Is community pharmacy on a road to nowhere?

If the community pharmacy sector wants to work better with other healthcare providers, something has to change.

Health Minister Greg Hunt recently announced that the Federal Government rejected many of the proposals in the King review of the community pharmacy sector.

This means for example that pharmacies will not be required to separate alternative remedies, including homeopathic products, from evidence-based medicines.

Community pharmacy owners want to be taken seriously as healthcare providers yet, at the same time, they continue to behave like a commercial interest group.

Recent actions of the sector, such as the pro-codeine lobby, raised many eyebrows. Political donations and backdoor lobbying are still the norm in this industry.

Chemist shop model

“The Guild looks forward to continuing our close dialogue with the Government on all matters to do with the sector and community pharmacy’s role,” said Pharmacy Guild President George Tambassis in response to the announcement by Minister Hunt.

And the Guild’s David Quilty stated: “When it comes to pharmacy, the Federal Government has taken the very reasonable approach that when something works very well, why tinker unnecessarily with it?”

These responses speak for themselves.

The question is, does the chemist shop model work ‘very well’, or is it relying on lotions and potions, anti-competitive regulation and protection, lobbying and political donations to stay afloat?

In the Financial Review Stephen Duckett commented, “Once again, the power of sectoral interest groups in Australian health policy is exposed.” And, “Once again, the public interest has lost out.”

I couldn’t agree more.

I’m looking forward to the day the community pharmacy sector shakes its retail sales focus – we need more team players and collaboration.

About addictive painkillers and dirty backdoor deals

It is concerning that those who have been given responsibility to look after the health of Australians take decisions influenced by commercial interests instead of sound evidence and common sense.

As I have said before we have an opiate problem in Australia and it is the responsibility of doctors, pharmacists, consumers and governments to solve it.

One of the opiates that are harmful is codeine. Codeine is closely related to morphine and can cause dependence, addiction, poisoning and, in high doses or in combination with other drugs, death. That’s why in many countries this painkiller, like other opiates, is only available via a doctor’s prescription.

The independent Therapeutic Goods Administration (TGA) has decided to do the same in Australia after extensive consultations with stakeholders including doctors, pharmacy groups and state health departments.

From 1 February 2018, medicines containing codeine will no longer be available without prescription in pharmacies. There will still be safe and equally effective alternatives available through the pharmacy without a script.

Unfortunately some of the stakeholders are undermining this process, putting patients at risk.

Wheeling and dealing

Publicly the Pharmacy Guild of Australia states that it is not seeking to overturn the decision by the TGA. It has, in fact cashed in a large sum of money from the federal government to develop and deliver education, information and communications for community pharmacies and patients to enable a smooth transition to the upscheduling of codeine.

However, behind the scenes it seems other things are happening.

Pharmacy Guild lobby
Shortly after Pharmacy Guild representatives spoke to NSW Deputy Premier John Barilaro he called for a reversal of the TGA decision. Image: Pharmacy Guild

For example, shortly after Pharmacy Guild representatives spoke to NSW Deputy Premier John Barilaro, he made the following statement: “(…) the Nationals are calling on the Federal Government to reverse their decision in relation to the way customers can access codeine products over the counter.”

The Guild’s approach was clever: They picked a pharmacy in a town with no doctor, invited Barilaro, took a picture with him and issued a press release thanking the Deputy Premier for his support of the Guild’s ‘common sense’ proposal to allow pharmacists to continue to supply codeine, stating: “What are patients with headache, toothache or period pain meant to do in Harden when there is no doctor within a hundred kilometres for a week at a time? The AMA has no answer.”

The AMA reiterated the concerns around codeine, including that 75 per cent of recent painkiller or opioid misusers reported misusing an over the counter codeine product in the previous 12 months and that these products were even more likely to be misused by teenagers.

The AMA also expressed concern about the Guild’s lobbying of State and Territory Governments to undermine the independent TGA ruling.

The Guild immediately responded on social media saying this was ‘overblown self-serving nonsense from the AMA’.

President of the Royal Australian College of General Practitioners (RACGP) Dr Bastian Seidel reminded Guild representatives that opiate painkillers including codeine are not normally recommended for tension-type headaches.

