The difference between STAKEHOLDER and MEMBER is critical

One of the challenges encountered in everyday life is the different interpretations people put on what they read or hear.

CHN readers recently witnessed a great deal of reaction to OPA Chair Carlo Berardi’s commentary in the Canadian Healthcare Network , wherein Carlo takes a strong position re the need for all pharmacists to pull together in the same direction in the face of the many challenges facing the profession of pharmacy today.

Carlo makes the point that anyone who pits one member against another is “divisive”, and is therefore misguided and counterproductive to the common cause. Carlo has made this point in the past as well.  I could not agree with him more. I have already submitted my formal response to Carlo’s piece.

Although Carlo has offered no response to the dozens of pharmacists who wrote into his commentary, I believe he is sincere in his strong support of the OPA and the direction it is currently taking, and he believes that current OPA members share common cause.

I have given this considerable thought and I have come to the conclusion that Carlo, the OPA, and many other provincial pharmacy associations are confusing members with stakeholders. There is a very big difference between these two entities.

If any provincial pharmacy association sets itself up as representing all pharmacy stakeholders then the list becomes extensive.

Here is a potential list of pharmacy stakeholders:

  • Independent pharmacists who own pharmacies as business owners,
  • Publically owned billion dollar chain stores,
  • US box stores
  • Grocery stores
  • Banner operations
  • Practising community pharmacists, largely employees of non pharmacist owners
  • So described, “Associate” owner/operator pharmacists
  • The public/patients pharmacists serve
  • The ethical pharmaceutical drug industry
  • The generic drug industry
  • The regulatory bodies
  • Academia

All of the preceding can be described as legitimate stakeholders in pharmacy with stake holdings as a business, as a profession, as a distribution conduit, as a department within a multidepartment store, as an educational institution, etc.

But being a stakeholder does not necessarily entitle every entity membership in a particular organization.

Witness how chain drug stores have formed their own separate association, the CACDS which now appears to include (in addition to the big players), any pharmacy business operation with more than one location. These entities have common and unique interests as retailers and businesses. Individual practising pharmacists are not invited to join.

Then there was an attempt, a few years ago, by independent pharmacy owners (the IPO) to form their own separate association as small business owners. This group attained some attention and political clout during the heat of the battle surrounding Drug Reform. Membership was restricted to drugstore owners. Unfortunately, it appears that the IPO has now been reduced to a buying group and is not politically active as far as I know.

Hospital pharmacists have very specific interests as they are predominantly public servants/hospital employees. These pharmacists very much operate outside the turbulence of present community pharmacy. They have their own association which deals directly with governments and hospital management.

This reality speaks to the crux of the challenge facing the OPA specifically, and  other provincial pharmacy associations as well. When OPA Chair Carlo Berardi speaks of being inclusive while describing others as being divisive, he is confusing stakeholders with members.

I submit that all stakeholders may be relevant, but not all stakeholders should be members if their specific interests are not aligned.

The Ontario PHARMACISTS Association should represent the particular interests of practising community pharmacists, some of whom work as employees for small businesses owned by pharmacists, but the majority of whom work for large non pharmacist owned mega businesses.

These mega retail businesses have very predictable ways of behaving, especially in the highly competitive retail marketplace of today and increasingly as well in the internet.

The fact remains that some of this behavior is not in the interest of the profession of pharmacy, or of practising pharmacists, or of patients. We speak here of quotas, low value MedsChecks, unacceptable working conditions, and severely reduced compensation.  In the meantime, regulatory bodies appear to remain on the sidelines.

Is it such a radical notion that practising community pharmacists should have their own association which represents their specific interests and advocates for their specific issues?

Is it such a radical notion for the OPA and others, to publish a set of standards which forbid such practices as quotas for billable services, and set some clinical guidelines/protocols for doing MedsChecks and other billable services which government healthcare dollars pay for?

