s The "Knee-capping" of HMR Services | I2P: Information to Pharmacists - Archive
Publication Date 01/07/2014         Volume. 6 No. 6   
Information to Pharmacists

Editorial

From the desk of the editor

Welcome to the July 2014 homepage edition of i2P (Information to Pharmacists) E-Magazine.
At the commencement of 2014 i2P focused on the need for the entire profession of pharmacy and its associated industry supports to undergo a renewal and regeneration.
We are now half-way through this year and it is quite apparent that pharmacy leaders do not yet have a cohesive and clear sense of direction.
Maybe the new initiative by Woolworths to deliver clinical service through young pharmacists and nurses may sharpen their focus.
If not, community pharmacy can look forward to losing a substantial and profitable market share of the clinical services market.
Who would you blame when that happens?
But I have to admit there is some effort, even though the results are but meagre.
In this edition of i2P we focus on the need for research about community pharmacy, the lack of activity from practicing pharmacists and when some research is delivered, a disconnect appears in its interpretation and implementation.

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Newsflash Updates for July 2014

Newsflash Updates

Regular weekly updates that supplement the regular monthly homepage edition of i2P. 
Access and click on the title links that are illustrated

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Feature Contribution

Woolworths Pharmacy - Getting One Stage Closer

Neil Johnston

It started with “tablet” computers deployed on shelves inside the retailer Coles, specifically to provide information to consumers relating to pain management and the sale of strong analgesics.
This development was reported in i2P under the title Coles Pharmacy Expansion and the Arid PGA Landscape”
In that article we reported that qualified information was a missing link that had come out of Coles market research as the reason to why it had not succeeded in dominating the pain market.
Of course, Woolworths was working on the same problem at the same time and had come up with a better solution - real people with good information.

Comments: 5

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Intensive Exposition without crossing over with a supermarket

Fiona Sartoretto Verna AIAPP

Editor's Note: The understanding of a pharmacy's presentation through the research that goes into the design of fixtures and fittings that highlight displays, is a never-ending component of pharmacy marketing.
Over the past decade, Australian pharmacy shop presentations have fallen behind in standards of excellence.
It does not take rocket science - you just have to open your eyes.
Recently, our two major supermarkets, Woolworths and Coles, have entered into the field of drug and condition information provision - right into the heartland of Australian Pharmacy.

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The sure way to drive business away

Gerald Quigley

I attended the Pregnancy, Baby and Children’s Expo in Brisbane recently.
What an eye and ear opening event that was!
Young Mums, mature Mums, partners of all ages, grandparents and friends……...many asking about health issues and seeking reassurances that they were doing the right thing.

Comments: 1

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‘Marketing Based Medicine’ – how bad is it?

Baz Bardoe

It should be the scandal of the century.
It potentially affects the health of almost everyone.
Healthcare providers and consumers alike should be up in arms. But apart from coverage in a few credible news sources the problem of ‘Marketing Based Medicine,’ as psychiatrist Dr Peter Parry terms it, hasn’t as yet generated the kind of universal outrage one might expect.

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Community Pharmacy Research - Are You Involved?

Mark Coleman

Government funding is always scarce and restricted.
If you are ever going to be a recipient of government funds you will need to fortify any application with evidence.
From a government perspective, this minimises risk.
I must admit that while I see evidence of research projects being managed by the PGA, I rarely see community pharmacists individually and actively engaged in the type of research that would further their own aims and objectives (and survival).

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Organisational Amnesia and the Lack of a Curator Inhibits Cultural Progress

Neil Johnston

Most of us leave a tremendous impact on pharmacies we work for (as proprietors, managers, contractors or employees)—in ways we’re not even aware of.
But organisational memories are often all too short, and without a central way to record that impact and capture the knowledge and individual contributions, they become lost to time.
It is ironic that technology has provided us with phenomenal tools for communication and connection, but much of it has also sped up our work lives and made knowledge and memory at work much more ephemeral.

