A PHARMACIST’S CONUNDRUM in 2019 JANUARY 1ST, 2019

It often seems that as the elephant in the room gets larger and larger, the tendency to look away, and to pretend that the elephant does not exist increases in direct proportion.  The dominant control of the profession of pharmacy by Big Pharmacy Retail (BPR), and the concurrent failure by the regulatory bodies to apply any influence to stem this control, and to put it back into the hands of individual pharmacist practitioners, is such a case in point.

Regulatory bodies like the Ontario College of Pharmacists (OCP) continue to justify their inaction by stating that it is their sole mandate to protect the interest of the public.  “Business models are not within the mandate of the OCP”, the OCP states.   Accepted.  But when the means to deliver standards of practice are not in place, then such models become condition critical and must draw the attention of the regulatory bodies, including the OCP.

Witness that within the next few months, it has been recently announced by OCP, that an initiative will be launched in collaboration with Health Quality Ontario to release a set of system-focused indicators for community pharmacy in Ontario.  An OCP spokesman recently indicated that this initiative is about improving patient and health system outcomes and establishing a way for everyone to measure the impact of pharmacy care in the community and to continually improve.  Who could argue with this one?  What a great initiative and dead on the mandate of the OCP…to protect the public’s interest.

In direct contrast to this highly worthy initiative are the hard facts of life.   The vast majority of pharmacists (80% or more) remain unrepresented retail employees of non-pharmacist owned mega corporations, whose single purpose is selling as much merchandise as possible in an ever increasingly competitive environment, now under fierce attack by internet shopping.  It’s total war for the consumer’s dollar.   We know the players, and we know their strategies.  One player alone, Weston Group, through its control of Loblaw and Shoppers Drug Mart must have close to 50% of the retail pharmacy market.  Chairman Galen Weston Jr. is the most important pharmacy leader in Canada today and he may not even know it.  Has anyone at OCP even met him?   Has anyone told him about the new quality assurance initiative?   Has anyone been to a Costco pharmacy lately with customers lined up at the counter 20 people deep waiting to benefit from a $3.89 dispensing fee?

In such a fierce retail environment, driving revenues and controlling costs are the two important orders of the day.   How is pharmacy affected by this reality?  Pharmacists are increasingly forced to work alone, without any tech support, meaning more time spent on technical functions like counting pills, wringing up sales, and bagging groceries.  All this, while at the same time performing flu shots on demand,  and meeting increasing quotas for MedsChecks and other assorted billable services which drive those important revenues.

How is it that the OCP can set out to create professional standards for quality pharmacy services and at the same time totally ignore the hard reality that most pharmacists working in BPR environments are considered (like all the other retail employees) a means of production?  This means driving costs of production as low as possible, while driving top line dollar revenue production as high as possible.  This quest is at the heart of retailing and it never stops.  Sales per square foot is a key retail measurement tool and it has no upper limit.

This is the conundrum, but what brings it to tragic proportions is the failure by regulatory bodies like the OCP to address what is an impossible situation.   This is not just about professional satisfaction, it is about human health.  Pharmacists are actually becoming sick both physically and mentally.  How can pharmacists deliver quality professional services like “therapeutic appropriateness” when they are checking 200 Rxs an hour with no help?

It is well within the regulatory bodies’ purview to set standards like the number of prescription an hour which a given pharmacist can safely fill and still meet minimum professional standards; they just don’t want to tackle BPR.

So much effort has been put forth to create the professional title of ‘Pharmacy Technician’.  What a tragic joke, as these people cannot find work, or when they do, they are not financially rewarded for their status but still must now pay OCP increasing annual dues.

The talk has started that the self-regulation of professions like pharmacy and medicine should go under review.  Some may look in horror at the prospect of government oversight of pharmacy, but one must wonder if it could get any worse than the present untenable situation.

 

18 thoughts on “A PHARMACIST’S CONUNDRUM in 2019 JANUARY 1ST, 2019

  1. Bill, Happy New Year. Your 3rd last paragraph, about the number of prescriptions per hour that can be safely filled with professional standards adequacy. What is that number ? If that number isn’t known then how to get it ? Maybe the Quality Standards Initiative will eventually find it, and then there is finally meat on the bone.

    Like

    • Happy New Year to you as well Randy. I don’t know what that number is. Probably it will be a range. For certain I know it is not limitless. Right now it is set at waiting until it breaks the camel’s back.

      Like

      • Might have to have one broken backed camel, then remove one straw for the rest. Pity the patients of that first camel.

        Like

      • Perhaps, this one reference will assist as far as our neighbours to the south have in place. Note that it isn’t just one state… https://www.pharmacytimes.com/publications/issue/2016/june2016/pharmacy-technician-regulation (thank you Kristy Malacos, MS, CPhT).

