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In a previous set of articles I have outlined procedures for establishing and marketing a formal and independent consultancy service, utilising government funded services to create an initial cash flow, but looking to establish a balancing private sector activity.
My closing remarks in the last article (Article number 6) were to the effect that for consultancy to become a vital part of pharmacy, it must have a healthy private sector component, so as to avoid manipulation by governments, competing professions, and global drug companies.
Already, we are seeing some evidence of this in the doctor area, particularly as Domiciliary Medication Management Review Services (DMMRS) are being rolled out.
I would hasten to add that I have confidence in the eventual outcome, even though I would have wished that the whole scheme could have been organised differently, and at better remuneration rates.
However, pharmacists are both survivors and innovators.
Economics, practicality and the need for a service will become the final arbiter of what will survive.
I also stated that you had to become a "generalist" across a wide range of services, before volume of activity forces you to specialise in a particular field.
If you have not read previous articles, then I would advise that you visit the links at the foot of this article to understand the perspective from which I am viewing the consulting process.

All consultants, no matter in what field or discipline consultancy is practised, are essentially problem solvers. Hence, any service provided by pharmacists that has a large component of research and problem solving content, can be regarded as a true consulting service.

In this regard, I would like to discuss the service of "compounding".

Prior to the National Health Scheme coming into being, nearly all dispensing was of the compounding or extemporaneous variety. There was only a minimal amount of dispensing of branded manufactured products. A distinct antagonism existed towards branded products, and even when pharmacists counter-prescribed, as many compounded preparations as possible were devised for patients.
This led to the pharmacists of the day to carry around with them their own personal pharmacopoeia of personal formulas and remedies, in an indexed note book.
It was a jealously guarded piece of intellectual property.
While the laws of the day did not protect intellectual endeavours to the extent they are covered today, it would have to be assumed that this process, updated to today's environment, would be legally protected.
In earlier days, to preserve secrecy, pharmacists would personally dispense their own formulations, after previously consulting with their patient. They would also counsel patients on the return visit as to how they should take their personally compounded medication.
This type of service was in high demand by consumers, and patronage was built around an individual pharmacist, regarded by patients as "their pharmacist".
The service was profitable, built prestige, and embraced all the components of "forward pharmacy" and "consultant pharmacy" which are being re-established today in a more formal sense.
What I am talking about is the "core business" of a pharmacist.
In the rush to establish "new services" in pharmacy, you tend to forget that these services have always existed. The segments of service are simply being identified, enhanced, and made more specialised.
My previous articles reflect this development and have pointed out that consultant pharmacists need to be divorced from the mind-numbing, prepackaged mass dispensing process, which does not allow for creative thought development.
It is this reactive process of mass dispensing which prevents pharmacists from entering into the creative process of consulting.
Yet even mass dispensing is a "core business" of a pharmacy.
It just needs to be separated out and managed by "mass methods" involving minimal overheads. This means that this area now is essentially delegated to pharmacy technicians, up to the point of patient contact, when professional input is required.
It cannot work otherwise, as mass dispensing volumes build up year by year.

However, there are specialised dispensing areas that consultant pharmacists have a real role to perform in.
They are classified as:

1. Doctor initiated compounding.
2. Hospital initiated home services (Parenteral Nutrition and Intravenous Antibiotics).
3. Cytotoxic dispensing.
4. Patient initiated herbal compounding.
5. Patient initiated allopathic compounding.

Pockets of pharmacy compounding are found in hospital pharmacies, pharmacies located near specialist centres, pharmacies servicing hospital outpatient clinics e.g.oncology, pharmacies that have specialised in a disease state, and pharmacies (generally family owned) that have carried forward traditional services.
Some herbal dispensing services are offered in a few pharmacies, but because compounding skills have been lost, these are often performed by naturopaths or medical herbalists.
Perhaps the subjects of pharmacognosy and materia medica need to be revived and expanded as part of a continuing education program.
It is probably fair comment to say that community pharmacy has abandoned compounding due to the pressure of mass dispensing, but with a re-arrangement of work flows, space and human resources, it could again flourish.
In America, it has become a "boom" business where specialty is developed and marketed accordingly.

Pharmacy compounding in Australia is controlled under the various Poison Schedules and the Therapeutic Goods Administration (TGA).
Pharmacists have to observe certain provisions:

* The compounded product must be individually prescribed for an identified patient (this excludes pharmacist formulated and dispensed house labels, such as cough mixtures, which require TGA approval).
* That active ingredient chemicals individually qualify for use under the TGA approval system.
Pharmacists interested in developing a compounding wing to their business should contact the TGA for a copy of all legal requirements, as the above is only a basic overview.

It has been said that:
"the compounding pharmacist is a problem solver in the community, working with patients and physicians, to gain positive outcomes".

No other health care professional has studied chemical compatibilities and can prepare dosage forms. Even when modern technologies have produced new chemical entities, the ability of the pharmacist to combine one or more chemicals into a new preparation, or process the existing dosage form into one that is better suited to the patient's needs, has remained the domain of the pharmacist.
Every patient is different, and compounding will always be an essential practice of the profession.
There have been recent moves by global drug manufacturers (in America) to have compounders submit their products to the Food and Drug Administration (FDA)for the same approval process required for each of their manufactured products.
Every compounded product is seen as an erosion of the "branding" process.
Fortunately, legislators have recognised that restricting the process is not in the interest of consumers generally, and would be impractical to implement.
However, it does send a signal that because of the rise of compounding, manufacturers see this as a threat to their own activities, however minimal, and will seek to control the process another way.
This may occur by purchasing and controlling all compounding centres, and is another reason why pharmacy ownership in Australia should remain under the control of pharmacists.
Consultant pharmacists should always ensure that they are practising well within the TGA guidelines and develop procedures that eliminate medication errors.
Any adverse event will be seized by manufacturers as a reason for eliminating compounding by pharmacists.
Every step of the compounding process requires a unique knowledge base developed from personal research, an ability to communicate with patients and doctors, and a specialised skill to produce the final product matched to patient need.
Isn't this consulting?
While the actual dispensing of the product may not strictly be regarded as consulting, it should be noted that there is always a small structured component to any consulting activity. However, purists may prefer to contract their dispensing with a community pharmacy established for this process.
If you have structured your practice along the lines mentioned in my earlier articles, then you would already be leasing space in a community pharmacy and referring your dispensing to the dispensary located within that pharmacy.
If your practice was fully developed, you would,as the consultant, have had interviews with the patient (by appointment), and the patient's doctor (if the prescription was doctor initiated).
The actual compounding would be delegated to the pharmacy technician and the Forward Pharmacist would have been briefed on the dispensing supervision needed for the technician, and the counselling points to provide the patient on pickup.
Instead of one person being involved as for pre-NHS times, three specialised people are involved, each utilising a high level of qualified skills

In future articles I will touch on each of the areas of compounding services noted above, and in particular, will look at partnering opportunities that are beginning to open up with public and private hospitals.

Article 1

Article 2

Article 3

Article 4

Article 5

Article 6

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