10 September 2019
What does the future hold for medicine dispensing?
Imagine a world where the Pharmacy Guild of Australia was just your average lobby group with middling power and influence. What might the pharmaceutical landscape look like?
With talks for the 7th Community Pharmacy Agreement (CPA) under way and due to wrap by the end of the year, everyone is putting in their two cents’ worth on how medications should be dispensed in Australia.
Federal Health Minister Greg Hunt has reportedly said “all relevant options” are on the table – even the two-pack prescriptions recommended by the PBAC but so pointedly shelved before the budget (and federal election) after pressure from the guild.
Minister Hunt also said, back in March, that the government was committed to pharmacy location rules, ownership rules and the community pharmacy model. Labor’s health spokesman Chris Bowen has said much the same.
So the likely result is business as usual, give or take aspects such as the $1 optional discount that the Guild wants scrapped.
But what if the minister wanted to do more than just tinker at the edges?
Here are the views of the major players, starting with the most strident statements on either side and converging to the middle.
The powerful advocate for community pharmacy owners, which is by law the sole CPA negotiator on behalf of pharmacists, is angling to expand its medical role while retaining the location rules that largely insulate them from competition. Responding to recent criticism of those rules, national president George Tambassis said they were “the one reliable mechanism to guarantee near-universal access to the basic services and health advice that their local pharmacist delivers”.
In a paper released last month, “Community Pharmacies: Part of the Solution”, the guild paints an apocalyptic picture of GP shortages, waiting times and out-of-pocket costs, and says pharmacists can relieve the burden with vaccinations and low-risk prescribing, such as oral contraception repeats.
Most recently the Guild used new visa restrictions for overseas-trained doctors as further reason to expand pharmacy practice. “Allowing pharmacists to work more closely with GPs to treat common ailments will free up doctors to spend more time with their patients and treating complex issues,” Mr Tambassis said.
But it’s unclear how the Guild expects pharmacists to be paid for consultation time, further training, regulation or professional indemnity; when The Medical Republic put this question in May we were told there were “no firm answers yet”.
AMA president Tony Bartone has blunt advice for pharmacists wanting to practise medicine: get a medical degree.
Responding to the “Part of the Solution” paper, Dr Bartone said the guild “should be focused on the interests of its members and individual pharmacists, not looking to make profits from usurping the roles of other health professions”.
The AMA and the RACGP fiercely oppose pharmacists taking on traditional GP duties, saying it will fragment and compromise quality of care.
RACGP president Harry Nespolon told The Medical Republic earlier this year that pharmacists prescribing created an unacceptable conflict of interest: “Most GPs try to limit the amount of medication a patient is on, so there are fewer problems and interactions. But pharmacists will be making money off it … They should stick to their perfumes and probiotics and let doctors do the prescribing.”
Gold Coast GP Evan Ackermann, former chair of the RACGP’s Expert Committee on Quality and Safety, told us the retail pharmacy model was broken and should be phased out, citing a Productivity Commission review in 2017. He said pharmacists should instead work in primary care as the professionals responsible for medications and medication safety.
The pharmacists’ professional peak body, the Pharmaceutical Society of Australia, softly spoken compared with the Guild, will be a signatory to this CPA for the first time. It, too, is committed to the community pharmacy network and wants greater scope of practice.
In its “Pharmacists in 2023” paper, the PSA lobbies for, among other things, better remuneration (the average pharmacist earns about $80,000 a year), and notes pharmacists’ “strong desire … to address individual remuneration and funding opportunities that do not rely solely on the Community Pharmacy Agreement”. It advocates funding through PHNs, rather than the MBS, and a move towards consultation-based payments.
Asked whether it was right that the business owners’ lobby had effectively all the say over how medications are dispensed, a spokesperson said the PSA “sets the professional practice standards, competency standards and guidelines for the provision of all pharmacist services, including dispensing”.
“PSA does not support locating pharmacies in supermarkets as it would not provide an environment that is conducive for good health care, promote the principles of quality use of medicines, nor promote a professional image expected of a health professional.”
The Guild has both a friend and an enemy in the Consumers Health Forum of Australia, which supports pharmacists being able to offer a wider range of professional services, but also wants more competition and availability of medicines.
It has criticised the dominance of the Guild and has done its best to bolster the PSA.
“We think supermarkets or other retail outlets should be allowed to dispense prescription medicines, provided there is a pharmacist in attendance to do the dispensing and provide advice to consumers on the medicines being dispensed,” a spokesperson told The Medical Republic. “This could improve access for some consumers, particularly after hours.
“There are opportunities for improved efficacy and consumer access where immunisations are more readily available at pharmacies than through GPs, and where prescriptions involve routine repeat medications, for instance. This gives consumers more choice and should not be seen as ‘duplicating’ GP services.”
Former Australian Competition and Consumer Commission chair Professor Graeme Samuel has called for the scrapping of location and ownership rules. He told Nine newspapers the guild had engaged in “straight political blackmail” and “unashamed” lobbying in the past to maintain an anti-competitive regime, and that only one rule was needed to protect consumers: that no PBS drug should be able to be issued to a consumer without a fully-qualified pharmacist.
Discount chain Chemist Warehouse, the nation’s largest pharmacy retailer, would like to open shops in dozens more regional towns and to discount medicine prices further than is currently allowed. The company uses a franchise structure to get around location rules.
Chemist Warehouse always applies the $1 discount to drugs that smaller businesses often don’t and sells other items at large reductions. Co-founder and chairman Jack Gance proudly acknowledges that community pharmacists hate the business because if they matched its prices they’d go broke.
Convenience stores, as represented by the Australasian Association of Convenience Stores, would like to be able to sell prescription medicines, similar to Walgreens in the US.
Woolworths applied to register the trademark “Pharmacy-in-Supermarket” in 2003 – then CEO Roger Corbett called the pharmacy industry “the biggest anti-competitive gerrymander in Australia” – and quietly reapplied in 2013 when the application lapsed. But it, and its rival Coles, have been silent on the issue this time around.
Finally, the Grattan Institute’s health economics guru and voice of reason, Dr Stephen Duckett, says pharmacies should be part of a larger vision for primary care.
“Unless you’ve thought that through, the CPAs are always going to be pharmacy industry-focused rather than either primary care-focused or patient-focused. There’s no framework within which the CPA is negotiated other than shovelling money to the pharmacy industry,” he told The Medical Republic.
He said the vision should include pharmacists taking on more responsibilities, such as immunisation, and being more closely integrated into primary medical care as well as – not instead of – operating in retail shops. These could include supermarkets and convenience stores, because the issue was consumer access.
“From a consumer point of view, we wouldn’t lose anything if there were fewer standalone community pharmacy shops around as long as we still had access to those prescriptions.
“There’s no particular reason why Woolies and Coles couldn’t establish pharmacies within their services, with a pharmacist employed in each. It works in other countries, of course.
“Pharmacists want to use their full range of professional skills and they’re much more interested in the higher-order things that involve giving advice and managing multiple medications than they are in selling teddy bears.”
Ultimately, everyone is entitled to voice their opinion. But as things currently stand, the only voice guaranteed to be listened to is the Guild’s.