A good explanation of some of the problems with codeine can be found in this article written by a pain specialist from Deakan University: Over the counter codeine gives as many headaches as it fixes.

Substandard rural solutions 

Sales of codeine-containing medications without script represent a revenue of $150 million per year for pharmacies.

The Guild has been busy lobbying State Health Ministers – successfully, it seems.

This weekend the Australian newspaper reported that all State Health Ministers, except for South Australia, have written to Federal Health Minister Greg Hunt “relaying unnamed stakeholder concerns about the unintended consequences of requiring a script” for codeine. NSW Health Minister Brad Hazzard was one of the signatories on the letter according to the Australian.

Here’s a screenshot of (part of) the letter to Minister Hunt in which the State Health Ministers explain why they are worried about the upscheduling of codeine:

Letter from state health ministers

If it is true that people in regional areas are indeed “managing chronic conditions with codeine medications” bought from a pharmacy than that is of course a concern as codeine should not be used for this purpose.

Pharmacy Guild lobby
Pharmacy Guild lobbies NSW Health Minister Brad Hazard about codeine. Image: Pharmacy Daily

The State Health Ministers seem to implicate in the letter that it is preferable to treat chronic conditions by self medicating with over the counter codeine purchased from pharmacies instead of going to a doctor to get appropriate treatment.

This would indicate a lower standard of care for people in rural and regional areas. The upscheduling decision by the TGA could actually help regional patients receive more appropriate treatment via a doctor and cut out-of-pocket medicine costs.

Cash for access unethical

The Australian also revealed that Queensland Health Minister Cameron Dick, who also signed the letter, failed to disclose seven cash-for-access meetings with Labor donors. One of the donors was the Pharmacy Guild of Australia.

Queensland’s Premier Ms Annastacia Palaszczuk had earlier announced she had a moral responsibility to ban certain donations.

The Guild gets high level access to politicians in all states via significant donations. Their political donations are on the rise (see graph). Concerns have been raised for a while now that the Pharmacy Guild is able to influence healthcare decisions based on commercial principles instead of sound evidence.

The Guild regularly negotiates a massive agreement with the Australian Government to the value of $19 billion for dispensing PBS medicines. This begs the question how ethical it is that the Guild, at the same time, transfers money into the bank accounts of the political parties it is negotiating with.

Pharmacy Guild donations
Political donations (Australian dollars) by the Pharmacy Guild Australia 2012-2016. Source: AEC.

The Guild’s solution is weak

The Pharmacy Guild said on their website: “When we put our solution to the politicians they think it makes sense, particularly when we explain how up-scheduling alone will mean a loss of convenience and higher costs for patients, as well as the clogging up of GP practices.”

Although the medical profession and health consumer organisations can see through this rhetoric, it appears some politicians have more difficulties and I don’t blame them – at first glance the arguments by the Guild sound convincing.

The recent Health of the Nation report showed that most Australians can see their GP when they need to and are able to get an appointment for urgent medical care within four hours. The argument of ‘clogging up GP practices’ as a reason for over the counter opiates is deceptive and it is probably not the Guild’s place to comment on this.

So let’s look at the Pharmacy Guild’s preferred solution. They believe that pharmacists should continue to sell codeine without a script for acute pain and state pharmacies would monitor misuse via their real-time monitoring software called ‘MedsASSIST’. The Guild continues to remind everyone that they are the only one with this pharmacy software package.

The problem here is first of all that medications issued without a script in a pharmacy must be substantially safe and without risk of misuse.

Clearly codeine is not safe and there is unambiguous international evidence of harm and misuse. So it makes no sense for codeine to be freely available in the pharmacy on the one hand but on the other be subject to real-time monitoring.

There are also serious problems with MedsASSIST. It is not an independent tool but owned by the Guild. Not all pharmacies use it so it is easy to get around for those who use codeine for the wrong purposes.

The Therapeutic Goods Administration has considered the evidence around MedsASSIST and found that it did not lead to a significant number of people being denied codeine medications in the pharmacy.

