On the 24th March 2004, a conference was held in the Rydges Hotel, Jamison St, Sydney (The Australian Pharmaceutical Summit).
I was a speaker at that conference, and presented a paper titled "Pharmacy on the Edge".
Perhaps it needed to be more accurately titled "Pharmacy over the Edge".
The conference embraced most of the elements that make up the pharmaceutical industry and was characterised by the general feeling that community Pharmacy had already lost the ownership battle.
There was a general feeling that Pharmacy needed, and should, be protected.
However protection did not extend to exclusive ownership.
There was also a feeling that Woolworths is telling a lot of people a lot of things that they want to hear, and that the integrity of their statements is not being tested.
Given that this is an election year, the PGA needs to be seen to be at its "rough and tumble" best in dealing with our political masters, no holds barred.
I cannot shake the feeling that all major decisions have been already made, including ACCC approval of a pharmacy takeover (Gordon Samuels was recently quoted as saying he could not see the difference between a pharmacy inside Woolworths, adjacent to Woolworths or across the mall from Woolworths).
While the PGA have an excellent record of political lobbying, they have a woeful record in terms of shackling community pharmacy, to the extent that it is now unable to defend itself in an open market place.

The price is about to be exacted, as all the predators circle Pharmacy to pick its bones and take the juciest morsels unto themselves.
If everything goes according to the Woolworths plan, the PGA may indeed find that its credibility with pharmacists will plummet so low, a new leadership group will need to emerge.

To view the slides for the presentation, click on the following link:

Australian Pharmaceutical Summit slide presentation

PHARMACY ON THE EDGE (Slide 1)

It's two minutes to midnight and the major decisions, to shore up a bright future for pharmacy, have yet to be made.

The clock is ticking while Woolworths and Priceline methodically determine what strategy they will employ to wrest large components of market segments, that have traditionally been pharmacy's domain.
The clock is ticking as National Competition Policy has weighed in and 'king-hit" the NSW state government with a fine of $59 million, for having anti-competitive legislation on its books. The liquor industry was targeted first, but pharmacy is not too far behind.

The clock is ticking since The Wilkinson Report pointed the way four years ago, but Pharmacy governing bodies have not yet come to terms with it. There has been little movement.
The new Australian Community Pharmacy Agreement is about to be negotiated, with location rules and ownership back on the agenda.

The clock is ticking while pharmacy lacks a suitable operating structure to work out of, giving depth of management and control.

The clock is ticking as our basic IT systems are not keeping pace with requirements. Once, pharmacy led all the professions in its take-up of computers and systems. Now, we are lagging behind.

The clock is ticking as our "connectivity systems" are now talked about in years, rather than months.

The clock is ticking as no new IT systems are appearing to handle the big problems, particularly dispensing. Dispensing volumes threaten to swamp all other internal pharmacy systems, as pharmacists literally hang on for the roller-coaster ride.
And there does not seem to be any move to create internal connectivity between all major pharmacy (non-dispensing) systems.

The clock is ticking as only a handful of pharmacists succeed in establishing a retail e-commerce connection to their customers/patients. The extra reach of organizations such as e-Woolworths and e-Pharmacy Direct is continually eroding local market shares, yet most are totally unaware that this process is actively happening, let alone being able to quantify market loss.

The clock is ticking as the demand for pharmacists and other trained staff, outstrips the supply, and will continue to do so, up to 2010 and beyond.

The clock is ticking as our supply chain costs remain at a point well above our competitors, and pharmacy is unable to control the costs of distribution.

The clock is ticking as education and training programs for practising pharmacists are falling behind, as pharmacist time management is stretched to the limit with all of the above.

The clock is ticking because all the above "holes" in the pharmacy fabric create defence problems - which "hole" will be attacked first and more pertinently, what strategy and tactics will be employed to prevent our competitors from driving straight through, and in the process, capturing the best "bits" for themselves, leaving pharmacy with a sadly depleted residue. There are some bright spots in the development of cognitive services. But how can they be successfully grown in such an unprepared environment?

We must restructure today, or there will be no tomorrow.

THE CLOCK IS TICKING (Slide 2)

Woolworths and Priceline
Both the above entities have been mounting strategies to deliver pharmacy retail market share under their own control, using different methods.
Woolworths has been actively been involved since the mid 1960's, first in helping to break down a very effective "chemist own" policy, and then progressively transferring many pharmacy products into their own environment, where currently their HBA department has taken on the "look and feel" of a pharmacy.
Priceline, on the other hand, looks to be part of the pharmacy environment seemingly like a traditional pharmacy wholesaler banner group.
However, they are more potent in their application of market research, and run their pharmacy franchises concurrent with their own totally owned retail stores.
Both Woolworths and Priceline make no secret of their ambition, to own pharmacies outright.
To achieve this outcome, state legislation has to be changed.
However, Gordon Samuels from the ACCC is quoted in a radio interview dated 17th March 2003 has stated that he can see no reason why a pharmacy cannot sit inside a supermarket - "a pharmacy located beside or across the mall from a supermarket to capture customer traffic is no different to being inside".

National Competition Policy(NCP)
NCP may prove to be the mechanism that will loosen the stranglehold on various components of state legislation, particularly where they are deemed under NCP to be anti-competitive. No state government can withstand the punitive fines that are imposed by the Federal Government ($59 million alone in NSW), in favour of protecting a special group, such as pharmacists.
Liquor retailers were targeted first - how long before pharmacy appears on the radar, and what will have go, or be allowed to come in? There is recent talk of loosening restriction on pharmacy numbers owned by individuals.
What next?
Ownership? Registration of premises? Allowing incorporation? Distance requirements between pharmacies?
Much of this was predetermined when the Wilkinson Report was published.