Is this not the type of activity that practising pharmacists would naturally expect from an institution which calls itself The Ontario PHARMACISTS Association…with or without an apostrophe?

How could such notions be considered divisive?

When association membership fees for individual pharmacists are paid for by non pharmacist employers, is there a question as to who controls the agenda?

These are important questions all pharmacists should be asking themselves at this time, when these provincial associations are asking for membership initiation or renewal.

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‘The present is the point of power’

The response to my last blog, ‘What’s a pharmacist? What’s a pharmacy?’ has been overwhelming. Many thanks to all who have written inIn response, I would like to offer some comments:

I actually have put more than words into the effort to wrest back control of the profession of pharmacy from vested interests back into pharmacists’ hands.

In the spring of 201I, I led a delegation of pharmacists, and met several times with senior Ontario Ministry of Health officials on this subject.

The purpose of these meetings was to emphasize the difference between ‘pharmacists’ and ‘pharmacies’, and to advocate for direct billing numbers for pharmacists. The difference between actual practicing pharmacists, and those corporate entities which owned pharmacies actually took some effort to clarify with these senior officials

We received a good hearing but they were puzzled why we had not approached the subject through the OPA, which they had considerable respect for. The pharmacy/pharmacist distinction we were advocating for had not been presented before, & we were encouraged to “go out there and get the numbers” to support our position.

After some soul searching, I turned my attention towards trying to get the OPA to take on the mantle, and to lead the charge to advocate for the interests of individual practising community pharmacists. To my thinking, the OPA already had the name Ontario PHARMACISTS Association and it already had established credentials with the MOHLTC.

To date, these efforts have not received much traction, as vested interests appear too firmly entrenched within, not only Ontario, but all Pharmacy Associations across Canada.

A quick glance at many Associations’ board structures reveals dominance by individual pharmacy owners (mostly smaller/rural centres) & a seat representative by the chains (CACDS). In Ontario, if past history is followed, the CACDS, which holds the vice chair position presently, will chair the OPA in 2014.

In spite of this, I still believe that existing Pharmacy Associations remain the best avenue to improve the present unfortunate situation which the majority of community pharmacists, employed by non pharmacist corporations, find themselves in today across Canada.

These Associations have existing credibility and existing infrastructure; however, in order to move them to a new mandate, they will first need a significant overhaul.

Failing an overhaul, only newly formed and newly mandated advocacy groups can succeed in creating the necessary turnaround. This would be unfortunate and divisive, as well as costly & difficult to do…but certainly not impossible, and very much inevitable in the end.

In the meantime here are some concrete steps which can be taken today, beyond just griping & talking:

  1. Email your present district Provincial Association rep and make your demands for advocacy for practising community pharmacists known… and Cc the CEO, the Chairman, Past Chairman and Vice Chairman of the Association. Email the rep even if you are not a member of the Association. These Associations constantly attest to “representing all pharmacists”, even though actual membership is around 50% of licensed pharmacists. So write in regardless, as a practising pharmacist in your province.
  2. Write a letter/email to your provincial College of Pharmacy and indicate where/how/when you have been put in a position of compromise with regards to patient safety and interest as a result of your employment arrangement…i.e. tell them about the MedsChecks & flu shot quotas being imposed upon you, as well as the unsustainable/unsafe workloads. Demand that the College act on its regulatory responsibilities. They have the power; they are just not exercising it. Drown them with letters & emails.

3, Resolve to take control of your day to day practice.

…Refuse to do anything that you do not believe is in your patient’s interest.

…Ignore quotas that serve retailing interests and revenue targets, and which compromise quality.

…Shun products you know are useless or even harmful, and take the time to instruct patients to avoid these products; it’s your professional duty.

…Be the pharmacist you want to be and trained so hard to become…especially you new young fresh graduates.  Hold onto your ideals. It’s in your hands. The future of pharmacy depends on you.

