s Pharmacy Leaders Need Courage- a View of the Blackmore's Controversy | 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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News Flash

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

Comments: 1

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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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Pharmacy Leaders Need Courage- a View of the Blackmore's Controversy

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.

I was reading up on the management experiences of two successful US companies that found they had to take some positive action to prevent a downwards slide.
Both stories are good analogies for current events in pharmacy - the first for the Blackmore's controversy and the second for mindless discount pharmacies.
The story for one company was that they agonised for over two months to decide to plan some layoffs of their employees, plus a further two weeks to implement them.
The downside was that it took two years for the company to recover from that decision.
When the CEO was asked why the company had done something that caused so much damage, the reply was “that it was expected by Wall Street and my CEO peers”.
The comparison to Blackmore's is that with vested interests jumping all over the PGA/Blackmore proposal, it damages a genuine opportunity (properly handled) for pharmacy and the issues surrounding responsibility for complementary medicines.
The controversy could delay, (even deter), pharmacists from becoming involved for at least two years.

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A second case study involved the Bank of America making poor loans.
They were well aware that their loans were of poor quality, but every other bank was following a similar strategy provided there was adequate security to back the loan and the loan could eventually be “off-loaded”. Each bank created pressure for the other to follow a downward spiral that eventually was to become a trigger for the Global Financial Crisis.

The underlying flaw that existed in both the above case histories is that the CEO of both organisations lacked the courage to go against the trend, mostly because their belief system was outdated.
For the past 25 years, CEOs of many major corporations (local and global) have relied on a flawed set of beliefs to lead their organisations. This set has influenced them to place way too much emphasis on maximising shareholder value and not enough on generating value for society. The result in the US and other economies has been a deep recession that was brought about by the near collapse of the financial system.
The analogy to discount pharmacies ought to be obvious.

Australia, to this point, managed to escape the worst of the collapse due to earlier economic reforms, but unless debt is stabilised throughout the global economy, we will have some damage inflicted upon us.
This environment and the behaviour produced by the prevailing set of beliefs to which CEOs subscribe has deepened a widespread public distrust of corporations and capitalism.
How often have we observed senior executives of companies being rewarded for leading their companies into a poor performance but still end up with multi-million dollar value “golden handshakes”?
Most have seen this process as somewhat obscene.

A lot of this belief system has been exported by the US to other countries such as Australia, through their global businesses particularly tobacco, pharmaceuticals, banking and Information Technology giants.
By stirring this mix using manipulative and unprincipled advertising as the driver, we see societies evolving in an unhealthy and unbalanced manner.

We are currently seeing the Australian PBS under attack by US tobacco and drug interests through government-to-government trade treaties, in an effort to gain an unreasonable advantage. Unreasonable, because Australia’s health policies geared to good health for the majority of the population are undermined by immoral arguments surrounding protection of intellectual property that collides with public health policy (e.g. the display of branded tobacco products that have been proven to cause major illness and the instance where plain packaging will destroy the tobacco market).

In a similar way we are seeing arguments from all over the place opposing a recent alliance with the Pharmacy Guild of Australia and Blackmore’s Laboratories.After all that, pharmacy is a business model consisting of professional goods and services plus a judicious mix of commercial goods and services.
Always has been and will probably remain in that mode for the forseeable future.
The controversy is related more to a PR disaster by a Blackmore's executive than any wrongdoing by the PGA. The resultant uproar however, will slow down the initiative which simply has patient health at its centre. Each complainant has a different agenda.
For example, drug companies don’t wish to see their products negatively impacted through the general public being educated by pharmacists as to the problems of nutrient loss or displacement – a common side-effect that might eventually impact on the volume of drugs taken by patients.
Jumping on to the band-waggon the Australian Medical Association (AMA) see an opportunity to denigrate pharmacists because they are daring to enter into the fringe area of prescribing, somehow showing up doctor prescribing habits as being inadequate.
Well, incomplete at best.
Even APESMA and the PSA get in on the act so as to be seen to be part of this negative debate – covering their backsides at best!
Both their interests would be better served in simply ensuring that the Blackmore's proposal runs ethically in conjunction with the PGA.