The TGA mentioned an example where an individual was able to receive 660 codeine tablets in one month despite their purchasing behaviour being tracked by the software. This raises questions about the efficacy and safety of the Guild’s preferred solution. Is it just smoke and mirrors?

The Guild continues to accuse others that they have done nothing to monitor the use of  drugs of dependence. This is also incorrect as many groups, including the AMA, RACGP and coroners have repeatedly asked for an effective national real-time prescription monitoring system, accessible by doctors and pharmacists.

What do consumers say?

The Consumers Health Forum has raised concerns about the Guild’s solution and said in their press release: “We do not support the proposal from the Pharmacy Guild of Australia and the Pharmaceutical Society of Australia to allow pharmacists to dispense codeine products without a prescription for people with one-off acute pain under certain conditions.”

“CHF supports the role of TGA as the regulator; we believe overall it does an excellent job of ensuring Australians have access to safety and high-quality medicines. We also note that this decision brings Australia into line with most other developed countries. As recently as July 2017 France has moved to make codeine products prescription only. The evidence for harm from codeine and other opioids is growing and their efficacy in assisting with pain management is coming under more and more scrutiny.”

Other groups also expressed concerns about the Guild’s undermining of the TGA. Pain Australia, the RACGP and the RACP have issued a joint press release. Painaustralia CEO Carol Bennett said:

“Chronic pain is a major health issue in Australia – we need to do much better than offering medications that are often both ineffective and potentially harmful in responding to chronic pain. Providing appropriate pain management should be a much higher priority, particularly in rural locations where reliance on opioids is a significant issue.”

“Painaustralia supports a co-ordinated, whole of sector strategy to address the issue of access to optimal pain management, including public and clinical education programs, linkages between rural health care clinicians via Telehealth with specialist city based services.”

And addiction specialists?

Last month, addiction specialists from the Royal Australasian College of Physicians (RACP) reaffirmed their support to make codeine-based medications available only with a prescription because of the many reports about misuse, addiction, and secondary harm.

The RACP said in a press release: “Addiction is a serious medical condition which should be avoided at all costs. (…) Addiction alters life choices, life chances and life trajectory. Addiction specialists have seen the number of patients with addiction to over the counter codeine grow at an alarming rate.”

“People with persistent pain should talk to their doctor to develop an appropriate treatment plan. This may include a referral to see a pain specialist or pain management clinic to manage their condition on an ongoing basis.”

The response from the Pharmacy Guild: “doctors are missing the point on codeine.”

Conclusion

Protection of the Pharmacy Guild’s significant commercial interests seems to drive behaviour that is not always in the interest of the health of Australians. Sadly, feedback or criticism is met with aggressive counter punches. Working with the community pharmacy sector is becoming difficult for other health groups.

It is sad to see because the Guild represents a respectable profession. It appears that the Australian healthcare system, which makes pharmacies dependent on commercial activities, is partly to blame for this situation. I am not accusing anyone of backdoor deals but this whole codeine saga is not a good look. Political donations and cash-for-access programs also seem highly inappropriate, especially in the healthcare sector. We desperately need more collaboration.

Doctors vs corporates: who’s winning?

When trying to inform government policy, the medical profession is often up against lobbyists representing large corporate commercial interests. This usually does not improve patient care. It is also difficult for patients to distinguish between groups that advocate for the public good versus those that are after increased profits, power or influence. Below are some examples.

There are strong indications that funding for after-hours medical services in the community is used inappropriately. For example, I have received reports from some of these services (who mostly employ non-GPs) delivering repeat prescriptions after-hours to patients’ homes. After-hours visits classified as “urgent” attract a Medicare rebate of $130–$150 compared to non-urgent visits of $55 and $36 for standard GP surgery consultations.

The after-hours industry is booming.

Let’s look at the ACT: since the arrival of the bulk-billing National Home Doctor Service in the capital, home visits rose from 1588 in 2013–14 to 20,556 in the last financial year. This trend is seen at a national scale and there is no reasonable explanation for the steep rise in home visits.

What we need is ethical and efficient after-hours deputising services that work seamlessly with day-time medical services.