The Wilkinson Report
This report underwent some minor transformation when it was referred to CoAG, and eventually became part of National Competition Policy.
As this process has been well publicised I will only draw attention to the fact that location and ownership rules are required to be reviewed in the 2004 in negotiations for the fourth Australian Community Pharmacy Agreement (ACPA).

Any retained state legislation must be reviewed within 10 years, and the CoAG committee that commented on the original report, has already stated that more evidence will be required for justification for location and ownership rules, given that there is open ownership in the US and UK.
Also why pharmacy needs to be treated in a manner quite distinct to other regulated professions.

THE CLOCK IS TICKING (Slide 3)

Lack of a suitable operating structure
The basic ownership structures that pharmacists can employ in most states and territories are sole traders or partnerships.
South Australia is the only exception, allowing a form of incorporation.
The first two noted are extremely limited models, give little legal protection, and are difficult to finance.
Often there is a separate company service structure associated with the above models, which may alleviate and minimise tax, or even give limited financial protection, but the structure is still clumsy.

The Wilkinson Report clearly sanctioned a restricted form of a proprietary limited company based on the South Australian model.
I believe that the failure not to have company structures up and running over the last four years, will prove to be the primary reason for pharmacy to be disadvantaged in the battles yet to be fought.

Our IT systems are not keeping pace

Theoretically, if our IT systems were adequate to the task, many pharmacy problems would evaporate, or become more manageable.
Pharmacist's singular lack of IT knowledge is the main problem here.
We simply don't have the depth of knowledge to make good decisions about systems and equipment, and paralysis is the result.
We should have been recruiting these skills ages ago and learning from the people providing them.
Divisions of General Practice have set up this specialty in each division, and recruited suitable people who are shared among all the doctor practices in their region.
They also employ individual practice managers with IT skills.
Where is the pharmacy equivalent?

Our connectivity systems are not appearing quickly enough

Here I am primarily talking about MediConnect.
It is now said to be years away, rather than the initial optimistic promise of "just a few months" for delivery.
The system is possibly too big to deliver in one lump sum.
But we can connect at other levels, and we should be doing this to gain experience.
For example, we could connect our book-keeping system to our e-commerce Internet site, and again to our ordering system and point of sale system.
We could be learning about these problems at our own controlled level, and gain experience by connecting everything in sight without having to re-key information.
This we can do in advance of major systems and know what problems we can expect to face when a larger system has to connect with us.
We could also connect with each other, replacing insecure fax machines with encrypted messaging systems that avoid Spam and Viruses.
There is much we can do before worrying about MediConnect.

I have this feeling that tackling a system as large as MediConnect, employing one large database, managed by the HIC, is a recipe for disaster.
Smaller components of the system locally managed and feeding into a central database would seem to me to be more feasible.
And while this system purports to represent patient safety as its reason for being, the routing of scripts through HIC first, then the pharmacy, smacks of a patient having to wait for their prescription until everyone else has had a fiddle!
If large volumes of scripts slow the system down, even collapse it, where is the element of customer service?

THE CLOCK IS TICKING (Slide 4)

Only a handful of pharmacists are succeeding in retail e-commerce
While pharmacists may not yet have come to grips with retail e-commerce, those who have are merrily stealing market share from every pharmacist in Australia.
And while the PGA has officially frowned on the initial entrants into this field, all that has happened is that potential entrants have been frightened off.
Do Woolworths, Coles and Priceline have e-commerce sites?
To be sure they do!
So where is the support for pharmacy e-commerce?
It is a legitimate extension of a "bricks and mortar" pharmacy practice that can provide complementary support to the main business (or it can even be the main business).
To be successful, e-commerce sites need to be integrated at all levels of the existing pharmacy practice, and cross-fertilised with internal catalogue promotions, newsletter promotions, mail order promotions etc., with the Internet site offering incentives not found in other parts of the pharmacy business.
The pharmacy even needs a computer kiosk, encouraging customers to use it, and using the order filling as a means of extending trading hours and leveraging staff economically.

The demand for pharmacists outstrips supply
Even with planned increased intakes into pharmacy schools, there will still not be enough pharmacists.
Pharmacist demand up to 2010 and beyond is predicted to worsen, so it follows that businesses that can solve their human resource problems in a creative manner, will be the clear winners.
An aging population will increase demand for existing pharmacy services plus add stress to the development of new cognitive services.
Added to this, if Woolworths win the right to own their own pharmacies (or likewise, any other retailer), pharmacist shortages will exacerbate again in line with the net increase in pharmacy numbers.
Worst affected areas will be rural/isolated where average age is high, particularly in hospitals, where the lead-time to train a hospital pharmacist is much longer than for community.
Retirements over the next five years will simply add to the problem.
One major "non-strategy" is that pharmacy does not have a suitable program to retain retiring pharmacists, nor a program of planned succession.
This problem will be more evident from 2005+
I recently suggested a simple strategy to a community pharmacist, who was scathing because his 64 year-old pharmacist appeared to be physically flagging.
Consider that this pharmacy dispensed between 400-500 prescription items per day, with one pharmacist attending for a 9-10 hour day.
My suggestion was to make his pharmacy "senior pharmacist friendly" by dividing his working day into sessions of 4 hours, 5 hours and six hours, and recruiting senior pharmacists into whatever number of sessions he could fill in a week.
Then ensure that the pharmacist was properly employed in checking and counselling finished prescriptions, and that this process could be performed in a seated position.
John Howard is currently preaching we should work longer and harder. Pharmacists have always become locums after retiring, but now they are running and hiding because of the punishing workloads.