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Academics on the payroll: the advertising you don't see

Staff Writer

This article was first published in The Conversation and was written by Wendy Lipworth, University of Sydney and Ian Kerridge, University of Sydney
In the endless drive to get people’s attention, advertising is going ‘native’, creeping in to places formerly reserved for editorial content. In this Native Advertising series we find out what it looks like, if readers can tell the difference, and more importantly, whether they care.
i2P has republished the article as it supports our own independent and ongoing investigations on how drug companies are involved in marketing-based medicine rather than evidence-based medicine.

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I’ve been thinking about admitting wrong.

Mark Neuenschwander

Editor's Note: This is an early article by Mark Neuenschwander we have republished after the soul-searching surrounding a recent Australian dispensing error involving methotrexate.
Hmm. There’s more than one way you could take that, huh? Like Someday when I get around to it (I’m not sure) I may admit that I was wrong about something. Actually, I’ve been thinking about the concept of admitting wrong. So don’t get your hopes up. No juicy confessions this month except that I wish it were easier for me to admit when I have been wrong or made a mistake.
Brian Goldman, an ER physician from Toronto, is host of the award-winning White Coat, Black Art on CBC Radio and slated to deliver the keynote at The unSUMMIT for Bedside Barcoding in Anaheim this May. His TED lecture, entitled, “Doctors make mistakes. Can we talk about it?” had already been viewed by 386,072 others before I watched it last week.

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Dispensing errors – a ripple effect of damage

Kay Dunkley - BPharm, Grad Dip Hosp Pharm, Grad Dip Health Admin, MPS, MSHPA

Most readers will be aware of recent publicity relating to dispensing errors and in particular to deaths caused by methotrexate being incorrectly packed in dose administration aids.
The Pharmacy Board of Australia (PBA), in its Communique of 13 June 2014, described a methotrexate packing error leading to the death of a patient and noted “extra vigilance is required to be exercised by pharmacists with these drugs”.
This same case was reported by A Current Affair (ACA) in its program on Friday 20 June
http://aca.ninemsn.com.au/article/8863098/prescription-drug-warning

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Take a vacation from your vocation

Harvey Mackay

Have you ever had one of those days when all you could think was, “Gosh, do I need a vacation.”
Of course you have – because all work and no play aren’t good for anyone.
A vacation doesn’t have to be two weeks on a tropical island, or even a long weekend at the beach. 
A vacation just means taking a break from your everyday activities. 
A change of pace. 
It doesn’t matter where.
Everyone needs a vacation to rejuvenate mentally and physically. 
But did you also know that you can help boost our economy by taking some days off? 
Call it your personal stimulus package.

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Explainer: what is peer review?

Staff Writer

This article was first published in the Conversation. It caught our eye because "peer review" it is one of the standards for evidence-based medicines that has also been corrupted by global pharma.
The article is republished by i2P as part of its ongoing investigation into scientific fraud and was writtenby Andre Spicer, City University London and Thomas Roulet, University of Oxford
We’ve all heard the phrase “peer review” as giving credence to research and scholarly papers, but what does it actually mean?
How does it work?
Peer review is one of the gold standards of science. It’s a process where scientists (“peers”) evaluate the quality of other scientists' work. By doing this, they aim to ensure the work is rigorous, coherent, uses past research and adds to what we already knew.
Most scientific journals, conferences and grant applications have some sort of peer review system. In most cases it is “double blind” peer review. This means evaluators do not know the author(s), and the author(s) do not know the identity of the evaluators.
The intention behind this system is to ensure evaluation is not biased.
The more prestigious the journal, conference, or grant, the more demanding will be the review process, and the more likely the rejection. This prestige is why these papers tend to be more read and more cited.

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Dentists from the dark side?

