AUGUST,Edition # 32, 2001

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In the fifth article in this series, concerning the establishment of a consultant pharmacist practice based in a community pharmacy, I will be looking at the various activities that can be undertaken by a consultant pharmacist, and how they are to be marketed.

In the evolution of the model being constructed for consultant pharmacy, I have discussed structural changes to fixtures and fittings, the use of pharmacy human resources as "directing forces" for selling consultant pharmacy (primary practice assistant, dispensary technician and the forward pharmacist), and the concept of charging a fee for a private service.
It should be noted that within this model, the forward pharmacist is not a consultant pharmacist. This person is part of the dispensing process and has to be paid out of the profits of dispensing. The forward pharmacist is also the visible face of the free services offered by the pharmacy, and because of this, has to budget time for each service
The model is an idealised one, but many elements are in place in community pharmacies now, in some form or another.
A progressively changing floor plan has been illustrated in each of the previous articles, and it is now basically completed.
For this reason, it is not reproduced in this article.
However, the need for differing types of office space is discussed for consultant pharmacists. The office space delineated in previous floor plans is important space, but not necessarily the primary space.
As consultant pharmacy will actually grow out of community pharmacy, recognition of pharmacy located consulting space, is acknowledged as being a permanent feature of community pharmacy.
However, consultant pharmacists may need diversity of space, and this is noted further along the article.
Because each article in this series builds one on the other, it would probably be a good idea to review all previous articles.
The links at the foot of this text will navigate you to the appropriate locations.

Consultant pharmacists will have to be able to operate by dividing their total working week into segments, to take account of patient interviews, interviews with co-professionals, research time and internal practice management time.
They should not be involved with the dispensing process and should practice as a business independent of the pharmacy, simply leasing the space.

The services that consultant pharmacists could offer fall into a number of categories:

* Services contracted with the pharmacy (or pharmacies) in which space is leased.

* Services contracted with general practitioners.

* Services contracted with self-help groups

* Services contracted with health agencies for lifestyle promotion.

* Individual patient programs initiated as a unique consultant service.

Because a community pharmacy may see a consultancy service as being a valuable adjunct to the pharmacy business as a whole, it may be possible to contract a range of services which are on-marketed by the pharmacy, with payment underwritten by the pharmacy in part or in total.
Remember, that in this model, the consultant is operating within a totally separate business structure to that of the pharmacy proprietor.
They should be two distinct people and at "arms-length".
This aspect will assume more importance as the process of "being a consultant" emerges.
The nature of consultancy is that it should be, and appear to be, completely independent of any processes that can manipulate a result, particularly in the financial area.
The progress of pharmacy consultancy has been clouded from its inception, and other writers have pointed out that the structure of the Australian Association of Consultant Pharmacists (AACP) is not one controlled by the actual consultants.
It is really controlled by the Pharmacy Guild and the Pharmaceutical Society.
I do not want to be seen as being negative in respect of the work accomplished through the AACP, because their achievements are to be commended, particularly with regard to the minefield of medical and federal government politics that have to be contended with.
Nor do I wish to seem at odds with community pharmacists who will have to undergo a transition involving reduced returns from current dispensing volumes, coupled with reduced numbers of prescriptions, which have to be replaced with clinical services for a fee.
This is going to be a painful process for some.
However, I must remain committed to developing my "idealised" model for consultant pharmacists, which will also seem at odds, in some aspects, with the official evolving model.
Please make use of the reader's forum link to post any comments that will help to extend the debate towards an accepted mutuality.
The pathway ahead will have some difficulties, and we should also note what recent history has taught us.

To sum up for the moment, for a consultant to be in a position to develop a clinical practice, he/she should be incorporated within their own business structure (not being a community pharmacy), have their own office (home-based or commercial), with extensions into leased space from pharmacies or other professional areas.
The consultant will operate under a separate code of ethics designed specifically for their calling.
On the Computachem site, I found a Code of Ethics prepared by the Institute of Management Consultants, from which I extracted two clauses. They will become more relevant as time progresses.

"· A member will neither accept commissions, remuneration nor other benefits from a third party in connection with recommendations to a client without the client's knowledge and consent, nor fail to disclose any financial interest in goods or services which form part of such recommendations.

· A member will avoid acting simultaneously in potentially conflicting situations without informing all parties in advance that this is intended. "

Discussion around the above two clauses will continue later in the article.

