Issue 4 / 8 February 2016

A RECENT MJA InSight opinion piece by Dr Evan Ackermann attempts to highlight perceived issues with the role of pharmacists in the health industry.

While it is disappointing that this article was heavily focused on negative attitudes and unsubstantiated claims of improper dealings by pharmacists, the larger issue at hand is that the article failed to address a more relevant issue: the perception by a small but vocal minority of GPs that pharmacists have a conflict of interest in the supply of medication.

The Minor Ailments Scheme (MAS) is a proposed funding model that would recognise the role that pharmacists in community settings have provided on a daily basis since the inception of pharmacy degrees.

Pharmacists consult with patients regarding their health conditions as part of their everyday role in providing health care services to the community. This is not new, and while some pharmacists may operate in their own version of “6-minute medicine”, this does not represent the majority of my colleagues.

While some commentators regard pharmacists as little more than shopkeepers who sell any trendy, unproven product that enters the market, this misconception fails to recognise that advice provided by pharmacists focuses on the best outcome for the patient. Achieving this regularly means that the patient is advised to use something different to what they requested. A significant proportion of this advice includes no sale – the patient may already have the product they need at home, their ailment may require no treatment, or they may require a referral to another health professional.

Dr Ackermann’s article fails to recognise these two key points: That pharmacists already provide minor ailment services (funded only via the sale of relevant medications or health aids), and that pharmacists (in applying their clinical expertise) often forego the sale of these products to patients if it is not in the patient’s best interest.

By not being aware of these two factors of everyday pharmacy practice, Dr Ackermann has mistaken this program as a way to generate sales of products. This is a shame, since what this kind of program is designed to do is de-link pharmacy remuneration from the sale of products. It is about recognising the clinical expertise pharmacists provide to patients presenting with health concerns or seeking health advice, whether that advice results in a referral, a reassurance, or a recommendation for a certain treatment.

Dr Ackermann missed a perfect opportunity to engage with community pharmacists for his article – instead of talking about pharmacists, he could have talked TO them. Instead of implying that there is no integrity in pharmacy, he could have observed for himself the reason that pharmacists are continually regarded by the community as one of the most trusted professions in the country. Instead of claiming that pharmacists put profits before consumer benefit, he could have recognised the professionalism and expertise that The Consumer Health Forum recognised when surveying patients about expanding the professional services provided by pharmacists.

Dr Ackermann would like to have it both ways – pharmacists should not benefit from the sale of products within their business; nor should they benefit from remunerated services that utilise their expertise and clinical training.

The majority of GPs that I know personally don’t feel that way, nor, I suspect, do a majority of GPs.

Thankfully, most GPs and pharmacists in Australia are more concerned with collaboration, interprofessional cooperation, and putting the patient at the centre of care in a way that meaningfully and effectively improves outcomes.

Jarrod McMaugh is a community pharmacist, based in Melbourne, with a strong interest in clinical services offered through community pharmacy. He is also an asthma specialist pharmacist with spirometry training.

9 thoughts on “MAS – the pharmacists’ reply

  1. Peter Tomasiello says:

    Every time that I am in a pharmacy waiting for a script (and that is quite often), I stand around and observe what is happening. Most times when customers ask advice I observe that they purchase a product and nearly all the time it just so happens to be one of their own Chemist brand.

    Get a script from your doctor and if they allow a generic brand substitute. guess what. You end up with a generic brand with the chemists own brand and packaging.

    So Mr McMaugh, chemists DO have it both ways – and they are after more.

    It’s a pity the government doesn’t look after the GP’s to the same degree that they look after Pharmacys and Pharmacists.

    Medicare rebates for GP’s services continue to be frozen with no end in sight while expenses like wages, rent and electricity etc have all gone up.

    Not only do GP’s have to put up with a government determined to undermine their viability but now we have the Pharmacists trying to take their slice as well.

    Give us a break with your hard luck story.