Loretta Marron OAM BSc

While dining out with an elderly friend, I noticed that he kept his false tooth plate in his shirt pocket. He had recently had seven amalgam-filled teeth removed, because he believed that their toxins were making him sick; but his new plate was uncomfortable. He had been treated by an 'holistic dentist'. Claiming to offer a "safe and healthier alternative" to conventional dentistry, are they committed to our overall health and wellbeing or are they promoting unjustified fear, unnecessarily extracting teeth and wasting our money?

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Planning for Profit in 2015 – Your key to Business Success

Chris Foster

We are now entering a new financial year and it’s a great time to reflect on last year and highlight those things that went well and those that may have impacted negatively in the pursuit of your goals.
It's also a great to spend some time re-evaluating your personal and business short, medium and long term goals in the light of events over the last year.
The achievement of your goals will in many cases be dependent on setting and aspiring to specific financial targets. It's important that recognise that many of your personal goals will require you to generate sufficient business profits to fund those aspirations

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ReWalk™ Personal Exoskeleton System Cleared by FDA for Home Use

Staff Writer

Exoskeleton leader ReWalk Robotics announced today that the U.S. Food and Drug Administration has cleared the company’s ReWalk Personal System for use at home and in the community.
ReWalk is a wearable robotic exoskeleton that provides powered hip and knee motion to enable individuals with Spinal Cord Injury (SCI) to stand upright and walk.
ReWalk, the only exoskeleton with FDA clearance via clinical studies and extensive performance testing for personal use, is now available throughout the United States.

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Attracting and Retaining Great People

Barry Urquhart

Welcome to the new financial year in Australia.
For many in business the past year has been described as a challenging period.
Adjectives are a key feature of the English language.  In the business lexicon their use can be, and often is evocative and stimulate creative images.  But they can also contribute to inexact, emotional perceptions.
Throughout the financial pages of newspapers and business magazines adjectives abound.
References to “hot” money draw attention and comment.  The recent wave of funds from Chinese investors, keen to remove their wealth from the jurisdiction and control of government regulations is creating a potential property bubble in Australia.

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Updating Your Values - Extending Your Culture

Neil Johnston

Pharmacy culture is dormant.
Being comprised of values, unless each value is continually addressed, updated or deleted, entire organisations can stagnate (or entire professions such as the pharmacy profession).
Good values offer a strong sense of security, knowing that if you operate within the boundaries of your values, you will succeed in your endeavours.

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Evidence-based medicine is broken. Why we need data and technology to fix it

Staff Writer

The following article is reprinted from The Conversation and forms up part of our library collection on evidence-based medicines.
At i2P we also believe that the current model of evidence is so fractured it will never be able to be repaired.
All that can happen is that health professionals should independently test and verify through their own investigations what evidence exists to prescribe a medicine of any potency.
Health professionals that have patients (such as pharmacists) are ideally placed to observe and record the efficacy for medicines.
All else should confine their criticisms to their evidence of the actual evidence published.
If there are holes in it then share that evidence with the rest of the world.
Otherwise, do not be in such a hurry to criticise professions that have good experience and judgement to make a good choice on behalf of their patients, simply because good evidence has not caught up with reality.

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Laropiprant is the Bad One; Niacin is/was/will always be the Good One

Staff Writer

Orthomolecular Medicine News Service, July 25, 2014
Laropiprant is the Bad One; Niacin is/was/will always be the Good One
by W. Todd Penberthy, PhD

(OMNS July 25, 2014) Niacin has been used for over 60 years in tens of thousands of patients with tremendously favorable therapeutic benefit (Carlson 2005).
In the first-person NY Times best seller, "8 Weeks to a Cure for Cholesterol," the author describes his journey from being a walking heart attack time bomb to a becoming a healthy individual.
He hails high-dose niacin as the one treatment that did more to correct his poor lipid profile than any other (Kowalski 2001).

