“Expanded Scope of Practice” (ESP) is the current mantra for pharmacy’s salvation, constantly embraced by pharmacy regulatory bodies and pharmacy associations. As drug costs continue to fall through the floor, and while pharmacists’ compensation continues to be tied to drug costs, ESP is seen as the answer to the survival of the profession of pharmacy. But is it really?
First of all the term itself is misleading. Flu shots are not an expansion of pharmacy knowledge/expertise. Injections are a technical or nursing skill. Secondly, diagnoses be they urinary tract infections or contraception or other so called ‘minor ailments’, all of these are not an extension of pharmacy as it is currently being taught in any of the universities in Canada today.
So the word should probably be changed from ‘expansion’ to ‘accretion’ or maybe to ‘replacement’, but this new ESP direction is not an expansion of core learned skills, it’s the assumption of skills currently held by other professions be they nursing, lab technicians, or medicine.
This then begs the questions: Do pharmacists possess the required education and/or training to perform these new duties? Having studied for one profession based on pharmaceuticals/therapeutics primarily, do pharmacists really want to perform acts associated with other professions? How happy are pharmacists across Canada today doing flu injections?
Another critical question is: How welcoming are other professions with this ESP development? The following is an edited version of a letter recently published by the president of the Saskatchewan Medical Association entitled “Patients Should Be Wary of Simple Solutions”; I have a hunch it represents a large chunk of medical opinion in Canada today.
“We at the Saskatchewan Medical Association are all for improved patient access to high-quality care. Doctors don’t lack for things to do and we are happy to share duties with other professional colleagues. Unfortunately, sometimes problems that appear to be simple (read minor ailments) and easy to fix turn out to be signals of something more complex.
We have raised concerns about this new development. (read Pharmacists’ ESP) The SMA believes it is critical for patients to have what is called a medical home: a continuous source of comprehensive care, where patients have a relationship with their family physician and other providers. In such a setting, signs and symptoms of a health issue can be diagnosed and interpreted in the context of a patient’s overall life and health experience. This isn’t pop psychology or overkill — it is verified by a great deal of research. Put simply, fragmented care increases the risks of something going wrong.
Many community pharmacists practice in independent facilities (read your local food/drug combo) and may have little or no relationship with their patients’ doctors. Will the pharmacist accept responsibility for an adverse event? Will the diagnosis and treatment automatically become part of the patient’s health record? Will the patient get conflicting advice from her doctor and her pharmacist?”
The SMA President goes on to state further observations. When pharmacy professes that ESP will save the healthcare system big money (presumably by decreasing the number of visits to doctors’ offices) the inference must be that pharmacists will do these activities for free (not surprising if we look at historical experience). Or will pharmacists be paid by governments but at lower fee rates? Or will pharmacists charge patients directly for their services? …as there is current encouragement from pharmacy associations to do. And if pharmacists do charge patients directly for their services (because governments refuse to pay them) then doesn’t this fly in the face of free universal healthcare, the touchstone of Canadian identity and the direction of government political wind?
What about conflict of interest? If the only way that pharmacists continue to be compensated is when they actually sell something, isn’t there a conflict of interest when the pharmacist is both the prescriber and the dispenser of medication? Isn’t this why pharmacy and medicine were separated a thousand years ago? Isn’t this why physicians are forbidden to own an interest in a pharmacy? (Though many physicians do through astronomically inflated rents to pharmacists in physician owned medical buildings).
How long before some number cruncher in ‘head office’ figures out that 60% of customers coming through the door are women, and at any point in time 8% of them have a UTI? Look forward to quotas from head office for pharmacists for the prescribing and dispensing of MacroBID. You heard it here first.
So on the surface, although ‘expanded scope’ has a nice ring to it, there exist many pitfalls and a potential mine with further implementation.
When I discuss this issue with my physician colleagues, I invariably get the same response, which many of us have heard before: “If you want to practice medicine, why don’t you just get a medical degree?”.
Just because pharmacy may be headed towards increasing irrelevance through automation and corporate/commercial (BPR) domination, encroaching upon the professions of nursing, lab technicians, or medicine may not be the soundest strategy for survival.