The lack of supply chain reform
This will forever keep pharmacy's base costs above its major competitors.
Why is it that wholesalers cannot see a benefit beyond using their own proprietary product numbering system?
Certainly, the adoption of the EAN system by suppliers, would seem a logical step in improving pharmacy's (and the supplier's) cost of doing business.
Pharmacy, because of the nature of its business, will always have a higher cost supply service.
Comparison of the distribution system in pharmacy, with that of grocery, is not really comparing like-with-like.
Grocery is totally shareholder oriented, while pharmacy is patient care driven (this is one reason why a Woolworths-owned pharmacy would not necessarily be in the public interest).
Pharmacy needs to engineer every advantage it can create.

THE CLOCK IS TICKING (Slide 5)

Education and training

This is also falling behind requirements, primarily because pharmacists (and their staff) are too busy, too tired, or may have to travel long distances to access course materials, and at the end of all this, the cost is rapidly increasing.
This is an urgent problem, and it should be noted that the organization that can deliver cost-effective education in a practical manner, will virtually control the human resources of pharmacy.
Logically, this should be the PSA, and it must be said that they are endeavouring to bridge some gaps through the application of some of their research grants, to get local representatives into health areas in mentoring roles, particularly rural health areas.
Pharmacy political strength is derived at the "grass-roots" level and control of education and training is seen as building this strength.
Monetary investment in a "one-on-one" mentoring system will see better-trained and informed pharmacists, with a quick response time.
The recent down scheduling of Postinor provided a good example.
This product was rescheduled without an effective strategy in place.
We could blame the scheduling authorities and label them irresponsible, or we could tidy up our own act to deliver positive patient counselling strategies with adequate assurances for all legal aspects.
Certainly, pharmacy was caught unprepared, because this was an unexpected event.

Will PSA emerge as the clear leader in this activity?
I certainly hope so, simply because they are the most representative of the pharmacy leader bodies

Defending the "holes" in the pharmacy armoury
Is a difficult enough job if you only had one "hole" to manage.
Managing all on a broad front is a major problem.
Many will be sequentially solved e.g. if corporate pharmacy is allowed, then mergers and takeovers would move, I believe, at a rapid pace.
A merger could resolve human resource problems in that both pharmacists from each entity are then contained in one environment.
If one part of a merger involves a retiring pharmacist, then that pharmacist may accept a board position ensuring a retention of experience built up over a lifetime.
An exchange of shares reduces the need for third party financing through supplier bills of sale.
Salary packages can be built to attract graduate pharmacists through the use of shares, creating a sense of ownership at the very beginning of a career, a means of creating wealth through capital gains, and the possibility of a long-term relationship through pride of ownership.
As scale of economies improve with each merger, perhaps a suitable platform can be built to launch cognitive services in a sustainable manner, and that automated dispensing equipment can be afforded, to control script volumes.
As you will note, one problem resolves with the solution to a previous problem.

THE VISION (Slide 6)

A structure that is stable
To me, the only stable structure for a pharmacy business is a proprietary company.
A company does not die, and it is able to retain its corporate memory.
Sole traders and partnerships are notorious for their instability, depending too much on the individual.
The services that a pharmacy has to deliver now, are getting beyond a single individual. Future service delivery will be even more demanding and will require structured and specialised management for implementation.
Small sole trader/partnership pharmacies may continue to exist, but they will be mainly in rural/isolated areas.
As previously mentioned, shares in a company can form part of a salary package for an employee, giving a sense of ownership.

Companies offer a vehicle for investment:
· Retired pharmacists can continue to invest in pharmacy without management responsibility.
· Female pharmacists may find owning company shares a more manageable and tangible contribution to pharmacy, rather than the current option of having to own a pharmacy outright as a sole trader/partner.

Companies can develop a scale of economy and provide:
· A suitable platform to launch, and manage, cognitive services.
· Extended hours services because of the ability to employ additional shifts of staff.
· Provide better rosters for semi-retired pharmacists e.g. a 4-5 hour daily session instead of 8-12 hours.

A model that is competitive and delivers economies of scale
To deliver on this premise requires a high degree of management skill and control.
We always acknowledge that Woolworths can deliver in this department, but we never seem to have the vision of being able to match or better the Woolworths offering.

If we did deliver in this area, do you think there would be the same interest by a pharmacist in Woolworths/ Priceline/ Wholesaler banner group variations?
Of course not!
They only use these mantles for perceived protection, which is not there, because all these entities want to own pharmacies in their own right.
Protection only comes through your own inner strength.

Overseas experience already tells us that where pharmacists have had a reasonably level playing field, they have no trouble in competing with major retailers, and they do so with complete confidence.

So maybe the lesson applicable here is that our pharmacy leaders and government policy makers should be helping pharmacy to clear all the impediments required to run a pharmacy practice anywhere in Australia.
For example, would it not be ideal to be able to gain Australia-wide registration as a pharmacist, by being able to register just once, after graduation?
Again, the Wilkinson Report pointed the way.

A profession that provides interesting jobs
What we learn at Universities as undergraduates, we hope to apply in the real-world of our post-graduate environment.
This has not ever been a reality during my pharmacy life.
Cognitive services are seen as a way for pharmacists to develop and apply the training they have received at university.
Cognitive services just don't appear without some form of visualisation, creative and research process.
They need management to give form and structure, and marketing, to communicate to patients, before there is forward movement.
The average pharmacy is a very busy and reactive environment, and does not allow for quiet unstructured time.
This is a necessity if cognitive services are to be identified, and allowed to develop.

So an interesting job may be found in inventing a service, or simply by managing the service, by marketing the service, or being a practitioner within the service.
Each of those jobs may be interesting to one, or a range of people, but the average pharmacy practice finds it difficult to deliver all of the above to meet individual pharmacist aspirations.

Corporate pharmacy models would find it easier to build and match these aspirations.

Proper retirement and succession planning
We never seem to have valued our senior pharmacists, and have not developed ideas to encourage them, to keep making a contribution, even in active retirement.