  2. Dr Evan Ackermann says:

    Mr McMaugh fails to respond to the key issues raised within the original article  MAS a push for drug sales, ie that pharmacy relationships with drug companies, pharmacy software development to boost drug sales, and pharmacy staff training to boost S2 and S3 drugs sales; generates a environ to legitimately question the appropriateness of a pharmacy based minor ailments scheme (MAS).

    These practices remain unopposed and unexplained in Mr McMaugh’s reply.

    These are not “perceived” but very real issues, these are not “unsubstantiated claims” as Mr McMaugh suggests. Every claim has been supported. It should be concerning to every professional community pharmacist that these relationships, developments and sales tactics exist.

    Mr McMaugh raises further issues eg pharmacists have a conflict of interest in medication supply; pharmacists being little more than shopkeepers who sell any trendy, unproven products; that some pharmacists operate their own version of “6-minute medicine”; and a view on the MAS as extra funding for pharmacy. I did not raise these issues; Mr McMaugh both confuses and avoids the critical arguments with their inclusion in the debate.

    Mr McMaugh is correct that GPs and Pharmacists seek professional collaboration, but this requires a level of professional integrity and an appreciation of fiduciary responsibilities. That collaboration is threatened when community pharmacy embarks on schemes that promote profit and drugs sales over patient welfare.  

    Mr McMaugh’s response suggests that community pharmacy can’t recognise yet alone address a major professional issue for the sector

  3. Greg Hockings says:

    There is a real problem developing with the concept of role substitution in health care in Australia. We have clinical pharmacists, nurse practitioners and so on who are practising medicine (not pharmacy or nursing) with limited clinical knowledge and training. Without having medical training, there is a real risk that they will not appreciate when an apparently minor or trivial complaint is indicative of a serious underlying disorder, and “treat” the symptom rather than diagnose the disease.

    Mr McMaugh mentions ” guidelines” in his article. Guidelines asre meant to be a guide, as the name suggests; they are not intended to be blindly or strictly followed and those who apply them need an in-depth understanding of their limitations. Clinical medicine is not like being a chef; you can follow the recipe (guidelines) precisely buit still end up with a poor clinical outcome.

    So I completely agree with Dr Ackermann. Any spare funding in the health budget should be used to strengthen the role of GPs, not fund role substitution by non-medically qualified health professionals. I wonder how Mr McMaugh sees his role as an “asthma specialist pharmacist with spirometry training”. At what stage will he decide that a customer’s asthma symptoms are not trivial and that medical consultation is needed? If he wants to work in clinical medicine, he should go back to university and do a medical degree.

  4. Jarrod McMaugh says:

    Thankyou to the people who have taken the time to read and respond to my article.

     

    The point of the article was to highlight the disconnect that exists between the two different relationships between pharmacists and doctors: the every-day interaction between pharmacists and doctors on a professional basis, and the public-relations/political relationship.

     

    one of these relationships is productive, respectful, and is a true representation of professional collaboration.

     

    the other is the opposite, and really should stop.

     

    I understand that many doctors are frustrated by the state of the health industry, as displayed by two of the responses to this article. For some reason, this frustration is publicly directed towards other health professionals (this isn’t restricted to pharmacists). It really baffles me that there is so much negativity, 

  5. Mary Kay Dunkley says:

    Collaboration is the key to better patient outcomes. Not only in relation to patient care but also to reducing the cost of care. In addition if the health professions banded together and lobbied as one politicians and government would be far more likely to listen and provide the much needed funding required to ensure that Australians continue have access to high quality health care.

    GP rebates have been frozen and the PBS has been cut. Thus both professions are under financial pressure, especially at the community level (GPs and Community Pharmacies). There are members of both the medical profession and the pharmacy profession who are motivated by financial gain. Conversely in both professions the individual has to make a living. Thus the two professions have much in common.

    United we stand and divided we fall. Fighting over turf achieves only benefits those seeking further cuts to the health budget and is likely to be detrimental to patient care.

     

     

     

     

  6. Goksel Doganay says:

    Doctors need to get a grip. Pharmacists are here to stay and will not be going anywhere.