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Culture Drive & Pharmacy Renewal

Neil Johnston

Deep within all of us we have a core set of values and beliefs that create the standards of behaviour that we align with when we set a particular direction in life.
Directions may change many times over a lifetime, but with life experiences and maturity values may increase in number or gain greater depth.
All of this is embraced under one word – “culture”.
When a business is born it will only develop if it has a sound culture, and the values that comprise that culture are initially inherent in the business founder.
A sound business culture equates to a successful business and that success is often expressed in the term “goodwill” which can be eventually translated to a dollar value.

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ReWalk™ Personal Exoskeleton System Cleared by FDA for Home Use

Staff Writer

Exoskeleton leader ReWalk Robotics announced today that the U.S. Food and Drug Administration has cleared the company’s ReWalk Personal System for use at home and in the community.
ReWalk is a wearable robotic exoskeleton that provides powered hip and knee motion to enable individuals with Spinal Cord Injury (SCI) to stand upright and walk.
ReWalk, the only exoskeleton with FDA clearance via clinical studies and extensive performance testing for personal use, is now available throughout the United States.

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Pharmacy 2014 - Pharmacy Management Conference

Neil Johnston

The brave new world of health and wellness is not the enemy of Pharmacy, it is its champion.
Australian futurist, Morris Miselowski, one of the world's leading business visionaries, will present the Opening Keynote address on Pharmacy's Future in the new Health and Wellness Landscape at 2.00pm on Wednesday July 30.
Morris believes the key to better health care could already be in your pocket, with doctors soon set to prescribe iPhone apps, instead of pills.
Technology will revolutionise the health industry - a paradigm shift from healthcare to personal wellness.
Health and wellness applications on smartphones are already big news, and are dramatically changing the way we manage our personal health and everyday wellness.

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Generation and Application of Community Pharmacy Research

Neil Johnston

Editor’s Note: We have had a number of articles in this issue relating to pharmacy research.
The PGA has conducted a number of research initiatives over the years, including one recently reported in Pharmacy News that resulted from an analysis of the QCPP Patient Questionnaire.
Pharmacy Guild president, George Tambassis, appears to have authored the article following, and there also appears to be a disconnect between the survey report and its target audience illustrated by one of the respondent comments published.
I have asked Mark Coleman to follow through, elaborate and comment:

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The "Knee-capping" of HMR Services

Neil Johnston

articles by this author...

Neil Johnston is a pharmacist who trained as a management consultant. He was the first consultant to service the pharmacy profession and commenced practice as a full time consultant in 1972, specialising in community pharmacy management, pharmacy systems, preventive medicine and the marketing of professional services. He has owned, or part-owned a total of six pharmacies during his career, and for a decade spent time both as a clinical pharmacist and Chief Pharmacist in the public hospital system. He has been editor of i2P since 2000.

The various pharmacy media (particularly the social media) have been alight with the news that PGA had negotiated a “cap” on the number of home medication reviews a provider can provide.
One commentator, Professor “Charlie” Benrimoj, has stated:

“The people who are putting the arguments out there at the moment are people with vested interests, they are not thinking about the profession as a whole,” he said.
“I don’t think people understand that the Agreement is between s90 pharmacies and the Government. It’s not between anybody else.
“Therefore all those people who are not owners of pharmacies are commenting on something that they don’t have a right to comment on.
“The Agreement does influence practice, but it is still an agreement with pharmacy contractors and the Government. It is these contractors that really put their money into the network of pharmacies, and it is their contract.”

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While I have tremendous respect for Charlie Benrimoj and the great work that he does at UTS,I think that he misses the problem of the total business model suitability.
That it is a confused model is evidenced by the various interpretations inferred and the lack of a cohesive development since HMR inception.

I have turned once more to Seth Godin for some wise words to guide me in my own response, and I found the following:

Might as well burn that bridge all the way down to the pilings

It's not that hard to have a misstep. In fact, if you interact with enough people, it's certain that you will.

Sometimes, if we're quite lucky, when we get it wrong, the person we wronged will politely point it out to us.

At this point, we have a choice. We can elegantly (and with gratitude) make things right, which often builds a better bridge than we could ever hope for...

