacist.

Now the system is clogged up with too many patients passing through a GP practice, and with a continually increasing fee for service becoming impossible to manage by patients, the system is showing signs of stress.
Complex patients are not being given sufficient time and fees for the majority (80%) of minor ailments, are just too expensive for the taxpayer.

While the UK system is still developing it is almost certain to become the model that will be adopted and developed here in Australia.

RCGP chair Dr Maureen Baker said:
‘The feedback that we have received from our members who already have a practice-based pharmacist is that they play an invaluable role, so we are pleased that NHS England has taken the idea so seriously and so swiftly brought it to fruition.’

NHS England chief executive Simon Stevens said:
“The pilot would be a ‘win-win for GPs, pharmacists and patients”.
“By testing these new ways of working across professional boundaries we are taking another step forward to relieving some of the pressure that GPs are clearly under and ensuring patients see the health professional that best suits their needs.”

GP’s have not really changed in their intent and the new package makes funds available to increase GP training, and increase the number of Physician Assistants (‘mocktors”) which will directly compete with both nurses and pharmacists.
GP’s will work towards replacing a pharmacist with a new GP or a Physician Assistant.
I have no doubt that because the practice pharmacist role attracts a higher calibre of pharmacists, not many will be dropped as new GP’s and Physician Assistants become available.
But the collaborative pharmacist experience will inevitably cycle back to a community pharmacy after displacement , the natural home for these clinicians, if community pharmacy leadership can get itself into a state of recognition of the opportunities that clinical pharmacists can generate (and form up into a pharmacist-led patient home).

A mutual collaboration in a GP practice setting will create an appreciation by all the health professionals involved of one to the other.
This is, more or less, what happens within the walls of a hospital, and perhaps even these institutions will have their teaching facilities universally expanded to accommodate all health professionals.

There will be some disharmony, selfishness and fallout as has been illustrated through earlier articles in i2P in the equivalent US setting.
Hopefully, this activity will be kept in a minority.

With cross-fertilisation at the GP practice level there may be hope for our lopsided use of health professionals and the unbalanced allocation of funds that are inappropriately divided between practitioners, as we have in Australia at the moment.

Disruption and change will remain with us all until the wheel has made a full turn, and that may take the best part of a decade.
So hang on for the ride and be aware of opportunities as they occur.

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