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On
the 9th February, 2000, the Prime Minister wrote to the Premiers
and Chief Ministers suggesting the Council of Australian Governments
(COAG) provide a coordinated response to the Final Report of the
National Competition Policy Review of Pharmacy (in the context
of this article, called "The Review"), in order to provide
national consistency in pharmacy regulation.
This was the review chaired by Warwick Wilkinson.
COAG
eventually referred this "Final Report" to a committee
of senior Commonwealth, State and Territory officials for considered
comment (called "The Working Group"). These comments
are important, for many have not officially found the light of
day, and given the upheavals that are daily occurring to the structure
of pharmacy, it is important that the thinking of this committee
be illuminated, so that pharmacists can develop appropriate strategies.
Because
the committee's comments are fairly lengthy, I will try to paraphrase.
Words in inverted comments relate to actual sections of the comments.
"Review
Recommendation 1.
a.
That legislative restrictions on who may own and operate community
pharmacies are retained; and
b. With existing exceptions, the ownership and control of community
pharmacies continues to be confined to registered pharmacists.
The
Review concluded that 'on balance' pharmacist ownership of pharmacies
provided a net public benefit to the community through improved
professional conduct of pharmacy practice. The Review suggested,
however, that ongoing ownership privileges are dependent on continued
industry participation in recent self-regulation activity, and
the further development and adherence to professional standards
and industry quality assurance benchmarks."
The
result of Review Recommendation 1 has been the development and
implementation of the accreditation process by the Pharmacy Guild
of Australia. It is important to share the Pharmacy Guild's concern
about ensuring that the majority of community pharmacies become
accredited, because not to so do, would leave a clear gap for
open ownership of pharmacy. Existing pharmacies would be thus
shown to be below a recognised standard.
This
is reinforced by the working group conclusion to the above which
was:
"The Review's recommendation to restrict ownership
to pharmacists was reached 'on balance' having regard to net public
benefit. The Working Group did not find The Review's arguments
persuasive (as a range of pertinent factors was apparently not
examined). Although the Working Group proposes that these recommendations
be upheld, in view of their contradiction with normal market principles,
it is suggested that the restrictions be revisited once other
reforms have been implemented, and in conjunction with the planned
review of location rules in the ACPA.
Suggested
COAG response to Recommendation 1
*
Accept recommendations 1(a) and 1(b) noting that doing so does
not imply an obligation on the ACT and NT to amend their legislation;
and
* Noting the reservations of the Working Group, revisit this issue
when other reforms have been implemented and in conjunction with
the planned review of the location rules in the Australian Community
Pharmacy Authority (ACPA)."
Remember
that this is the thinking of the "power brokers" behind
the scenes. They noted that The Review was hampered by a lack
of available evidence, and did not consider broader evidence such
as a comparison of the regulatory environment pertaining to allied
health and other professions within Australia.
They were also concerned that a comparison to the regulatory environments
overseas (particularly the U.K and the US) where pharmacy ownership
is not confined to pharmacists, was not undertaken.
This
means that the door is still open on pharmacy ownership, which
is contrary to what most community pharmacists have been led to
believe. This writer has long held the belief that the "carrot
and stick" approach adopted by the regulatory authorities,
in respect of pharmacy, was simply to make pharmacists jump through
the hoop, until they give up in sheer exhaustion, thus leaving
open ownership as the only alternative.
One can sense the powerful lobbying interests of Woolworths and
Coles behind the scenes, combined with pressure from global pharmaceutical
companies, who want an unfettered entry into Australia.
The
fact that pharmacy has held on for so long is tribute to the individual
management skills of pharmacists, and the collective political
skills of official pharmacy.
But
can this continue?
With
the economic rationalists still in ascendancy and guiding national
competition policies, the rush to join the "new economy"
and become part of a global network, is fueled by governments
of all flavour.
This can only serve the interests of giant global corporations,
that do not necessarily serve the best interests of "micro"
Australian towns and cities, in their local economies.
Already the top 1000 Australian companies cream off 87 percent
of all business profits within Australia.
And they will not stop until they have 100 percent control.
This is why there are two separate economies within Australia
and why major banks are happy to service the global economy, leaving
the rest of us to fend for ourselves in an "underclass"
economy.
The Federal Government appears to actively assists in this transfer
of wealth, from small business to global corporations, through
its administration of new Taxation Laws, which do actively discriminate
against small business.
Perhaps
now is the strategic moment for official pharmacy to plan strategies
to counter the arguments relating to the lack comparative UK and
US evidence, as mentioned by the Working Group of the COAG committee.
I am sure some work has been done in this regard, but I would
point to a comment made recently in the British Pharmacy Journal
(Vol 268 No 7185 p208 16th February 2002), which can be reached
online at http://www.pharmj.com/Editorial/20020216/comment/spectrum.html
.