Or, in frustration, embarrassment and a bit of pique, we can choose to make things worse. 

Here are some of the magic words that might help build that bridge:

  • "I" (not "we" or some magical use of the third person)

  • "sorry"

  • "thank you"

When someone gives you gentle feedback, it's because they want to connect, not because they want to help you finish burning down the bridge you ignited in the first place. They don't want an excuse, a clever comeback or a recitation that you're just doing your job.

It's there if you want it.

The various media (particularly social media) have been alight with the news that PGA had negotiated a “cap” on the number of home medication reviews a provider can provide.
This was an extremely unpopular decision because of the disruption that will occur to alternative business models that have successfully flourished over time.
That the negotiations with government were virtually conducted in secret is evidence that the Guild was well aware of the impact they would have on all accredited pharmacists.

The causes leading to the collapse are known to be from a relationship developed between a doctor group and a corresponding group of accredited pharmacists.
This particular model was geared towards a volume output that is generally believed to be of low quality. The evidence for this assumption has not surfaced as yet.

However, it did illustrate insufficient attention was given to budgeting for this service and so the primary reason for the “cap” and as the Guild have made themselves front and centre to all pharmacy negotiations with government, they copped the blame – rightly or wrongly.

As Seth Godin points out, it's not that hard to have a misstep given the large number of people involved, and it is being pointed out to the Guild in many different ways.
Charlie Benrimoj points out that these commentators have a vested interest and are not thinking of the profession as a whole.
If the existing process was fair and equitable everyone would support it without disruptive comment.
That this is not the case, and as Set Godin points out, there is now an opportunity to “make things right” and “build a better bridge than we could ever hope for” - or “we can choose to make things worse.”

So in building a better model it is suggested:

1. That one accredited pharmacist group be formed up. Debbie Rigby's SHPA-based group would seem to be the logical choice, because it has built trust and would embrace a range of pharmacists across many jurisdictions.
All other groups, including the Guild/PSA group, should merge into this single unit.

2. That the Guild negotiating skills be acknowledged and that the Guild be appointed to negotiate all deals based on the accredited pharmacists' organisation needs list.

3. That community pharmacy infrastructure be acknowledged as the logical infrastructure to engage with in terms of suitable alliance relationships, but not be limited solely to that infrastructure.

4. Have the accredited pharmacist group (not the PGA) develop a range of policies that would manage all the processes involving their members, to that infrastructure.

5. Have provision for member expulsion if there is a serious policy breach.

6. Have an agreement with PGA that only accredited pharmacists that are in good standing with their professional body, will be retained in producing HMR's.

7. Negotiate a similar agreement with doctor group(s) that clarify previous issues and intent.
This to eliminate preconceptions that appear regularly in medical publications.

8. Spell out all areas of conflict of interest, including within and between leadership organisations that are involved with HMR issues, and work towards eradication.

Simultaneously, a codification as to the type of accredited pharmacists, their approved nomenclature and the type of business structures they may form up into should be documented.
For example, the current designation of “consultant” pharmacist is not appropriate because the pharmacist involved is not able to recruit clients on a direct basis, only as a referral.
Face-to-face should always be a feature of a consultancy, and client “ownership” should be negotiated in clear and concise terms (not all clients will magically appear because of pharmacy marketing)
Also, the name consultant pharmacist has restricted use within an existing organisation with a narrow focus of medication review processes.

A wider focus should be envisaged within which primary health care services can be delivered.
Consultant pharmacist terminology should be reserved for specialist functions e.g. independent prescribing. All other processes come under the banner of “clinical pharmacist” and progression to different levels need to be understood and recognised.

Education then becomes important, because it needs to be delivered in suitable modules in convenient locations.
For example, if I wanted to deliver a health check service, one skill I would have to acquire is in the use of a stethoscope. I do not want to travel 800 km to an expensive city-centric education provider to achieve that skill- I want to embrace it locally and with minimal cost.
Plus there are many other areas that I would like to gain skills in.

