This is the first in a 4-part series examining the current policies and regulations in pharmacy practice that pose a barrier to pharmacy practice change. A recurring argument will be that the historical coupling of the pharmacy-pharmacist relationship must be undone.
Part 1: Reconsidering Pharmacy Ownership
Modern pharmacy practice and pharmacy business are constantly at odds with each other. Pharmacists are interested in optimizing patient therapy and compliance and improving overall public health. At times, that means spending extra time counselling patients on new disease diagnoses, recommending against filling an antibiotic prescription to curb resistance, consolidating two medications into a single combination pill to reduce pill burden, discontinuing medications that can cause confusion and falls as patients age, recommending against an OTC therapy, substituting for a less expensive alternative to ensure cost does not compromise adherence, and even just slowing down the workflow to reduce dispensing errors and worker fatigue. These functions which are central to effective pharmacy practice can increase wait times, reduce prescriptions sales, and generally reduce sales.
The pharmacy operators, on the other hand, are interested in maximizing prescription counts, increasing the sale of high margin products, reducing wait times, reducing labour hours, and maximizing revenue. When pharmacists were the sole owners of pharmacies, it was expected that professional obligations would supersede financial interests, and for a long time, that was indeed the case. No doubt the majority of independent pharmacy owners continue to operate this way, though there is evidence that this is eroding. Nowadays, many pharmacies are corporately owned, and many in the profession are expressing distaste over quotas for prescription counts, targets for professional services billed, and budget statements. The underlying mood among pharmacists is that the financial pressures on pharmacies in recent years has trickled down to their practice, leaving them with a feeling that they have lost control of their professional autonomy.
Given these conflicting incentives, the tether between pharmacist and pharmacy must be severed if pharmacists truly want to move out from behind the dispensary into a more active, patient-centered role. In an effort to reclaim their professional empowerment, many pharmacists have called for a return to a time when only individual pharmacists owned and operated pharmacies. The suggestion is highly impracticable. Corporate pharmacy is firmly established in the Canadian market. Moreover, the associate-model pioneered by Shoppers Drug Mart has demonstrated how to satisfy independent pharmacy ownership regulations while being a publicly traded corporation.
But even beyond the implausibility of the suggestion, pharmacists should not be looking for an increased monopoly over dispensing activities. The pharmacist-ownership requirement is the strongest contributor to the illusion that pharmacists are not much more than dispensers. A monopoly on any activity contributes significantly to the identity of the profession. Only dentists drill teeth. Only surgeons perform surgeries. Only engineers design bridges. Only chartered accountants perform audits. Asking for pharmacists to be the only pharmacy operators further cements the perception that the role of the pharmacist in health care is in dispensing.
In fact, the problem goes even deeper. As a self-regulating profession, pharmacists have a direct say in how they govern themselves and their practice. This is an important privilege that has been under-utilized. How the profession decides to regulate itself informs a large part of how government officials, policymakers, other health professionals, the media, and the public see the role that pharmacists play in the health system.
A close look at that self-governance shows just how deeply entrenched the pharmacist-pharmacy relationship is rooted. Most (if not all) the Canadian pharmacy professional colleges are responsible for regulating pharmacies, pharmacists, and pharmacy technicians. Pharmacists are therefore sandwiched between two dispensing-centric entities and, while this makes historical sense, it is at odds with how the profession sees itself today. Many of the Ontario College of Pharmacists’ recent activities, for example, have focused on increasing their regulatory control over pharmacy technicians, hospital pharmacies, and compounding pharmacies. A call to return to exclusive pharmacy ownership realigns pharmacists with these other two dispensing-centric groups, when in fact the hope is to move further away.
To be sure, pharmacists will continue to play an important role in pharmacy related activities, such as therapeutic prescription checks, OTC consultations, and medication and drug delivery counselling. But these activities are supplemental to the dispensing process, and are only a small fraction of the expanded scope of pharmacy practice. In fact, if pharmacists are ready to demonstrate their value beyond dispensing, there should be no resistance to what is inevitably coming down the pipeline: the authorization that regulated pharmacy technicians be allowed to independently own and operate pharmacies. Braver pharmacists will indeed encourage the move, as it further acknowledges the decision that RPhTs are at the centre of the dispensing process, and pharmacists have a completely independent role.
Is there still an argument, in the interests of patient safety, that dispensaries be owned solely by individuals, not corporations? Perhaps, but pharmacists do themselves no favour by attempting to limit that conversation to themselves. The regulatory colleges must recognize the dichotomy in their mandates, and advance the practice of pharmacy in the interests of improving patient safety and care, rather than deferring these initiatives to the professional associations.
Pharmacists are clamouring to regain their professional autonomy, while independent pharmacy may be in decline. The perception is that by regaining exclusivity over pharmacy ownership, pharmacists will regain that autonomy. But the vision is misaligned. There is a need instead to look forward to the future of pharmacy practice, and the establishment of pharmacist offices. Clinging to independent pharmacy ownership may not be the best signal to the outside world that pharmacists are ready and serious about practice change.