Now it is obvious that a discussion on pharmacy consultants, and their fees, cannot be done in isolation from what is being officially rolled out.
The establishment of a consultancy service will depend on a regular and reliable cash flow source.
In the initial phases of establishment, sources of income derived from schemes such as the Domiciliary Medication Management Review (DMMR) program will impact dramatically on the mix and balance on what services a consultant will provide. Consultants within my "idealised" model will participate in the official schemes as well as developing their own private initiatives.
To not have a private counterbalance will be to fall into the trap set at the original commencement of the National Health Scheme.
Promised was that only 25 percent of "life saving" prescriptions would be nationalised.
Today it incorporates 95 percent of prescriptions, many not life saving, with pharmacists having little say in where they might wish their dispensing business to develop.
Dispensing business has become part of a government health strategy, where the pharmacist takes all the financial risk and is literally a civil conscript, trapped in a process of diminishing returns.
This must not happen to consultancy services.

But it would seem that history is about to repeat itself, unless defensive strategies are developed early by consultant pharmacists.
Consider that with the rollout of DMMR, a doctor is being paid $120 to initiate the service of a medication review for a patient (for a minimal amount of work, and without having to leave the surgery).
The contract, under the rules, must be given to someone holding an approval number i.e. an established community pharmacist.
From this point, the community pharmacist does the actual work of a medication review, by visiting the patient in their home (if an accredited pharmacist), or farms the work out to another accredited pharmacist, who may be an employee or be in independent practice.
When the work is completed, a fee of $140 is paid to the approved pharmacist, by the government.
The time involved, relative to the doctor, will be much greater, and will involve the overheads of motor vehicle expenses, travel time plus other incidentals such as mobile phone calls.
The scope of the service is determined by the fee, which is fixed, and cannot be expanded unless there is a co-payment from the patient.
Herein lies the second lesson from history.
Pharmacists in their dispensing role have never legally been able to charge fees additional to the legislated dispensing fee.
Doctors have successfully avoided this trap down the years, and have also avoided becoming financially depressed.
Community Pharmacists suffered the consequences, and consultant pharmacists must not be led into this situation. A private market for consultants must be allowed to grow, by value-adding to services such as DMMR.
Now a true consultant deals directly with his/her client and works under an established fee system relative to their activities.

Who is the client in the DMMR scheme?

Is it the doctor who initiates the process?
Is it the community pharmacist?
Is it the patient who doesn't pay anything?
Or is it the Federal Government who ultimately bankrolls the process?

The person who pays the fee to the consultant will be the community pharmacist.
Is this person the client because of this?
If you think about it, the patient is the true client, but is clearly separated from the consultant pharmacist by layers of bureaucracy.
So for the moment, the community pharmacist must be regarded as the client and fees charged to this individual must be relevant to the time expended per assignment, plus overhead costs.
This may be in fact, be a charge higher than the community pharmacist receives from the government.
This relationship has the potential for the community pharmacist to influence a degree of control over the consultant pharmacist, to engineer an outcome that may develop a benefit for the community pharmacist.
This benefit may extend to the consultant pharmacist as well, which may further breach of the first clause in the code of ethics above.

There must also be an opportunity for the consultant to develop the real client (the patient) in some areas of value-adding. In these instances, direct dealing with the patient by the consultant, must be allowed to become a norm, without professional repercussion.
So the two clauses from the code of ethics for management consultants now have more import, particularly the clause relating to conflict of interest.
If an enhanced service arrangement develops, with the patient totally separate from DMMR procedures, then all relevant parties to the process must be aware and be in consent.

What is proposed officially for consultant pharmacists is not a true consulting arrangement.
It appears more to be a process to assist community pharmacists to develop a stream of income, not related to mark ups and dispensing fees (which will continually come under pressure).
I have sympathy with community pharmacists who will have to endure this transition, many against their will.
Those that are not prepared to adapt and educate themselves to a higher level, will obviously be consigned to a life of low return dispensing.
Some may like this, most will reject such a life.

Without labouring the point, consultant pharmacists must begin to take responsibility for their own professional lives, the direction of which may be different to that envisaged by the Pharmacy Guild, for its members.
This means developing a code of ethics relative to consulting, moving towards a governing body controlled by consultants and developing a scale of fees relative to the actual cost of providing services, plus developing a true client base in which you deal with each client directly.
Without the above, you can never be a true consultant, nor will you grow a professional market of services.

The need to work by appointment is also paramount, because there may not be sufficient work generated by one pharmacy for a full time consultant pharmacist, in the development stages of establishing the market.
Consultant pharmacists may need to stake out a region, visiting one or more pharmacies per day, to generate sufficient income.
Ensure that there is no conflict of interest by working in directly competing pharmacies.

In future articles I will work through the detail of establishing categories of services so that with more to sell, the region serviced can diminish in size and accommodate more consultants.

Article 1

Article 2

Article 3

Article 4

Ends

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