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EDITOR'S NOTE: In his final article for 2003, Con Berbatis discusses various influences that may occur in a deregulated pharmacy market, dominated by supermarket pharmacies.
He delineates defensive strategies utilising his research involving pharmacies globally, and also comes up with a proposed pharmacy model that is an ultimate Quality Use of Medicine model.
As we all ponder what lies ahead in 2004, Con Berbatis has cleared the pathway and given a sense of direction.
All that is required now is for the whole of pharmacy to fall in line with his thinking and reposition the new boundaries.
It is acknowledged that the Pharmacy Guild of Australia has some difficult decisions to make, but if they are delayed, we may see permanent damage to pharmacy infrastructure.
Political lobbying for more protection can only ever be a short term delaying tactic.

1.1 Rapid restructure of US pharmacy by supermarkets
If community pharmacy is deregulated in Australia to allow supermarket pharmacies then just watch how quick they will take over !
In a recent article I reported :
"…In the USA the supermarket and mass merchant (discount store) pharmacies transformed US community pharmacy in just a dozen years (see Figure 1) !
The main trends from 1991 to 2002 were a decline in the ratio of pharmacies : population by more than 20% since 1991 to 1 : > 5,100 in 2002 .
In contrast the ratio of mass merchant and supermarket pharmacies rose to 1 : <20,000.
Supermarket and mass merchant pharmacies almost doubled from 14.6% to 27.3% of the total community pharmacy outlets.
Independent (pharmacist-controlled) pharmacies decreased from 53% to 35.8% . The large chain drug stores are mainly non-pharmacist controlled with several chains such as Walgreen's now approaching 4,000 stores.
Their percentage composition has risen modestly from 32.4% to 36.9% of all community pharmacies in the USA over the period ( See figure 1).

The transformation in community pharmacy in the USA has been characterised not just by declining numbers of pharmacies overall and a change in the composition of community pharmacy but shifts in locations of sales and of prescription item numbers dispensed from pharmacist-controlled independent pharmacies to the other non-pharmacist controlled pharmacies including the supermarket and mass merchant pharmacies .
These data from the USA demonstrate just how quickly supermarket pharmacies reconstructed pharmacy there in the period 1991 to 2002.
No wonder John Bronger and the Guild are ringing the alarm bells!

1.2 Prediction 1 : Supermarket pharmacies - adopting the most effective defensive strategies by mid-2004.
The October issue of i2P focusing on the supermarket pharmacies was probably Australia's first serious national attempt to assess good and not-so-good strategies in resisting supermarket pharmacies, although the Guild had devised an internal strategy some time before.
On the assumption we need accurate historical , factual and comprehensive data on this specific subject ( which Neil commenced and Con continued but is still far from complete ) to guide us, then please consider the following tabulated summary of strategies arranged in a progressive order (Table 1) as a skeleton draft master plan to methodically tackle the incursion of supermarket pharmacies . National elections are presumed to occur in October 2004 hence the need to implement steps 1-6 beforehand.

Table 1. The supermarket pharmacy resistance strategies for Australian pharmacy

Pharmacy bodies in the UK had commenced systematically , nationally and effectively resisting pharmacy deregulatory moves in February 2003, so they weren't too far ahead of i2P!
(Editor's Note: For the record, i2P actually began campaigning in February 2000)

2. Prediction 2 - Harm reduction activities a model for preventive activities in community pharmacies by 2006
Harm reduction activities including methadone dosing and needle provision in pharmacies commenced in NSW around 1970.
The next step was the catalytic effects of the discovery of HIV and the realisation of prevention of HIV spread around 1985.
Our brave NSW and pharmacies elsewhere in Australia adopted harm reduction as primary and secondary prevention measures against HIV spread under the direction of an inspiring national Health Minister Dr Neal Blewett and certain community pharmacy leaders .
By 1990 Australia had plummeting incidence and prevalence of HIV, partly but significantly attributable to community pharmacy involvement.
Harm reduction and pharmacy involvement didn't happen in the USA and their HIV rates soared.
During the 1990s community pharmacies nationwide adopted harm reduction activities to facilitate state by state community methadone programs (incl ACT).
( The NT has been slow to respond and has had to fight ' licit morphine misuse' rather than 'illicit heroin use'.)
In 1994 pharmacist-statistician Dr Susan Hurley led an NHMRC group which demonstrated in a 1997 Lancet paper the very high cost-effectiveness of community needle programs in preventing HIV.
In 2000 Curtin University's Pharmacy researchers showed for the first time the rates of retention of patients in the community programs with community pharmacies involved were superior to retention in hospital clinic based programs and less costly than them.
The same researchers reported from the National Pharmacy Database results in 2003 that Australia's community pharmacies had the world's second highest provision of opioid replacement dosing (eg methadone and buprenorphine) and highest rates of needle provision of any country's pharmacies in the world.
Harm reduction will soon (when more of our practitioners, academics and pharmacy leaders realise it) become the model for Australian community pharmacy to quickly adopt primary and secondary prevention methods in many other areas.

My letter to the editor in the May 2003 issue of The Australian Pharmacist pointed to the great public health potential for screening by clinical testing in pharmacies to uncover over a million Australians with undiagnosed diabetes, hypertension and other underlying disorders leading to a big new source of prescriptions .
I also pointed to the great pharmacy benefit of monitoring by clinical testing which would
(a) cement pharmacy's hold on agents like the antihypertensives and lipid-lowering statins if they become de-scheduled to S3s and
(b) enhance pharmacists' dispensing fees for the many prescribed drugs which "require test results " to demonstrate their effectiveness. Clinical testing in pharmacies would be a professional and efficient way for pharmacy to be rewarded protecting society's health and saving governments the costs of many simple pathology tests and preventing the cost of treating the morbidity of these disrorders.