Blackmore’s claim to have filed their evidence for the proposed use with the TGA as required by law. Knowing the reputation of Blackmore’s I have no doubt that evidence exists.
The never-ending arguments surrounding evidence-based medicine seems to revolve around who is making the pronouncement and judgement regarding that evidence. The so-called evidence then becomes confusing and contaminated on both sides of the orthodox vs complementary medicines debate, because it is often skewed or set up to fail because of the parameters of the original clinical trial providing the “evidence”.
Somewhere in this argument there is one that the Pharmacy Guild and the PSA should be making, and that is a properly trained drug professional using their academic and clinical practice skills should be the proper person to interpret evidence and broadcast it.
In other words, a qualified pharmacist!
However imperfect pharmacists are made to feel through a “spin doctor” process, they are still the best and most accessible profession to interpret and deliver evidence to the general public.
It is also an obligation that individual pharmacists should have the courage to take ownership of – which was the point of the title of this article.
Continuous self improvement is the best strategy.

And while the PGA actively promotes an area where pharmacists are able to use their skills in an ethical framework, the PSA could be developing an evidence database publishing and star-rating evidence for drugs, complementary medicines and nutritional supplements.
It is not often that I find myself in agreement with Kos Sclavos, but in this instance I applaud his courage in standing up to the orchestrated media onslaught surrounding this venture. The fact that the onslaught is so intense is a measure of how all these vocal interests feel threatened by a singularly simple proposed service that revolves around the best interests of Australian patients.
It is unfortunate that a Blackmore's executive used a public analogy describing this new venture as a fast-food up-selling strategy (do you want coke and fries with that?).
The PSA have taken exception to that comment and while it is not good as a process to develop image, pharmacy will survive the comment by its future actions.
There is no price gouging envisaged, there is no proposal to create pressure through up-selling – just the provision of simple advice and “evidence-based” information to enable Australian patients to improve wellness so as to increase lifestyle in parallel with an increased lifespan.
They make their own decisions guided by pharmacists with a belief in the self-care process.
Pharmacists, because they are true health professionals, must maximise value for society and act as agents for society, rather than as self-interested pharmacy owners or employees. As George W Merck, founder of a now global drug company once put it:
"We try never to forget that medicine is for the people.
It is not for the profits.
The profits follow..."

This is probably a good time in the progression of the pharmacy profession to go back to first principles and embrace concepts practiced by outstanding leaders such as George Merck, for this is how pharmacists first gained the high approval ratings that were recognised by society.
In other words update your belief system to one that you are proud to practice under.
Then practice it and believe in it, for that is the best way to shake the manipulators of our profession to keep it strong and united.
Coincidentally, the PSA is just about to release its new Code of Ethics - all pharmacists should read, learn and inwardly digest.

And for the final word on courage, this is what Mike Myatt, a contributor to the Harvard Business Review had to say:
"Courage is a topic that doesn't receive nearly enough attention in a society so concerned with political correctness.
Courage is a trait possessed by all great leaders.
So much so, that leadership absent courage is nothing short of a farce.
Let me be very clear – I’m not advocating for bravado, arrogance, or an overabundance of hubris, but the courage necessary to stay the course and to do the right things.
Standing behind decisions that everyone supports doesn’t particularly require a lot of chutzpa.
On the other hand, standing behind what one believes is the right decision in the face of tremendous controversy is the stuff great leaders are made of.
I believe it was Aristotle who referred to courage as the first virtue, because it makes all of the other virtues possible.

It takes courage to break from the norm, challenge the status quo, seek new opportunities, cut your losses, make the tough decision, listen rather than speak, admit your faults, forgive the faults of others, not allow failure to dampen your spirit, stand for those not capable of standing for themselves, and to remain true to your core values.
You can do none of these things without courage.
Courage is having the strength of conviction to do the right thing when it would just be easier to do things right.


The best thing about courage is that a lack thereof can be overcome.
Courage is teachable and therefore it is learnable – proof of this can be found in every instance of overcoming a fear.
Courage should not be defined as the absence of fear – that’s ignorance.
Courage is finding the strength to move ahead in the presence of fear.
In short, courage isn’t a skill, it is a decision.
Here’s the thing – we’ll all be remembered for the decisions we make or don’t make, and the courage we display or we fail to exercise.
Leaders who consistently demonstrate courage will stand apart from the masses, and earn the trust and loyalty of those whom they lead."

