EXPANDED SCOPE OF PRACTICE (ESP)? (PART 2) MAY 14/2018.

The reaction to the topic of ESP, by way of comments, appears to have hit a nerve.  Clearly there is a high degree of mixed feelings as to the direction in which ESP is headed. Most comments suggest caution.

Everyone appears to agree that expanding the scope of pharmacy practice is urgent, especially at this historic juncture when automation, decreasing drug costs and corporate (BPR) domination are all approaching the high water mark.  Any divergence of opinion appears to be questioning the particular direction this expansion is taking.

It is a statistical fact that the majority of pharmacists are employed by Big Pharmacy Retail (BPR) as unrepresented retail employees.  U of T pharmacy Professor Austin Zubin refers to this as the “corporatization of pharmacy as a profession” in his seminal paper Barriers to Pharmacy Practice Change. It is also a fact that success in retailing is all about scale.  This means selling as much stuff, any stuff, as possible out of a given foot print of retail space.  Think Costco or Walmart here, masters of this skill.  This is what retailers are hard wired to do, and in a highly competitive market, threatened by internet shopping, only the strong will survive.

So the initial question becomes: how will these pharmacists (the 85% employed by BPR) who are to diagnose & to prescribe for minor ailments, and to perform more time consuming non scalable patient focussed care, square this with their employers’ number one, seemingly contradictory, priority which is to increase productivity at all costs in a razor-thin margin industry?  .

Severe cut backs in pharmacy assistants and technician assistance are the prevailing trend.  Larger quotas to perform even more medication reviews and any existing billable services are the rule.   Pharmacists are now expected to perform as many flu injections as come through the door while still maintaining their responsibilities as dispensers of medications.  As well, any existing monies which are derived from providing any of these professional services goes to the non-pharmacist owner, none goes to the professional who delivers the actual service.

The whole notion of non-scalable professional services is diametrically at odds with large scale retailing.  This becomes even more untenable when so far there is little or no funding for these professional services except when a product is actually sold.  In other words, only when a product is actually sold to the patient directly & money transfers hands.

Even in Alberta (the provincial leader in government recognition of pharmacy professional services) has recently slashed funding by 150 million dollars.  It boils down to one thing.  Government considers these payments as a cost, one to be controlled and minimized.  Government does not consider pharmacy professional services as an investment.  Pharmacy has done a very poor job of establishing a clear value proposition.

In jurisdictions where Med Reviews have enjoyed a significant thrust like in Ontario, evidence has shown little measurable financial benefit over the long run, and initially, at least, a significant degree of abuse and poor quality.  This has not been aided by aggressive quotas to churn out these “revenue generators” by big business imperatives.  It bears repeating that when and if professional services are recognized and funded, the business of pharmacy will predictably institute yet new quotas and treat such services as additional SKUs (stock keeping units).  Five UTI diagnoses per eight hour shift.  Retail business is hard wired to think this way.

Further, the inherent conflict of interest created by both prescribing and fulfilling medication cannot be denied.  This situation is greatly exacerbated when the compensation is all on the fulfillment end, and none is on the front end, which at present is largely free.  This reliance on the actual selling part is almost guaranteed to deliver compromised healthcare and to validate what physicians are already warning, fragmented healthcare.

When it comes to the provision of flu injections, some pharmacists profess it brings them ‘closer to their patients’.  But how far does this thinking go?  Are wound management & direct diabetes care next? As one physician recently wryly wrote in, “will it be “pap smears in aisle four?”.

Many students enter pharmacy because they do not have to physically engage with patients; it is not their inclination.  It is clear that physicians, nurses and pharmacists are quite different from one another in personality and approach.  This has been borne out in many studies.  If pharmacists are going to do physician and nursing type stuff, then the entrance criteria into pharmacy schools will need to take this into account.  Professor’s Austin’s paper clearly sets this out.  But what about the existing cohort of pharmacists who will be around for the next 30 or 40 years who are being pushed in a direction they are not comfortable with and never asked for in the first place?

The reality is that pharmacists are missing the really big opportunity.  Pharmacists have a great deal to offer by way of medication management, therapeutic determination, dosing, monitoring therapy, therapeutic substitution etc.…all of which evolve out of their core skills which are by discipline pharmacological/pharmaceutical.  This happens today in many major hospitals.  This is what pharmacists are educated to do, and any practice expansion should consider this direction, not some whimsical notion of playing doctor or nurse.  As one physician recently aptly put it, “there is a big difference between medicines and medicine”.

To notion of imposing patient focussed, time consuming, professional services into a retail environment owned & controlled by non-pharmacists with little compensation, appears to be a significant leap of faith.  And then to suggest that it is sustainable under the present scenario where any compensation would flow not to the pharmacist, but to the non-pharmacist owner, is even a wilder stretch. Why would pharmacists want to do this?

ESP is timely, but presently it appears to be taking a poorly thought out direction out of a desperate attempt at survival, and is mostly based on the notion of ‘accessibility’.  Certainly pharmacists are very accessible.  In many urban environments there are at least two or three times as many pharmacies as the market actually demands.  If this is the value proposition, it’s an awfully thin one.

This accessibility notion, and the further self-described notion of ‘most trusted healthcare professional’ are very shaky platforms on which to build pharmacy’s future and they will not withstand the test of time.

Pharmacy ‘leaders’ must be compelled to take a second breath before going much further in this present rather ill-fated direction.