The comment was made by Graham Southall-Edwards, who is both a
pharmacist and a barrister.
It should be required reading by all Australian pharmacists, and
would be a good starting point for official pharmacy to begin
to gather their evidence.
Further, I would suggest that Mr Southall-Edwards would appear
to be an excellent consultant/legal resource for any of our official
bodies to retain.
What
follows is part of his commentary:
"Over
the years, almost every pharmacy my wife,or I, have worked in
has become part of a multiple chain; as early as the mid 1980's
this had resulted in centralised management, with pharmacist-managers
losing all power to manage and becoming merely the servant of
the "senior assistant".
Why
was all this happening? The answer is that the limitation of pharmacies
had started to drive the endless buying mania of the growing multiples;
almost every private sale became a corporate acquisition and every
small chain went to a larger one. Goodwill values soared and along
with them went the loss of the main ambition of the young pharmacist-future
proprietorship."
Does
this scenario sound familiar?
With limitation on pharmacy ownership, pharmacy numbers (per pharmacist),and
location, Australian pharmacy has arrived at a somewhat similar
situation.
The only difference is that pharmacists have retained ownership
to this point in time and have retained professional control.
The primary factor in this result has been the limitation of approval
numbers in a restrictive regulatory environment i.e. the free
market factor has been removed by government intervention.
Not quite as bad as the UK, but showing what is likely to occur
if Australia does not free up some of its market restrictions
(but still under pharmacist control).
The
commentary further noted:
"
What continues to surprise me is that these large companies have
never been externally regulated. Of course, there are internal
checks and balances, but there is no mechanism to ensure that
their activities further the profession of pharmacy. They are
often run by "risk averse" individuals who, on their
own, could never keep going for long. The senior management in
these companies and their line managers therefore seek to secure
themselves by endless rules, manuals, procedures, superintendent's
bulletins, pharmacy log books, and general restraints on the exercise
of personal professional freedom. It is what a well-known, successful,
experienced pharmacist friend of mine has termed the 'protocol
for blowing the nose'. Not an environment to experience job satisfaction."
What
Mr Southall-Edwards is talking about is a critical loss of professional
discretion and an almost total loss of professional development,
because the only "external regulator" to these corporations
is the shareholder, to which all is sacrificed.
A similar situation occurs in the US, as reported by Pharmacy
Week, the publication of American Health System pharmacists. From
a poll of their own members taken on the 16th October 2001, they
asked the question:
"Have you ever had your professional judgment challenged
or overridden by management for the sake of 'customer service'."
The 'Yes' response was 68.8 percent, and the 'No' response was
31.3 percent, with a total of 64 respondents.
It
seems that with both the US and the UK, with their open ownership
system, there is a decrease in professionalism, which cannot be
in the 'public interest'. These facts should be brought to light
now and delivered to COAG on a continuing basis, so as not to
wait until the confusion of the next 'revisit' by a government
committee.
Mr
Southall-Edwards calls for proper regulation of the pharmacy profession,
and some of his proposals may act as a deterrent on future non-pharmacist
owners, if they eventuate in Australia.
He recommends a regulatory pharmacy organisation that:
"*
Sets mandatory requirements for proper staffing levels.
* Sets minimum staff pay levels which properly reflect training
and responsibility and encourages continual employment.
* Sets limits on the number of prescriptions which any one pharmacist
can safely dispense in any given period.
*
Supports the individual pharmacist in his/her right to practise
their profession free from corporate interference and rules.
* Makes it a requirement that multiples should have at least,
say, 90 percent of pharmacies supported by a permanent manager
with proper authority to manage.
* Is prepared to take effective action against corporate superintendents
where such conditions are not met, or where the conduct of the
pharmacy is otherwise unprofessional, brings the profession into
disrepute, or simply dangerous as many locum-run 'volume-dispensing
hell-holes presently are."
From
the above suggested check list, it may be that Australian pharmacists
are already covered for a number of the points illustrated. But
there are some obvious holes e.g. legislation limiting the numbers
of prescriptions dispensed per pharmacist, and a mandatory level
of staff.
Mr
Southall-Edwards goes on to give the analogy of unscrupulous trucking
companies, before controls came into being (tachographs, controls
on driving hours, log books etc) as equating to similar companies
churning out open-ended prescription volumes. He describes the
end effect as being identical..damaging the pharmacist (and truck
driver) general health, and the public who they kill and injure
through stress.
He says:
" As a matter of law, if the death of an individual should
result from such inadvertancy or the unjustified running of such
risks, those at the top could well find that they are liable to
be indicted for manslaughter."
Food
for thought, indeed, and triggers off a need to think through
a suitable regulatory framework now, should open ownership result.
Plan B developed now, may act as a deterrent for later.
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NEIL
JOHNSTON