After a pushback by the profession and the launch of a Medicare Benefits Schedule (MBS) Review Taskforce, the National Association for Medical Deputising Services started an aggressive lobbying campaign to “protect home visits”.

Although several after-hours services recently quit the lobbying group – including the Canberra After-Hours Locum Medical Service, the Melbourne-based DoctorDoctor service and the Western Australian Deputising Medical Service – the campaign is still ongoing.

Big pathology

Another example of an influential lobbying group is Pathology Australia, representing several big corporations, which converted their public “Don’t Kill Bulk Bill” campaign to a backdoor deal with the government to reduce the rent they pay to GP practices for co-locating their pathology collection rooms.

The response from the Royal Australian College of General Practitioners (RACGP) was that the proposed changes will create an anticompetitive environment, propping up multinational corporations that make hundreds of millions of profit each year, while GPs running small businesses lose funding on top of the ongoing MBS freeze.

The Australian Medical Association also made it clear that this proposal went too far, interfered with legitimate commercial arrangements that have been entered into by willing parties, and that it would damage medical practices.

Pathology Australia made five donations to political parties in the last financial year alone, totaling $69,600.

Big vitamins and pharmacies

A recent episode of Four Corners once again revealed the influence of the Big Vitamins industry, selling their unproven complementary products via community pharmacies.

Complementary Medicines Australia, a lobbying group representing the complementary medicines industry, argued on the program that, despite lack of evidence, there was a role for homeopathy and that “some consumers do find that it works”.

The Pharmacy Guild of Australia does not oppose the sale of unproven products, such as homeopathic ones, via community pharmacies.

The medical profession has been calling for more transparency about efficacy for years. RACGP president Dr Bastian Seidel said that the current retail business model of pharmacies, which allows products like vitamins and supplements to be sold to Australians, is inappropriate within the health care environment, and that these products must not be sold as complementary or alternatives to evidence-based medicines prescribed by a doctor.

Health consumers also have concerns: the Consumers Health Forum of Australia reiterated in a media release, following the broadcasting of the Four Corners episode, that the Therapeutic Goods Administration (TGA) does not include a check of the efficacy of most complementary products, and that a clear signal from the TGA about the therapeutic worth of these products is required.

The Pharmacy Guild made 37 donations to political parties in the last financial year alone, totaling $236,530.

There are other examples, such as the private health industry lobby and of course Medicines Australia, the pharmaceutical manufacturer lobby group. The Grattan Institute estimated that if the Department of Health kept vested interests out of the Pharmaceutical Benefits Scheme policymaking, taxpayers would save $320 million a year. As the Grattan Institute put it: “Seeking the advice of drug company lobbyists gave the foxes a big say in the design of the hen house”.

Medicines Australia made 17 donations to political parties in the last financial year, totaling $82,212.

Pressure

It appears that there is increasing pressure from a broad range of big corporations and lobby groups on the health care sector. I believe this usually does not improve patient care and, in some cases, will adversely influence health outcomes.

It is clear that politicians and decision makers are being heavily lobbied by these organisations, and the questions arise: will they be able to withstand these forces, and are they able to make decisions in the best interest of Australians – even though this may not always be popular?

This article was originally posted in MJA Insight

Follow me on Twitter: @EdwinKruysDisclaimer and disclosure notice.

Here’s a challenge for the Pharmacy Guild

One of the big questions in primary care is: will the community pharmacy sector and general practice be able to work together without fragmenting care or duplicating services? If we don’t solve the issues and start to work as team, patient care will suffer.

For that reason, I’d like to take the Pharmacy Guild up on their suggestion to collaborate.

The relationship between doctors and community pharmacists is an interesting one: the two professions rely heavily on each other. For example, I find the advice and support from pharmacists invaluable when trying to solve difficult medication problems with my patients. Pharmacists also act as a ‘second pair of eyes’ checking my prescriptions.

Both doctors and pharmacists are highly valued by consumers and are, with nurses, in the top three most trusted professions.

On another level doctors and community pharmacists are often at loggerheads. Issues that come up time and time again are differences of opinion about the commercial aspects of healthcare, conflicts of interest with regards to prescribing and dispensing, and who does what.