A range of simple ideas come to mind:

1. Set up a register of pharmacists in solo practice interested in retiring.
2. Introduce these pharmacists to a potential corporate pharmacy, interested in taking over the retiree's business.
3. Discuss a range of offers that could be accommodated by the buyer:
a. An offer to provide various management/marketing consultancies by the retiree to the corporate.
b. An offer to provide staff training and education by the retiree to the corporate.
c. An offer to provide locum services. Extend the offer so that work may be performed in four or five hour "sessions", rather than 8-10 hour days.
d. An offer to provide consultant pharmacist services within the corporate structure.
d. An offer to be a director on the board of the merged
pharmacy.

4. Move to negotiate fringe benefits associated with the merger
e.g. part of the purchase price negotiated for the retiring
pharmacist could include fringe benefits such as travel or
structured education or other investment opportunities that
may interest a retiree. These benefits could be provided in the
transition period before final merger, and could even include
providing a locum manager to assist in the preparation for a
merger.

I am sure the "package" can be massaged to be very meaningful to a potential retiree, and in the process retaining, a valuable resource for the fabric of pharmacy.

Perpetual training and localised economical education
The process of continuing education and training was always forecast to be a difficult situation.
People need study/learning time factored in to their workday as a fringe benefit if they are to present as highly trained professionals or technicians.
Because travel costs are often an impediment to receiving education, plus the cost of the actual course, there needs to be some more cost-effective way of delivering education and training as locally as possible.

Obviously, the Internet has not been exploited to its fullest potential in this regard, nor the concept of sponsored travelling workshops /seminars /conferences.
The Internet is such a cheap medium for the delivery of course content, it needs to be utilised to the fullest extent.
Marketing skills could be used to induce higher take up of courses e.g. the airlines pricing system for cheap fares - bookings get dearer each week closer to take off.
Or, buy one, get one free.
These are simple concepts, but they can help a course get established with a critical mass of participants.
Coming from a rural area, I face the problem first hand.
However, organizations such as PSA and the University Dept of Rural Health are beginning to make inroads in local education delivery. Budgets, however, are very modest for pharmacy and the disparity between what is provided for GP's compared to pharmacists is quite wide.
No matter, lean, mean and hungry can often produce better results.

To be able to claim back the weekend
There is a social movement towards the simplification of everyday life. People are finding that technology is not always working for them, and they do like to deal with human beings in their everyday endeavours.
Complexity is on the increase, as are work volumes performed by individuals.
Recent years have seen an exodus of Sydney people to live on the coastal fringe of NSW, primarily for the lifestyle.
It has often meant a step down in income and a change of lifestyle.
It is possible to conduct a value analysis on every aspect of a pharmacy environment, with the view to simplifying work.
How? When? Where? Why? Is it necessary at all?
If you are immersed in all the pharmacy problems that are at the "two minutes to midnight" stage, it is a little difficult to step back and gain an overview perspective.

However, this must happen at the macro end of pharmacy as well as the micro internal component of each pharmacy if we are ever to see the weekend again, enjoy the family and smell the roses.
Customers and patients will appreciate this review of activity, if it returns staff able to invest more time with them.
Despite the complexity, it can all be sorted out, and fairly quickly.
It just needs political will and commonsense.

TODAY'S SITUATION - A VIEW FROM THE PGA (Slide 7)

I was very interested to see a tender for a research grant advertised on the PGA website in mid December 2003.

On examination, it matched in well with my presentation for this conference.

Basically, the brief, in broad terms was:

1. How do we fix the current problems of community pharmacy?
2. Where do we go to from now?

In one sense, it is a relief to know that someone is taking a systematic approach to the range of problems inherent in contemporary pharmacy practices.

My only query is why this has not been an ongoing process and attempted to be addressed before trends became problems?

TODAY'S SITUATION - PGA IDENTIFIED PROBLEMS (Slide 8)

The PGA noted problems, in some instances, line up with my "two minutes to midnight" list.

Increased prescription volumes appears early in the PGA list, and here there is no disagreement. In fact there is no disagreement with their total list, except for the fact that the list is shorter than mine, and the emphasis for solution is different.

Accreditation is noted as one of the problems, and it is to a majority of pharmacist participants.
The concept of accreditation cannot be argued with.
Only the extent and depth of each procedure is arguable, and that the implementation has been a "top down" rather than a "bottom up" process.
As a management consultant, one of the first activities you establish with a client, is a survey of the entire organization, irrespective of the problem entry point defined by the client.
The survey is an accreditation-like process, because in looking at the entire organization holistically, you can develop a range of protocols and processes to assist the organization in its development and efficiency.
However, the recommendations a consultant comes up with are relevant to that specific organization, are prepared in consultation with staff and management, and in most instances, the consultant is employed in the implementation.
Vision and reasons explained, are methods employed to motivate acceptance, and help is at hand if the process comes under stress.
Accreditation has been taken up by a large number of pharmacists who have accepted the responsibilities in varying degrees.
In a significant proportion of pharmacies, this acceptance is performed under duress, because the accreditation procedures have not truly become part of the culture of those pharmacies.
With dedication and time, this problem will alleviate.
For the moment, there are a lot of overstressed pharmacists, particularly around re-accreditation time.

TODAY'S SITUATION - PGA IDENTIFIED PROBLEMS (Slide 9)

Consumer Medication Information: systems to economically publish this material, deliver it to a patient with proper explanation, and generate the time to economically fit this important procedure into a busy day, have yet to evolve.
The Internet may assist in providing some patients with this type of information, but there is a large gap of consumer knowledge as to how to access this information.
Long-term education of patients is required in respect of Internet usage, and this may involve in-store training.
In a different market, consumer use of computers in kiosks for image processing may point the way.