Interestingly, the Commonwealth Bank of Australia thinks the alliance makes good sense. Their analysts have backed a tie-up between Blackmores and the Pharmacy Guild of Australia to recommend nutritional supplements. CBA analyst Natalie Kelly said the initiative would help pharmacists "put increased commercial focus on their non-dispensary offering, given ongoing financial pressures to the dispensary side from recent Pharmaceutical Benefits Scheme reforms, upcoming fee cuts, price disclosures and tighter trading terms from wholesalers. Pharmacists were likely to be receptive to the deal because it would increase sales in the face of reforms that put pressure on profits, she said.

"While certain industry bodies such as the Australian Medical Association and some pharmacy groups have voiced opposition to the deal, pharmacists and patients will have the final choice in deciding whether to make the cross-sell and whether to accept the offer," Ms Kelly wrote in a note to clients.

So it won't hurt to include this type of information in your next bank loan application at the spot where you have to indicate where sales growth is going to come from, in the face of gross profit losses derived from multiple sources.

I hope Kos Sclavos has the courage to stay the distance with the Blackmore's decision and that all pharmacists promote the benefit in whatever ethical variation they deem fit.
It only makes good business and professional sense.

Return to home

Submitted by Dr Ken Harvey on Fri, 07/10/2011 - 07:45.

Dear Neil,

I was pleased to see that the Guild-Blackmores deal has been scrapped. Having said that, I agree that pharmacists have an important role to play in primary health care, especially by providing evidence-based about medicines (including complementary medicines) to both patients and doctors.

The NPS evaluation of the Blackmores “companion” products highlights the need for more independent information about complementary medicines. The recent Australian National Audit Office report titled, “Therapeutic Goods Regulation: Complementary Medicines” said (para 43):

“It would enhance transparency and help inform both consumers and healthcare professionals if the TGA were to place the summary of evidence it collects from sponsors, as received, on its website — with a clear indication of whether it had been assessed or evaluated by the TGA.”

I agree! For example, there are a small number of registered CAMs on the Australian Register of Therapeutic Goods (ARTG).

If these products have been registered recently, it means that they have been thoroughly evaluated for quality, safety and efficacy (unlike Listed CAMs which predominate on the ARTG). Examples of recently registered CAMs include Blackmores Flexagil Pain Relief cream (a clinically proven comfrey root extract) for the topical treatment of sprains and osteoarthritis and Flordis Iberogast (a clinically proven nine herb mixture) for Irritable Bowel Syndrome.

Unfortunately, some registered CAMs were “grandfathered” into the ARTG, without proper evaluation, e.g. ARTG no: 68083 ARTHRO-AID Glucosamine hydrochloride.

At this point in time, there is no way the ARTG can be searched to obtain a list of registered CAMs let alone those that have been properly evaluated as distinct from “grandfathered”.

I (and others) have suggested that the TGA compiles a list of properly evaluated registered CAMs and places this on the TGA web site. In the longer term, we've suggested that the ARTG database should contain an additional searchable field to easily distinguish CAMs from other medicines.

I’d be interested in your thoughts on this proposal.

Submitted by Neil Johnston on Mon, 10/10/2011 - 08:19.

Dear Ken,
All that is suggested sounds like a good starting point to me.
Because of limited space in the comments panels I will contact you privately to expand on the idea.

Submitted by Neil Johnston on Mon, 03/10/2011 - 16:05.