    It seems some doctors are interested in a turf war rather than practicing Medicine. The job of the pharmacist is to help their patients and before any doctor has a whinge about the role of pharmacists they should ask their patients how often do they go to their pharmacies for health advice.

    Pharmacists are trained in healthcare and pharmaceuticals. If Greg wants to question the role of pharmacists and devalue the role of pharmacists is he also going to advise his patients to use a spacer for a Accuhaler? Or is he going to advice his patients to cut in half patches to treat menopause? Or is he going to advice his patients to cut in half controlled release tablets?

    So before Greg advice’s pharmacists to go back to University to learn medicine how about he listens to the concerns of his patients and pharmacists to achieve a better outcomes. By collaborating with pharmacists he might reduce his workload and therefore see more patients and resolve more health issues.

  7. Sue Ieraci says:

    Professional rivalries notwithstanding, the bottom line is this: pharmacists DO have a financial vested interest in selling therapeutic products – both evidence-based and otherwise. The retail model of pharmacy appears to be unsustainable unless the store also sells a huge range of other products – from cosmetics to confectionery. More concerning is the growing number of supplements and homeopathic “remedies”  can cram the shelves – the latter being arguably fraudulent, as there is no evidence for effect beyond placebo and no way of showing that what is on the label is actually contained inside.

    Working in a public hospital, I enjoy a collaborative professional relationship with pharmacists which has no conflicts of interest and works well for the benefit of patients. Interestingly, there is no “role creep” because it is clear that the pharmacists are needed for their pharmaceutical skills, not for diagnostic ones. It is the retail pharmacy where the waters are muddied. Certainly people want something to help with minor complaints without having to wait for a doctor’s appointment, but reassurance is likely to be safer and more cost-effective than a ‘remedy’, as most minor ailments are self-limiting. While the author might be right about some encounters resulting in no sale, I suspect this is a small minority.

    In my childhood, out-of-hours pharmacies were regional, and supplemented their retail businesses with cosmetics and gifts (neither were claimed to be therapeutic – at least not directly!). Many pharmacies are now convenience stores, with a tiny dispensinig counter at the back. If pharmacists want to be initegrated within the community health care team, new models of practice might be required.

  8. Mary Kay Dunkley says:

    When considering the conflict it is important to remember that the majority of pharmacists in community pharmacy practice are employees hence they have no direct incentive to sell products. There are approximately 29,000 registered pharmacists and only just over 5000 pharmacies in Australia. Hence the pharmacists you see working are very often not the owner of the business. Employee pharmacists are paid wages usually based on an hourly rate. Thus they do not directly benefit from the sale of products. On the other hand doctors in private practice including GPs are usually paid on the basis of the number of patients seen thus their income is increased by seeing more patients hence the need for turf protection.
    Yes Sue doctors and phramacists in the hospital setting generally collaborate for the benefit of the patient. They are both on a salary and the patient is generally not paying for their treatment so the situation is not comparable to the community setting.
    Many patients want treatment even if it is not necessary for a minor ailment. Patients like to feel that they have a choice and are making the decisions. Purchasing a product is often their choice even if they are advised that it is not necessary. When comparing the roles of pharmacists and doctors we often forget that it is the patient who makes the choice to see a pharmacist or to see a doctor, to have a script dispensed or not, to buy a product or not. They are free to make these choices about their own health whether we think their choices are good or not.

     

  9. D.Antaki-Smith says:

    Great reply Mary, it’s important to understand that patients don’t consider turf as an issue. Patients just want to be cared for and educated, so they feel impowered to decide for themselves the way forward. Choice.
    collaboration (pharmacist – clinician) is key! I would guess that a large number of patients present first and foremost to a pharmacist for minor ailments, looking for education or an understanding of their condition. If they enter a pharmacy who has great collaboration with local clinicians (care collective) then not only will they get some education questions met, but be triaged when appropriate to the collective clinicians. Win for everyone and great care
    Turf wars can hinder this ideal approach and no one wins.
    Plus let’s consider health budgets also, they indirectly benefit…..mm another win!
    Care Collectives – care about patient outcomes – patient centric strategies are the way to a better future for health outcomes
    Cheers

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