Home Medication Reviews: while increasing in number, accredited pharmacists are not necessarily at a critical mass to handle existing reviews, or future cognitive services that may be required by government.
A lack of experience translates to a low confidence factor.
Various pharmacist facilitators are being deployed into health areas to assist in the motivation and training of pharmacists, also to ensure smooth management of procedures and engagements with GP's.
Not all the dots are joined here as yet, but they will be joined over time.
Meanwhile, it remains a worry, and some pharmacists are turning their back on the problem as a coping mechanism.
I have confidence that solutions will evolve, with the development of local self- sustaining support structures.

Medicare entitlements: this is a policing process imposed on pharmacy as a means of correcting a faulty government database.
There are many unfair aspects contained in this process, which will probably be overcome with negotiation, but it is a slow, laborious and stressful process.

Compliance with S2/S3 standards: the sale of medicines falling into these particular poisons schedules imposes a degree of personal supervision by the pharmacist.
Different priorities overtake a pharmacist in a busy practice each day, and in many instances, S2/S3 standards are not completely observed.
It is clearly not the intent of a pharmacist to abdicate his/her legal obligations, and herein resides a weakness exploited by the Woolworths of this world.
They can simply point to an alleged breach of these requirements by a pharmacist, and argue that they can provide the same service.
It is a spurious argument, but with PR and media hype, it can be made to look horrendous.

Revised residential medication review service (2004-5):
GPs have had issues with the current method of providing this type of review. A re-vamp makes sense.
By making the system more "user-friendly" for the GP, it is thought that more medication reviews would result.
This is probably correct, and it adds to the melange' of activity that is already in the melting pot.
How to handle this opportunity through the creation of space and time in a busy pharmacy practice is still the $64 question.

Case collaboration with GPs (2004-5):
This would represent a completely new service, another opportunity for pharmacy and at the same time, another management headache.
If there is minimal uptake of this service overall, government may not remain interested in developing more cognitive services with pharmacy.
It is a dilemma that must be resolved.

TODAY'S SITUATION - PGA IDENTIFIED PROBLEMS WORKFORCE PROBLEMS - (Slide 10)

The graphs clearly show the problem up to 2010- the demand, represented by the mauve line, is diverging from the navy blue line, representing the supply.
This despite increases in intakes into pharmacy schools.
A convergent set of graphs can only occur by reducing demand, which means reducing the number of pharmacists leaving the workforce.
Older pharmacists leave the workforce to retire, younger pharmacists leave because more stimulating work can be found elsewhere.
Solution: look after the retirees and make it easier for them to sustain a working session, rather than a full day. For the younger pharmacist make the work more interesting and stimulating.
This latter work clearly lies in cognitive activities.
One potential solution is to speed up the accreditation process for recent graduates There is a waiting period before they can be considered for accreditation)

Supply of pharmacists can only increase through higher university intakes, or importing from other countries. If importing from other countries, some thought needs to be given to ensuring that imports spend at least two years practising in a rural/remote area- where shortages are chronic.
Money also enters the equation, for despite pharmacist shortages, salaries paid to graduates are down the bottom end of the pay scale compared with other professions.

The Workforce Study clearly illustrates the fact that unless we find ways of leveraging pharmacists, the management and logistical problems will simply get out of control.

Perhaps it is time to move pharmacy technicians into positions of responsibility where they can be trained to complete the dispensing process to a stage where, by exception, pharmacist counselling or intervention needs to occur.
Here Pareto's Principle will apply where 80 percent of the problems will arise from 20 percent of the situations i.e. in reality, only 20 percent of patients will need to be looked at by a pharmacist.

In the clinical area, a ready-made support group is available in the form of nurses. With retraining, I have found nurses (in the hospital setting where I have worked) to be an excellent support in developing medication reviews.

They are used to extracting information from patient notes, can interpret pathology results, and with properly designed "tools" can isolate problem drugs with patients.
I am sure an adaptation of this process would work in community pharmacy, provided the right environment was available.
There is also a necessity for a pharmacist to properly control this process and be the final reviewer.
There has been a Canadian report that nurse-developed medication reviews caused problems with GP's.
Some doctor groups have used this report to argue that the medication review process should be abandoned entirely.
Some pharmacist groups have argued that nurses should be excluded totally, as being unsuitable for the medication review process, also based on the Canadian report.
My experience runs contrary to both the above, the proviso being that nurses be properly trained to identify drug problems.

With the reality being that unless pressure is progressively taken off existing pharmacists, they will simply wear out.

I recently visited four community pharmacies in a rural town in northern NSW. Three pharmacists were able to see me, while the fourth could not.
There was only a smile from one of them (the least busy). The one that could not see me was visible from the front of the shop and his body language was a sight to behold.
Had I been a patient, I would have exited immediately.
Interestingly, two of the four were accredited to do medication reviews, one was in the process of completing, but was also taking steps to retire from pharmacy in the immediate future, and quote: "was not coming back".
All interviewed pharmacists expressed a desire to be involved with continuing education.
All were critical of the cost and availability (city based at high cost).

Despite all the problems with the human resource side of community pharmacy, it is "fixable".

I keep coming back to the theme of incorporation as a means of providing scales of economy, and providing a structure that would help to manage the problem.
However, there has to be a political "will" to do this.
Pharmacists do not appear to have ever recovered from the "Boot's Syndrome" of the last century and have shied away from embracing this type of business structure.