In the eyes of many doctors, community pharmacy has gone off track with little connection at policy level with other primary care providers. Pharmacist will tell a different story. For example, some pharmacists – not all – seem to think that the main agenda of doctors is to protect their ‘turf’ – but there’s much more to it as I’ll explain below.

Unintended consequences 

A while back I published an article on behalf of RACGP Queensland, drafted with input from a diverse group of academic and non-academic GPs. I outlined various issues with the Queensland immunisation trials, which have led to a change in Queensland’s legislation allowing community pharmacists to administer certain private vaccinations to adults.

The idea behind pharmacy vaccinations is to improve vaccination rates in people who don’t receive care through GP services. This sounds appealing from a public health point of view, but the impact on existing services has not been reviewed or taken into account during the trials.

Unfortunately the change impacts on the care delivered by family doctors and their teams. For example, my patients now regularly tell me that they’ve been vaccinated at a community pharmacy but have forgotten where, when and what exactly – and communication from the pharmacy is usually missing.

One of my frail elderly patients who came to see me for something else declined a government-funded influenza vaccination by our practice nurse because she was booked in to have a private vaccination at the pharmacy the following week, and felt she couldn’t cancel that appointment.

This goes against the argument that pharmacy vaccinations are only targeting people who don’t have a GP or people who fall outside the national immunisation program.

Moving services away from general practice also has an impact on opportunistic screening and prevention of health conditions by GP teams. So far this season I have been able to pick up several health problems in people who came in for vaccinations, including an aortic stenosis, pneumonia and two melanomas.

We are all connected

The Pharmacy Guild’s Strategic Direction for Community Pharmacy. Source: Pharmacy Guild
The Pharmacy Guild’s strategic direction for community pharmacy. Source: Pharmacy Guild

The main message here is that a change in one part of the health sector always affects the other parts. We’re all connected – this has nothing to do with money or turf but is all about providing high value, coordinated care.

It would have been nice if RACGP Queensland had been involved in the recent Queensland immunisation trials; we could have flagged and perhaps solved some of the many issues at an earlier stage.

Will the My Health Record fix these problems? Not entirely, because uploading data to an electronic health record on its own will not replace the need for good communication and collaboration.

In the article we also warned against introducing further changes to care delivery in community pharmacies (see image) that may result in poorly coordinated, duplicated or fragmented health services.

How to move forward?

After voicing our concerns in the article various debates occurred on this blog and in the pharmacy press, for example here and here.

The response from the Pharmacy Guild in Cirrus Media’s Pharmacy News however contained incorrect information:

Response from the Pharmacy Guild

This statement is wrong for several reasons: part of my work as a family doctor involves giving advice to travellers but I am not a proprietor of a travel clinic and I don’t profit from the sale of vaccines or other products.

So how to move forward from here? I thought this response from Tim Logan was more encouraging:

“(…) it profits society more for GPs to work with pharmacists, citing a presentation at the Australian Pharmacy Professional conference earlier this year by US expert Dr Paul Grundy, who demonstrated the benefits provided by a model which encouraged GPs to do so.”

I’d like to take Tim up on his suggestion to work more closely together and invite the Pharmacy Guild to meet with RACGP Queensland. I acknowledge that there are always two sides to every story. Let’s see if there is common ground and room for agreement on how our professions can work better together at policy level, without duplicating services or creating more fragmentation of care.

As said before, the RACGP remains committed to working collaboratively with other primary care providers and government to develop innovative and effective models of care such as the patient-centered medical home, and we strongly advocate for solutions that support genuine integration of care, not more fragmentation.

At the time of writing Dr Edwin Kruys was Chair of RACGP Queensland.

The looming war between pharmacists and doctors

The looming war between pharmacists and doctors
Image: Pixabay.com
The war (…) was an unnecessary condition of affairs, and might have been avoided if forbearance and wisdom had been practised on both sides ~ Robert E. Lee

Separating the medication prescribers from the dispensers has merit. One of the advantages is that doctors and pharmacists don’t get tempted to diagnose problems to sell more drugs.