        Note that the ratios are “state-specific” and “it is up to each state to limit how many technicians a pharmacist may supervise at one time. This ratio usually varies from 1:2…to 1:6. Some states will vary the ratio depending on the practice setting or allow a higher ratio if one or more of the technicians is certified.”

        The State Boards of Pharmacy that have established such ratios must consider this to have been a “public interest” issue, having addressed the issue in the first place. Point being, they found a way to establish such ratios rather than avoid doing so based on the how-do-you-do-so “rationale.”

        Liked by 1 person

      • Perhaps that’s the way to start. Rx count leads to assistant/technician counts which leads to pharmacist count. Or the reverse, now that technicians check Rx’s. Something like that. At least it deals with the dispensing role.

        Like

    • Best of 2019 to all of you, gentlemen and ladies alike.

      I know that often, when “prescriptions per hour vs. staffing” discussions arise, it often fritters away due to the “what is appropriate” question. But since the OCP traditionally compares itself to other jurisdictions in reaching decisions (such as what is an appropriate fee versus the rest of the country), there are actually jurisdictions where such STANDARDS have been put into play — all with a view to protecting the public there. Iowa is one such state, where many years ago, the “staff ratios” were established and it didn’t matter who the big $$$ holders were; they were to be applied everywhere. Since then, other such jurisdictional decisions have arisen; yet Ontario continues to languish behind.

      Ironically, one of the reasons they state in raising fees for pharmacists, technicians, pharmacies (both community and hospital) across the board in what can only be described as gluttonous and ugly fashion (25% over 2 years), is due to the increase in the number of complaints being made and the costs of discipline. Let’s say that again: INCREASED COMPLAINTS.

      Time for another study, but on a realistic topic: what proportion of complaints as a whole, after investigation, show some sign(s) of staffing levels being contributory to the complaint’s substance? As such, is this not a “public interest” concern? If you answer (logically) “yes,” then establishing such standards for staffing is not at all arguable by “we don’t get involved in business operations” but rather, “we get involved when the public safety is involved.” So do it.

      Like

  2. Remember at one point last year the OCP board was 33% members affiliated with McKesson. These pharmacists are receiving “payments” from McKesson. They will NEVER go after the hand that feeds them. Look at Merani & Scanlon, ex Presdients of OCP taking “payments” from McKesson. Also remember the Registrar is hired by these board members. They will NEVER hire a true leader. The Registrar is happy taking her salary and not rocking the boat. I hear more “payment” revelations coming in January re another ex OCP President. What are they leading there? How to get around the REBATE laws????

    Like

  3. Hi Bill.

    Good column (again). I think I can say that for all your columns.

    Since you’ve touched on the aspect of self-regulation (rightly so), I wanted to once again remind everyone of this “elephant in the room” that is the college’s ongoing response that everything they do is geared toward “public interest.” It becomes tiresome because in fact, while it may be a major mandate, it’s not their ONLY mandate. And so once again, I raise this for people to drill into their heads because too often they “accept” that mantra of public interest alone.

    If you look at the Objects of a College under the RHPA Schedule 2 (which happens to apply equally to all 26 health professions set out in Schedule 1 of the RHPA), section 2.1 sets out the “Duty of the College,” being “…to ensure, as a matter of public interest, that the people of Ontario have access to adequate numbers of qualified, skilled and competent regulated health professionals.”

    Interesting, no? This (adequate numbers) goes directly to your comments.

    But don’t stop there. Section 3 sets out the “Objects of College”, and there are 12 (TWELVE!) of them. Some of them, if you read carefully, could be argued to serve no public interest at all. BUT THEY ARE STILL INCLUDED. Why would that be, if not required to be adhered to? As an example, pgh 5 refers to establishment of professional ethics, as well as their maintenance. As for pharmacy, that Code of Ethics is a novella, and many of the sections have nothing at all to do with the public. So why are they there, if “public interest” is not involved? I think a reasonable answer is, because a college DOES have responsibility regarding the profession ITSELF, not just the public safety/interest aspect.

    Now, take pharmacy one step further: we have other statutes that govern practice (eg., the DPRA). I could begin to list numerous sections of that statute that by themself, have absolutely NO PUBLIC INTEREST component. But again, they’re there. And enforced.

    I won’t go on, boring your readers, as there are literally dozens of statutory/regulatory sections that one could point to as being “not public interest” issues. But I wanted to make it clear that when we hear that “public interest” card being played, it’s not entirely relevant in every situation. And if they’re going to enforce SOME sections that have no such element, then they ought to do so for ALL such situations. Plus, the OCP is charged with “regulating the practice of pharmacy and pharmacies in the province of Ontario” and as such, that (in my humble opinion) includes ensuring that the environment in which one practises is safe.