TODAY'S SITUATION -
PGA IDENTIFIED OPPORTUNITIES (Slide 11)

Increase in professional services
The PGA have identified that there is a huge potential for community pharmacy to provide an increased range of professional services.
The problems of tapping this potential have been discussed in this presentation, but a road map has yet to be completed by the successful tenderers of the PGA contract.
Government sees cognitive services in pharmacy as one way of reducing national health expenditure, and pharmacy is willing to provide these services.
To not do so means that professional growth would be denied to successive generations of pharmacists.
A huge investment is required in decentralised training and educational services, for both pharmacists and their support staff.
This applies to city-based as well as rural/isolated pharmacists, because the delivery of this type of education needs to be online with access to a mentor for assistance.

Potential to provide business to government, value-based services
The network of community pharmacies is a valuable resource for the distribution of health services.
Pharmacy is the only health environment you can informally walk into without the obligation for a payment to occur.
This environment can be leveraged to provide any number of government health initiatives, that can be enhanced and supported with additional and personalised pharmacist services.
Most of the activity contained in these services can be delegated to pharmacy assistants, and the services themselves would generally be complementary to a pharmacy environment.
Initiatives here would be able to be integrated, virtually immediately.

Greater prescription volumes
The PGA, as would most pharmacists, see increased prescription volumes, not only as an immediate problem, but as an opportunity for increased core business.
However, it is obvious that increased volumes cannot logically occur until the problem of managing existing volumes of dispensing is solved.

TODAY'S SITUATION -
PGA IDENTIFIED CHALLENGES (Slide 12)

Greater consumer expectations
As retailers other than pharmacy develop higher levels of service, so do consumers expect the same levels of service from pharmacy.
Not only expectations of better service, but also better prices.
Woolworths has succeeded in integrating its purchasing systems with those of its suppliers, and it is said that there are savings in associated costs equating to 16 percent of the purchase price of goods purchased.
These savings come from reduced shrinkage of stock (theft, damage), automated invoice payments (reducing office staff), higher stock turns (less capital investment and less costs in holding stock), less stock handling (reduced staff).
By integrating the supply chain system with the front of shop, information is transmitted in "real time" and better forward planning and scheduling occurs in both supplier and retail environments.
The savings in the retail area can also be dispersed through a pricing system. Woolworths call it Every Day Lowered Prices (EDLP), which is a system that accurately reduces the margins applied to key product areas, without damaging net profit budgets.
Of course, if Woolworths competitors came up to the same level of efficiency, they would lose their marketing edge.
The key to all the above is IT system integration and the use of an EAN numbering system in the form of a barcode.
Unfortunately, suppliers to pharmacy have not yet adopted the EAN system.

Maintaining quality standards
Until pharmacy can factor in a person to manage all the quality and accreditation activities, this area will always provide difficulty.
Again, scale of business enterprise plays a part here, with large multi-unit pharmacies being able to support this type of manager.
Small cottage-industry type pharmacies can only go so far.
The direction and manner of how quality standards arise also needs to be reviewed, so that they derive from the "coalface" of the business (bottom up), rather than be imposed externally (top down).

Government requests for pharmacy assistance in PBS entitlement/accountability
This is generic code for "be a policeman for government systems, without payment and cop all the adverse PR "flack" from consumers and patients".
Problems of this type can only be alleviated through adequate payment for services provided, and proper approved advertising and PR to adequately explain to consumers why new changes are being imposed.
Pharmacy has often been "scapegoated" by this latter process as governments seek politically to apportion "blame" to sectors totally unrelated, for just a few extra votes at election time.
This is an immoral process and needs to be politically exposed when it occurs, to make it a real cost to government, when they entertain such thoughts.

Reduced Workforce FTE's
I have already covered most of the issues surrounding this identified challenge and have suggested possible solutions.
If society values its pharmaceutical service, then it must be prepared to meet all the fair and reasonable costs, through representative government agencies.
This means proper funding for pharmacists and their employees, for services rendered on behalf of government.
It is always the tail wagging the dog, as reimbursement of costs is always a delayed process.
Government has to be convinced a claim for costs is valid.
It sometimes seems that government employees involved in the process are deliberately endowed with a lack of urgency, and impaired future vision.

Reduced capacity to respond to change
As pharmacy is currently structured there is an inability to respond to change quickly, and little capacity to deliver results.
This does not have to be the case.
There are many small, but positive changes that can be made to increase both ability and capacity, and I have mentioned many of them during this presentation.

The above was the last item in the brief to the successful consultant tendering for this Guild Research Project.
It will be interesting to see what the consultants can come up with.

THE BIG QUESTION - CAN WE DELIVER? (Slide 13)

Yes we can, with inspirational leadership and a mindset to overcome cultural obstacles inherited from the last century.

Tunnel Vision
When you are swamped on many fronts it is difficult to have both a broad vision and a future vision.
It is too depressing.
But this is what individual pharmacists need to do, to be in a position to instruct their leaders as to what their aspirations are.
Leadership, on the other hand, has the responsibility to keep suggesting options, and informing their constituents to the best of their ability, and to be creative in their suggestions.
Many individual pharmacists feel disenfranchised and distant from their leaders, particularly in rural areas.
This process begins with a vision and a motivational process to enthuse constituents.
But it has to be skilfully communicated.

Shaking free of the "Boots Syndrome"
Ever since Boots the Chemist took steps in the 1930's to set up in Australia, there has been a mortal fear of multi-unit, large-scale pharmacies.
This cultural fear of corporate entities has become permanently embedded in pharmacist psyche, being passed on from generation to generation.
It would be true to say that most pharmacists experience this fear and do not truly understand what it is that they are afraid of.
Of course, pharmacy political bodies capitalise on this fear when they wish to manipulate the multitudes (much the same way as the current federal government engineered the Tampa crisis).
Until pharmacy political bodies openly support the concept of a corporate pharmacy (and the PGA has openly opposed it), then I truly believe pharmacy is in a bind.
The only bright spot is that the Wilkinson Review supported the concept and that competition policy will force state governments to change legislation allowing incorporation.
But this is not the way to do it, having pharmacy being dragged unwillingly into the 21st century, as they will be half-hearted about that sort of imposed change.
Better that a more representative organization such as the PSA grasp the leadership mettle and fill the breach.