The Australian Pharmacy Guild wants to change this. They prefer pharmacists to do health checks, give advice and perform interventions such as vaccinations – while at the same time selling the solution to the problems they identify.

The Guild’s strategy is marketed as providing better access to patient care, and is apparently based on overwhelming international evidence. Indeed, in some countries pharmacists offer a wider range of services.

I’m not sure it’s always better overseas. One New Zealand doctor seemed very unhappy about pharmacists managing medical problems (and I have heard similar stories from other countries):

“I practise in New Zealand where pharmacists are allowed to treat ‘easy’ diagnoses like urinary tract infection [UTI]. Last week I consulted with a young lady who had had two diagnoses of UTI and two courses of trimethoprim [an antibiotic]. When I examined her she had a significant UTI, thrush and the possibility of a chlamydia infection, results awaited. Nothing is ‘easy’ in medicine!

The Pharmacy Guild may be a politically clever bunch, but they should have suggested a multidisciplinary solution here. Their strategy will create a backlash. In the end nobody will be better off.

Where to from here?

The signs are on the wall. Dispensing medications is not sustainable for pharmacies. Just like video rental shops had to change their business model because people started downloading movies and using automated DVD rental kiosks, this particular part of the pharmacist’s job may soon be history. The authors of an article in the British Pharmaceutical Journal ‘Dispensing: it’s time to let it go’ said: “If the aspirations of pharmacy fulfilling a clinical role integral to public healthcare is ever to be realised, community pharmacists must shift their focus away from dispensing and towards NHS service provision.”

The key here is integration. According to the authors medications could be provided in-house by health care organisations or delivered by mail, and the focus of pharmacists should be on providing integrated services like medication reviews and drug utilisation reviews. This would indeed employ the skills of pharmacists and at the same time ad value to patient care provided by other health professionals.

Or maybe pharmacists should be made responsible for quality control of over-the-counter medicines and help to stamp out misleading claims made by the domestic complementary medicines industry.

We need honest medication advice. “(…) It comes as a shock to walk into some pharmacies to see them urging products on customers where there is no evidence base of effectiveness,” said NHMRC boss Professor Warwick Anderson recently. “If you’re providing advice and care to patients, you should be clear about the evidence for the treatment.”

The pharmacy industry is comfortably protected by their community pharmacy agreement with the Federal Government, and state laws stipulate only pharmacists can own a pharmacy. A new pharmacy cannot set up shop close to an existing pharmacy. Other professions, like doctors and lawyers, don’t have this competition protection.

The service expansion drift of pharmacy-owners will eventually provoke a response from the AMA and RACGP and other medical organisations. The idea of the pharmacist in general practice has been floating around for a while. Doctors may demand dispensing rights and lobby for an end to the pharmacy cartel.

A study in the Medical Journal of Australia showed that dispensing doctors issued fewer PBS scripts than non-dispensing doctors. This is one argument for dispensaries in GP surgeries; other arguments are evidence-based medication advice and consumer convenience. Think about it: What’s easier than, after having seen the doctor, walking to the dispensing machine in the hallway, scanning your script and receiving your medications? Robotic dispensing reduces medication errors (see video below) and nobody is suggesting multivitamins, supplements or probiotics at the same time.

But just because a service is more convenient, doesn’t mean that it is a good solution. Doctors should not do the pharmacist’s job, just like pharmacists would do well to stay away from medical services.

There is still time

Pharmacy-owners face reduced profits because the Government has set lower prices for generic medications under the price disclosure arrangements. Although it is understandable they are looking for other income streams, this is a dead-end. The last thing we need is a war between pharmacists and doctors.

Needless to say it’s not in the interest of health consumers. It will create confusion, duplication, false reassurance, frustration, missed screening opportunities, fragmentation of care and higher costs.

Doctors have to accept change too. If people feel they cannot access a GP when they need to, we should improve this. One solution would be to fund nurse-lead walk-in vaccination services within the safe, clinical environment of the GP surgery. The pharmacist can play a role as part of the multidisciplinary team.

The current community pharmacy agreement expires in June 2015. There is still time.

Follow me on Twitter: @EdwinKruys