A first simple step I explained years ago in a PSA monograph (Clinical testing, November 2000) is for pharmacies to adopt the simplest , least intrusive , cheapest and most useful form of clinical testing of all , namely anthropometric measurement - weight, abdominal and height, then to blood pressure , other bio-fluid measurements with the help of nurses to overcome cost for pharmacies and resistance by patients and health conservatives.
Curtin University commenced graduate pharmacist clinical testing teaching programs with real patients in 1996!
In 1999 the undergraduate teaching of clinical testing commenced in Uni Sydney's pharmacy faculty . Curtin University 's Jeff Hughes and Peter Tenni run regular sessions interstate on laboratory tests.
By the way did you know up to 50% of PBS drugs are given for primary or secondary prevention (eg antihypertensives, the statins and mini-dose aspirin) - that is they are chemo-preventive and not chemo-therapeutic!
So, I predict clinical testing in pharmacies in addition to harm reduction as a form of primary and secondary prevention to become regularly practiced in over 20% of pharmacies by say 2006.

3. Prediction 3. The primacy of pre-dispensing online clinical review over post-dispensing counselling by 2007.
Prof Bruce Sunderland and I reported in a 'letter to the editor' in the July 2003 issue of Australian Pharmacist that several of our studies had shown Australia may have the highest rate of misuse of licit S8s of any developed country.
We also referred to reports of 1% of doctors and other health workers in Australia misusing S8s and of course the most notorious case of all historically was Harold Shipman from near Manchester England, who was convicted in 2000 of 11 deaths of aged females , but probably responsible for 200 and associated with 260 deaths.
We proposed three- tier legislation to prevent misuse involving crucially single medical-dispenser source of S8s and online access to HIC and State S8 data available at prescribing and dispensing in order to prevent 'doctor shopping' , misuse and diversion.
Since then we have re-discovered a model system Pharmanet, which has worked outstandingly in British Columbia since 1995 according to my contacts with the College ( Board) of Pharmacists there . British Columbia is the only province in Canada to have Pharmanet although other provinces are on the verge of implementing similar systems.
This is what I wrote in another report:

"… Legislative changes are also necessary to streamline the provision of Schedule 8 drugs by pharmacies .
The primacy of online access by pharmacies to comprehensive medication histories before dispensing or issuing Schedule 8 and all other drugs is a priority for our national bodies.
The current system is obsolete (Berbatis and Sunderland, 2003) and demeans pharmacists' existing efforts.
Relevant model systems have operated successfully for years in British Columbia's Pharmanet for prescribed medicines and in Victoria and the ACT for S8 medicines and other dependence-producing S4s .
Issues of privacy have not hindered these systems.
That is, it is time for our State and national pharmacy bodies to press for the introduction of an efficient system which elevates these medication review and patient screening services to above the status these bodies currently give to counselling…"

That is, counselling is questionably effective in preventing deceptive or criminal pseudo-patients from medication felonies.
Counselling also is post hoc (after the event) clarification or reinforcement with patients.
Counselling is hence inferior to pre-dispensing medication reviews which are more likely to lead to communicating with prescribers and improving the drugs and doses .
In the 21st century pharmacists need to be seen to be pre hoc online therapeutic reviewers and custodians of medicines and not just be seen in post -dispensing counselling .
In Australia MediConnect is regarded as the avenue for introducing this practice for doctors and pharmacists for prescribed medicines but it is constrained by patients needing to opt in to the system. With eight years experience by community pharmacies in British Columbia's Pharmanet system involving a population of four million people and 35 million script items per annum, Australia now has a working model which is effective and has overcome privacy concerns to pacify consumer advocates and persuade our Parliamentarians of the dire need for the system.
Oh, and by the way, some tempting prescription data just released from Canada - in 2002 British Columbia had the lowest prescription items per capita dispensed in Canada : 7.38 compared with a national average 10.7 and Australia's nearly 10 .
These data suggest Pharmanet comprehensively makes doctors and pharmacists intervene more effectively before prescribing and dispensing leading to less prescribed drugs than in regions which do not have Pharmanet.
Can you imagine how excited our national politicians would get if they could introduce a system which didn't just erase doctor shopping with little prescription drug misuse, but cut PBS growth by 20% or more and lowered HIC drug bills while at the same time have prescribers and dispensers liaise more for better and safer therapy for all ?
A Health Minister's dream come true !
In summary, our pharmacists are not adequately resourced to perform their routine and legal therapeutic and duty of care activities.
They need either or both a quasi-Pharmanet system and legislation requiring patients to give access to their prescription drug histories so that online comprehensive medication review can occur before dispensing (refer page 514, APFH 2002).
I predict either a Pharmanet -like system or legislation facilitating access to S8 prescription drug histories by pharmacists will not be introduced in Australia before 2007 ( the national elections after 2004 ).
Pharmacy will need to improvise for proper pre hoc medication reviews of S2s and S3s.
Let's wait and see what Professors Benrimoj (Uni Syd) and Gilbert (Uni SA) advise after completing their big OTC study by June 2004 ( page 1 , 30 October 2003 issue of Pharmacy News ).

From Con Berbatis, wishing you a Merry Christmas

and a Peaceful New Year