Stop ignoring the Wilkinson Report and get on with the job
It's all in there, and it's four years old and still not being enacted.
I once spoke to a well-known pharmacy historian, who tackled me about 25 years ago, asking the question "what was I personally doing to help develop pharmacy".
I was greatly indignant at that time, because I was expanding my consulting practice rapidly, and felt that every living and breathing fibre of my body was dedicated to the betterment of pharmacy.
He then pointed out that change had never occurred historically from within pharmacy, it had always been an external force that had generated major pharmacy change.
That force was usually government, the medical profession or a major competitor seeking to own pharmacy.
I disagreed very strongly then, but with the perspective of time and life experience, I have now bowed to his academic foresight.
Set these comments against the background of this presentation and it is very easy to predict how pharmacy will react.
Pharmacy will continue to lobby to have protective legislation and will batten down the hatches and stay with traditional and familiar values - a world that they think they can individually own and control.

But all the external forces of change have grown stronger.
Pharmacy has also grown stronger.
However, the combined force of the change-makers is now so much stronger than pharmacy, we will simply be forced to change.

Yet again, despite ourselves, we will have the right corrections made for us, and we will reorganise and progress into the future.

So yes, we will deliver, but we will be kicking and screaming while we do it.
So much better if we had planned to do it, and methodically engineered the appropriate "baby steps" towards a universal vision.

Stop the rush into Priceline and Woolworths - Build our own corporate structures
And once again I allude to the need for our own corporate identity.
Why would we take on the mantle of a Priceline or a Woolworths or for that matter, the "banner" of a wholesaler marketing group?
If we had our own structures, we would have no need!

SECOND BIG QUESTION -
WHAT NEEDS TO BE DONE? (Slide 14)

1. Systematically deal with all the "two minutes to midnight" problems.
2. Build larger and more sustainable pharmacies through a corporate merger process.

This will initially reduce the total number of pharmacies, but after a period of reorganisation a period of regular and sustained growth would occur.
This presupposes that restrictions will be removed on the number of stores able to be owned, and that location rules will be eliminated.
3. Create a cognitive services platform connected to a localised education system.

Within a corporate structure, there needs to be a sheltered and nurtured area allocated to cognitive services.
It should be relatively unstructured in its time management and should be kept well away from the suction and noise of the reactive (retail and dispensing) areas.
This will be the embryo from which cognitive services will emerge from, and an area that will attract and encourage pharmacists.
If education services are localised, there will be a greater retention rate of pharmacists, particularly if they are salary-packaged into the ownership of the pharmacy.

This provides the "interesting jobs" and the financial return to satisfy basic aspirations, which will get the best efforts from our pharmacist community.

THE PRESCRIPTION QUESTION (Slide 15)

The big issue management problem
Without doubt this is the big issue management problem for pharmacy.
Pharmacists with successful practices are simply being "punished" with too many prescriptions to dispense in a legal and safe manner, let alone looking to value-add with counselling or other enhancement.
This creates vulnerability, a high stress level, and a sense of tiredness that makes a pharmacist feel they are staggering from one day to the next.
Obviously, there are degrees of the above symptoms, with younger pharmacists still imbued with energy and enthusiasm and eager to soak up and adapt to any new management processes.
But even they reach "burnout".
As the average age of a pharmacist is around 55+, consider the stress on the body as they literally stand for 8 to 10 hours at a time without a real break.
Forward pharmacy enables some pharmacists to be seated for part of the day, and this is sensible.
But not all pharmacies can physically accommodate a forward pharmacy design.
Something has to give.

Extended Hours
The time frame for dispensing obviously needs to be "stretched" so that the rate of dispensing, in terms of prescription items per hour, can be modified.
I have previously mentioned "sessions" of 4,5 or 6 hours for pharmacists, particularly senior pharmacists.
Working pharmacists over a week, with a choice of sessions may uncover retired, semi-retired or just plain tired pharmacists, willing to work reduced hours to suit their lifestyle.
Alternatively, you may pick up a young pharmacist with a big mortgage willing to moonlight a few evening sessions each week.

Extended hours shopping, introduced by major retailers, has raised consumer expectations for this service.
Pharmacists, along with other small retailers, have difficulty in matching extended hours, both in human resources and sales.
It is a management and marketing problem that must be resolved.

Financial incentives
For many years, the up-front impost on PBS dispensing has been regulated at a universal $ value, no matter where you practised in Australia.
This now needs to be negotiated to have a premium or discount in price, relating to the time of pick up.
It is unrealistic for patients to continue to expect to pick up a prescription in five minutes, or wait, because "it is only tablets", or "don't worry about a label because I know how to take it".
People that demand that level of service need to pay for it.
A prescription left at a time when there is a high intake of other prescriptions, ought to attach a financial benefit to the patient if they are prepared to pick it up in a normally quieter time.
This allows better scheduling of resources and an opportunity to provide a legally and professionally correct service.
Genuinely urgent prescriptions obviously require immediate attention, and such prescriptions would be exempt.
But it has to be said that pharmacist time management has become mixed up with marketing strategy, and they have been "hoist in their own petard".

E-Pharmacy solutions
These may eventuate slowly as systems like MediConnect evolve.
But big systems always take years to perfect and they still arrive with "bugs".
IT solutions, particularly those developed by pharmacists, should be given formal encouragement through official pharmacy, by arranging trials with interested groups of pharmacists.
This would encourage systems developers, and without a doubt, some interesting alliances would be formed, even between competing systems.
With official pharmacy acting as a catalyst and as a facilitator, this process could become a major plus, and progress the problems of pharmacy in an integrated manner.
It's worth a thought, although one wing of official pharmacy has recently confused the issue by patenting a system remarkably similar to components of MediConnect.
Perhaps PSA could lend a hand here.