    The Pharmacy Act, section 6, sets out “additional objects” for the OCP to what is in the RHPA Code — WITH NO SECTION SAYING TO DO SO WITH THE PUBLIC INTEREST AS A CONSIDERATION. Those objects include “to regulate drugs and pharmacies under the Drug and Pharmacies Regulation Act; to exercise the powers and duties of the College under the (DIDFA); and to develop, establish and maintain standards of qualfication for persons to be issued certificates of accreditation.”

    The recent “consultation” that the OCP made regarding (in part) increasing fees was insulting to all members given that the decision was made to raise fees at the September 2018 council, THEN sent around to members for comments, yet still rammed through in December with absolutely no adjustments being made to them. Almost “we have to consult under the statutes, but we don’t have to listen.” In terms of the magnitude of the increases alone, I don’t think anyone believes commenting made any difference. It shows a very disappointing “cycle” of costs of what they should be doing getting out of control (complaints, deterrence to stop recidivism, etc.), being “called” on that to some extent by government, and then finally deciding to do what members have called for over many years: deal with repeat offenders adequately to dissuade future re-occurrences and associated costs.

    But on top of that, this time around they’ve insulted all the members with obnoxious increases in fees across the entire spectrum of practice, penalizing the law-abiding members of the profession IN ADDITION TO suggesting higher cost assessments be pursued in specific areas regarding members.

    It’s almost as if all Ontario pharmacists, technicians, and pharmacies were found guilty of professional misconduct, and fined. But…at least we were “consulted” first, right?

    Like

  4. Great blog to end 2018 and start 2019, Bill. And I appreciate the thoughtful comments posted as responses here. I think we have a real crisis in “pharmacist leadership” – the crisis being there is no good leadership. I am not sure what it will take for that to happen…perhaps it never will.

    Like

  5. This study from BC is worth a read:

    “Factors associated with pharmacists’ perceptions of their working conditions and safety and effectiveness of patient care”
    https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4713891/

    “We found that many pharmacists expressed concerns regarding having enough time for breaks or lunches, enough time to do their jobs and enough staffing support. Pharmacists’ perceptions of their workplace environment were found to be negatively associated with workplace-imposed advanced service quotas (for medication reviews, immunizations and prescription adaptations), being employed at chain stores compared with independent pharmacies or hospitals/long-term care settings and higher prescription volume…Most studies to date have only explored the relationship between prescription dispensing volume and pharmacists’ well-being and patient safety. It has been established that increased prescription volume is associated with increased dispensing errors or near misses, thus compromising patient safety.“

    I don’t know whether the BC College of Pharmacists have paid attention to this study. I also don’t know whether NAPRA has taken any action to address this at a national level.

    The million dollar question in my mind is how many patients need to be exposed to unnecessary risk before regulators address workload conditions and staffing.

    Bill, I have mixed feelings about you concept about “hidden leadership.” Is not a mark of a good leader speaking out and acting even when your view may be unpopular? I think some academics are totally out of touch with the reality of pharmacy practice (how many faculties have professors that still work in community practice?). The professional associations seem beholden to corporate agendas. This is why I am so disappointed that regulators- who should be acting in the public interest- seem to dance around their obligations.

    On that note, Happy New Year all!

    Like

    • Suzanne,

      The ‘hidden leaders’ i was referring to are not leading the regulatory bodies, nor the pharmacy associations, not even the universities. The hidden leaders are leading those entities like members of BPR, or McKesson, or Costco, etc. who use pharmacy for their own purposes. In this way they lead their organizations for the benefit of their stakeholders. Pharmacy is just a means to an end for these leaders.

      Like

    • From BC- http://www.bcpharmacists.org/board-highlights-20160624

      “BOARD APPROVES AMENDMENTS FOR PODSA BYLAWS ON PHARMACY WORKLOAD TO BE FILED WITH THE MINISTRY
      The Board approved amendments to the PODSA bylaws regarding requirements for pharmacy owners, directors and managers with respect to pharmacy workload for filing with the Ministry of Health. In accordance with the College’s legislative process, the draft bylaws were posted on the College website for public comment in February 2015 and are now being filed. The draft bylaws take into account the feedback gathered during the public posting period.
      The intent of the bylaws is to ensure that registrant and pharmacy staff levels are sufficient to ensure that workload volumes – including meeting quotas, targets or similar measures – do not compromise patient safety or compliance with College bylaws, Code of Ethics or standards of practice.“

      Anyone know more about these BC bylaws and experience in practice? Are they the only pharmacy regulator in Canada to do this?

      Like

  6. Upon closer inspection of the article, I see that it is the pharmacy group that is proposing that strategy (not the government) as a counter to further across the board cuts. Maybe they could start by closing the pharmacies that are not run by pharmacists.

    Like

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out /  Change )

Google photo

You are commenting using your Google account. Log Out /  Change )

Twitter picture

You are commenting using your Twitter account. Log Out /  Change )

Facebook photo

You are commenting using your Facebook account. Log Out /  Change )

Connecting to %s