Hi Ken,
Thanks for posting.
Isn't it great that we now have the nucleus for a complementary medicines database?
And put together so quickly!
But will it be expanded progressively and updated with new evidence as it comes to light?
It would be great if a ratings section could be included for PSA evaluation for pharmacists, and another section where anyone could submit evidence for inclusion (after evaluation by NPS and others).
I am also disappointed that the information directs patients to GP's and excludes pharmacists.
There are many clinical pharmacists who can provide, dare I say it, more informed input than the local GP.
Here I speak from personal experience because 20 years ago I was prescribed Diabex for my Type 11 diabetes.
About six weeks later I started to develop symptoms of lactic acidosis.
I was working in a hospital at the time so I searched a few of the hospital databases and found a reference study by the American Diabetic Association that stated metformin reduces body stores of vitamin B12 and a low level of vitamin B12 was a trigger factor for lactic acidosis.
I had a nurse give me a NeoCytamen injection and then went home with a raging temperature/headache, calling in on my local GP to discuss extra treatment.
He inferred that I was trying to play "doctor" and brushed off any thoughts of having a blood test.
I remonstrated with him and insisted, and it happened with bad grace.
Later that night I received a panic-stricken phone call from my GP who told me my levels were such that I may not have much longer to live.
Fortunately, I was able to relieve his mind by stating that while not 100 percent, I was feeling better.
I attribute that to the B12 injection.
The next day in a follow-up appointment my GP asked the question "Should I write scripts for vitamin B12 for all metformin scripts?"
I answered that it ought to be his own decision based on his own clinical experience.
More pertinently, do I as a pharmacist upsell every metformin script I dispense?
Emphatically no!
When the opportunity to counsel a patient occurs I give the relevant information (including the symptoms of lactic acidosis) and recommend that they seek appropriate advice if they experience any of the symptoms.
Today I still take metformin but I also have a regular intake of vitamin B12.
I have not had a recurrence of lactic acidosis since, but I make sure one or two blood tests over the year show a measurement for lactic acid.
The PGA used to have a College of Clinical Nutrition where I, and many other colleagues, graduated with advanced diplomas.
Other pharmacists have other qualifications that make them more than capable to assist patients in a pharmacy environment - and dare I suggest know more about their subject than the average GP.
Sure there are blatant exceptions where inappropriate products and advice are promoted, but please do not lump all those dedicated clinical pharmacists (usually non-pharmacy owners)in the same bucket.
The outpouring of crticism against the PGA is justified, but I would like to see them given a chance to rectify this error of judgement.
I have probably been the most stringent critic of the PGA and the potential for conflict of interest developing in a lot of their commercial activities.
They are entitled to give Blackmore's a tick for their product (just like the National Heart Foundation), even the evidence provided (if it is good evidence).
This was the thrust of my article- that the evidence should be validated by an organisation such as NPS, PSA or both.
My greatest worry now is that because of all the uproar, capable and ethical pharmacists will shy away from an area they should actively take responsibility for.

While it may not have been the intended outcome envisaged by the PGA and Blackmores their initiative has produced a positive.
Commercially, the PGA are entitled to charge a fee for their "tick" but not receive an over-riding commission for global sales.
Blackmore's on the other hand, should do their detailing directly with pharmacists.
They will make their own clinical judgements despite rumours to the contrary.
I hope all those PGA critics will take the view that the PGA ought to be allowed to correct their error of judgement and be supportive to those clinical pharmacists who have patient interests at heart- there are more of them than pharmacy owners, but even the owners are imbued with good common sense- they are used to disagreeing with the PGA and silently rebel by ignoring what they know to be wrong and quietly go about their business.

Submitted by Professor David Jackson on Mon, 03/10/2011 - 15:55.

Possibly the most important issue here is--Where is Pharmacy going? A related issue is the enormous mismatch between how Pharmacists sell themselves (sound scientifically based advice on drugs) and the reality (most behaviour and advice from retail pharmacists is governed by the till ($$$$)). Pharmacy cannot have it both ways: or can it?

Submitted by Neil Johnston on Mon, 03/10/2011 - 17:47.

Hi David,
Yes pharmacy is definitely schizophrenic!
i2P has been promoting for some time the feasibility of clinical service companies that can lease space in a clinical setting and have an ownership structure divorced from an actual pharmacy.
Clinical settings to include general practice/medical centre environments, independant office setting, Medicare Local setting and yes, a community pharmacy setting.
Only with separation and with policies and procedures that support a clinical process plus independantly capitalised will we see what clinical pharmacists have the capacity for.
Unfortunately, with the PGA controlling government grant funds we will not see any of this type of model emerging until an organisation such as the PSA can wrest from PGA control sufficient seed money to launch this type of project.
Two of our writers, John Dunlop and Linda Bryant have successfully achieved this type of separation in New Zealand, but the practice environment is almost exclusively a medical centre environmnet rather than a pharmacy environment.
With the clinical nurse practitioner model emerging both within pharmacies and independent office settings, some pharmacists may endeavour to launch a similar model, even in partnership with the nurses.
That would be the direction hopefully that clinical pharmacy may take.
I am hopefully developing a model (through my consultancy practice) for early next year, that will contract its services to community pharmacy environments.
This type of development would also assist in the uptake of new graduates in a more fulfilling and self-funding role that is not reliant on PBS margins.

Submitted by Dr Ken Harvey on Mon, 03/10/2011 - 09:39.

I suggest that Neil and others read the literature review the National Prescribing Service (NPS) have published about Blackmores "companion products", see: http://www.nps.org.au/topics/companion_products

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