Accredited dispensary technicians
The UK has "prescription checkers" - pharmacy technicians that have been educated and trained to a high standard to legally complete prescriptions without direct pharmacist supervision.
The education process to get a technician to a diploma level has already commenced here in Australia, and other forms of training and standards are in place.
Consider that the old pharmacist qualification of PhC was, in reality, a diploma level.
It does not take much imagination to visualise an Australian pharmacy technician completing and handing out prescriptions.

If the final process of handing over the dispensed prescriptions is sorted into patients receiving a drug for the first time, and patients receiving repeats of previously dispensed drugs, then
by exception, pharmacists would associate with the "first dispense" function, delegating the remainder to a trained technician.
Thus technicians could be delegated a large percentage of the daily workload.
Other benefits accrue.
Technicians are generally recruited from the local area where they have potentially lived all their life.
They are not as mobile as pharmacists, who generally have to be imported.
If the technician diploma course could accrue credits for a pharmacy degree, I believe a more stable workforce would emerge.
It would create opportunities in local communities, and no matter where people are located, they would have a clear career path

THE PRESCRIPTION QUESTION -
CONTRACT DISPENSING AND ROBOTIC DISPENSING (Slide 16)

Contract dispensing
What I am endeavouring to do in this presentation is not only to highlight the problems of pharmacy, but to suggest a range of solutions.
Contract dispensing is a thought that may require assistance in the legislation area, particularly in regard to PBS dispensing.
In the past, pharmacy has had many contractors to assist in dispensing.
I remember when we used to have to prepare claims manually, and contractors appeared to do the job on behalf of a pharmacist, and many (myself included) gratefully availed themselves of the service.
Methadone is another service that springs to mind. Pre-packs of different doses enable many clinics and hospital pharmacies to be able to provide a regular service to a large number of patrons.
Many pharmacists continue to contract out their book-keeping.
So why not the actual clerical elements of dispensing?
It's worth a thought.

Robotic Dispensing
It would appear that this is where the real breakthrough will occur.
Dispensing is very similar to the production line of a manufacturer, without the luxury of a single product line.
Like manufacturing, dispensing follows a clearly defined workflow, with periodic inspections along the process for quality assurance.
Most of these inspections can be delegated to pharmacy technicians.
The final inspection currently requires the use of a pharmacist, but a large component of this may be able to be delegated in the future.
With the pharmacist completion of a prescription, a clinical and educational process involving the patient takes over, totally distinct from dispensing.
Hopefully, with all the above processes in place, the service can be provided in appropriate space and time.

REACHING A LOGICAL CONCLUSION (Slide 17)

1. Pharmacists should not expect the level of legal protection they have enjoyed in the past. Certainly, some consideration has to be given because of the nature of the business.
Instead they should be allowed to "grow" within themselves and develop the muscle to take on the Woolworths of this world.
Given the resources, I would personally enjoy the challenge.
2. Pharmacists should look at managing in non-traditional ways.
Thinking "out of the square" creates interest and excitement and allows different models of pharmacy to evolve.
The Wilkinson Report noted that pharmacy practices were too homogenous.
And it was right!
3. Genuinely compete for markets and manage them in a sustainable way.
Given the problems of dispensing and the introduction of cognitive services, many pharmacists have elected to drop a range of OTC markets, or delegate the management to an organization such as Priceline.
Pharmacists have always had good retail instincts, and many manufacturers out there have used pharmacy to launch their products.
Pharmacists were good at that, and always established a premium price point for the manufacturer.
But they could not sustain market growth, and manufacturers simply went to major retailers with most of the hard establishment work already done.
This process has often caused backlash within pharmacy, but with simple marketing strategies in place, this would have been avoidable.
Pharmacy should have been able to sustain market growth for longer periods and ought to have been able to offer real competition if the product went "open", or use its market muscle in a different direction.
Abdicating the retail market is not a good strategy, because a less flexible and dynamic pharmacy is the result.
Pharmacy can have it all….provided it learns the current lessons very well.

4. Develop and establish new markets
Why not?
This is where interesting work is created.
And why not involve cognitive services here.
Marketing processes, particularly the advertising component, are communications processes.
This is not being done too well in respect of, say, Home Medication Reviews (HMRs).
Have a look at a recent poster issued by the Dept, of Health and Aging that advertises HMRs.
It is not very inspiring.
However, this market is still very young and there is no doubt that it will pick up in momentum, with all the obvious gaps being filled.
My point is that the community pharmacists have still to win their weekends back, to enable them to think the logistics of new markets through to a suitable end point.

5. Being automated and integrated in all the systems that handle the volume loads in a pharmacy, is an ultimate goal.
Being able to pick the right systems to work with is currently like trying to pick a winner at the Randwick races.
Big money is lost when you don't pick a winner, and if you are not an educated punter, you are more likely to lose.
How to get this expertise?
Put yourself back to school, or at least hire an IT manager to educate you.
To accommodate this management skill, and all others mentioned along this presentation, you need a scale of economies to support them.
This is only likely to emerge within a corporate structure.
Divisions of General Practice have established good working models - much can be learned from this.

I would like to conclude with a forecast that it will take at least a decade for pharmacy to work through its current range of problems.
This will involve massive change - more in the next 5 years than has been encompassed in the past 150 years.
But face it we must, and there will be many casualties along the way.
If we don't succeed, then we will have the Woolworths of this world picking up the pieces.
They are barking at our heels right now, and we should move along from a leisurely walk to an outright sprint, if we are to shake them off.