Charlie Benrimoj, in further commenting on the HMR caps, said:

“The Agreement does influence practice, but it is still an agreement with pharmacy contractors and the Government. It is these contractors that really put their money into a network of pharmacies, and it is their contract.”

While that is substantially true, if a more liberal approach is not taken in the wider development of consultant/clinical services you will end up with distortions and unnecessary restrictions within the pharmacist professional services market.
While pharmacy contractors have put considerable capital into their pharmacy network, those same contractors have developed expensive and restrictive legal processes to limit new pharmacy openings.
This means that new pharmacists are frustrated in progressing to their own ownership of a pharmacy.
Therefore, it is logical to nurture these pharmacists into their own clinical services business.
In the early stages they will have to practice from multiple pharmacies until services evolve to a mature and profitable level.
Along the way they too will be investing capital in specialist education, their own equipment and IT connectivity and perhaps demountable partitions to create decent clinical spaces.
It is not just the pharmacies investing.
In fact, the slowdown of traditional business and profitability will see most new investment occur in clinical services if they are assisted, rather than "tripped up".
So we must disagree with Charlie Benrimoj on that point, because clinical pharmacists will expand their networks differently and may embrace doctors, other health practitioners and even counterparts in other countries to embrace a global reach.
Also, they can practice from private offices, doctor environments, Medicare Locals and any other suitable environment.
Pharmacies should be looking to the future and building their infrastructure to encourage the best talent, because that talent will be generating various types of prescriptions that logically should flow within the pharmacy they are written.

Pharmacies have had in excess of 150 years to develop to their current stage. They have always provided specialist dispensing services and primary health care support services.
There has been a deliberate campaign to eradicate a pharmacy presence within the scope of primary health care that has been orchestrated by the medical profession on a range of levels, political and professional.
It is time to re-balance the equation because neither pharmacies nor GP's can cope with the volume of primary care, because populations are ageing.

But individual pharmacists locked out of total pharmacy ownership can.
Suitably structured alliance partnerships can equitably fill these gaps, bearing in mind that
when pharmacist prescribing is enabled, it will be the clinical pharmacists with no pecuniary interest in a pharmacy that will be selected for prescribing roles.
A prescribing role is a natural fit for a pharmacist who does not have a conflict of interest.

So pharmacies should value all pharmacists they have access to whether they employ them or not.

Peter Breadon in a recent edition of The Conversation commented:

“Yet, as many other countries have realised, pharmacists shouldn’t be valued by the cost of the pills they sell. They are trained for four years about drugs and their impacts. They know how to dispense drugs safely and provide advice on medicines. They are a highly trusted group located throughout Australia, including in areas with low access to primary health care.”

Note that it is a small cadre of accredited pharmacists that are actually establishing that value through dedication and personal interest.
But it seems as though The Guild is set on eradicating this germination process to the detriment of the entire profession.

The core business of pharmacy comprises dispensing + clinical services.
If pharmacy does not get its act together very quickly, it will wither on the vine.
There is evidence now where pharmacy is being castrated by both government and its own constituents.
Government is attacking the profit base through the PBS while warehouse type pharmacies seek to commoditise every aspect of pharmacy, seeking world domination.

The trick will be to develop markets that require personal inputs by pharmacists that are unable to be discounted.
Each area of political pharmacy has its own specialised set of skills and processes. If supported, they will contribute to a "whole of pharmacy approach", but this will require a consensus approach by organisations and a sense of collegiality between each pharmacist.

Negotiating caps on HMR's is not the way to go without including the principal players - no matter who owns the contract.

While a range of pharmacy commentators (including Charlie Benrimoj) support the Guild's right to impose caps on their own contracted services, there is still no overall implementation plan for the entire spectrum of pharmacy services- what they will be, who will have carriage of them and how they will be equitably shared between pharmacies and pharmacists.

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