Everyone must work together. Big movements begin with thousands of small steps which eventually become a rumble. Change your attitude and grab control of your pharmacy practice, regardless of where you are employed. You have the power. Seize it.

Look at what one man, Nelson Mandela, achieved, and he did it peacefully.

More to come

What’s a pharmacist? What’s a pharmacy?

There was a time not that long ago when a ‘pharmacist’ and a ‘pharmacy’ were almost synonymous.  Generally pharmacists graduated from a pharmacy college, became provincially licensed, opened a pharmacy store (more currently referred to as a practice) and then began their 30 or 40 year pharmacy careers.

Today, we do not refer to ‘a physician’, and then separately to another entity ‘the physician’s office’   People simply ‘go to the doctor’ wherever his/her location of practice might be.  It’s the doctor’s intervention the patient is after; the location is moot.

It is more than evident that today the pharmacy landscape is very different from what it was a generation or more ago. Now, pharmacists and pharmacies are entirely different entities.

In fact, in many cases, these two entities are actually working in diametrically opposite directions…and in some cases even cross purposes.

Practising pharmacists (though more highly educated), have remained largely unchanged, notwithstanding that demographics are quite different:

…more female than male dominated,

…high number internationally trained,

…employees rather than self employed,

…cognitive skills emphasized over technical skills.

The really big difference is the Pharmacy part.  In Canada today we have single pharmacy entities with revenues in the billions of dollars & with over 1,000 locations.  One single pharmacy entity will soon control over 35% of the entire nation’s pharmacy business.  Some, including box stores, are amongst the largest retailers on earth.  Pharmacy has become a really big business and this trend is likely to increase.  Witness the US.

We still have small business pharmacies in smaller towns (those towns not yet large enough to attract a box store or chain store), and in secondary/tertiary urban locations.  Some of these smaller ‘independent pharmacies’ are into their 2nd or 3rd generations.  These independent pharmacies actually represent more than half of pharmacy locations (in Ontario at least).

The reality though is, that in spite of this 50% physical presence by location numbers, more than 80% of all prescriptions are filled by chain/box store operations

Clearly the pharmacy consumer has made an important decision.

Therefore, the challenge for pharmacists becomes:

The words ‘pharmacists’ and ‘pharmacies’ are used interchangeably as if they are the same entity when clearly they are not.

In government documents, in the press, in controlled circulation publications…everywhere and constantly, the words are used interchangeably.

This represents a major challenge.  It is licensed graduate pharmacists who do the actual work, not pharmacies: whether dispensing, cognitive services like meds checks/pharmacy opinions, flu shots, etc….but, the money is always paid to the ‘pharmacy’…by far & most often this is a corporation owned and controlled by non pharmacists.

Pharmacists remain the only professionals in Canada who have no means of earning a living without being employed by another entity…a pharmacy, through which they are then paid a wage determined by that pharmacy, which pharmacy in the majority of cases is not owned or controlled by pharmacists.

To repeat the point again:  It’s all about control and who has it.  Pharmacists today have little control over their profession. The control is in the hands of pharmacies.

The first step to get some of this control back…i.e. into the hands of pharmacists is:

To create a mechanism for pharmacists to be paid directly for the services they provide.  This includes all dispensing fees (no longer to be discounted for retail imperatives), cognitive fees, flu shots, meds checks etc.

One would think that this single item would be foremost on the agenda of provincial pharmacy associations…not setting fees, just advocating for a mechanism for pharmacists to be paid for services.  This single act would go a long way to shifting control back into pharmacists’ hands.  This is referred to as ‘Possession is 9/10ths of the law’.

Why is advocacy for direct payment for services not even being discussed?

Perhaps because giving up control is not exactly on the agenda of those who currently have it.  These same entities also control the agendas of the pharmacy associations

Notwithstanding these significant obstacles, this objective can still be achieved; it must.

More on this in subsequent blogs, but in the meantime, what are your thoughts & ideas?