Column

Do they teach perfume dispensing in pharmacy school?


Harry Nespolon


13/02/2019 3:35:14 PM

RACGP President Dr Harry Nespolon reminds pharmacists of GPs’ pivotal role as respected medical specialists in their communities.

The RACGP President said GPs will continue to advocate for patients to receive appropriate rebates to ensure they can see their doctor for longer, more comprehensive visits.
The RACGP President said GPs will continue to advocate for patients to receive appropriate rebates to ensure they can see their doctor for longer, more comprehensive visits.

My first encounter with the Pharmacy Guild was over 20 years ago, when I was working for the AMA.
 
‘Hello, I’m from the Guild.’ It was a well-known media representative on the phone.
 
‘Harry, we need to have lunch.’
 
‘Why?’
 
‘I need to tell you a few things.’
 
I had made some less-than-complimentary comments about pharmacists and clearly I needed some ‘education’.
 
I said he could tell me over the phone. That did not happen, and the relationship hurtled downwards from there.
 
So I am not at all surprised by the extraordinary, baseless comments made last week by the President of the NSW Pharmacy Guild, Mr David Heffernan, in the amusingly-titled, Pharmacy Guild says GPs working ‘turnstile operations’ filling time-slots with easy patients.
 
It’s just the way you do business if you are from the Pharmacy Guild.
 
I feel compelled to respectfully inform Mr Heffernan that if he had taken the time to read the RACGP’s 2019–20 pre-budget submission, he would have found that Australia’s GPs – in their central role as respected medical specialists in our communities – continue to advocate for patients to receive the appropriate rebates to ensure they can see their doctor for longer, more comprehensive visits.
 
The evidence is clear: the more time a GP spends with their patient, the better the outcome. I have never seen research showing a similar conclusion for patients who see pharmacists for their minor ailments.
 
The recent Pharmacy Guild diabetic screening trial found that it cost between $788 and $6000 to diagnose new diabetes patients. That’s the equivalent of 21 to 163 Level B consultations. Cost effective?
 
The Pharmacy Guild’s biggest push would appear to be maintaining their geographical ownership rules, completely anathema to modern economics and many government reports. The banking royal commission has shown what happens when you have what is effectively an uncontrolled oligopoly.
 
The only initiatives you hear about from the Pharmacy Guild are how to increase profit by upselling non-evidence-based products. ‘Some vitamins with your prescription today?’
 
Is this really what a so-called health professional should be doing? The National Health and Medical Research Council (NHMRC) made clear in its report that there are no studies showing benefit from naturopathy. It’s time for us to see a return on the billions of dollars spent on boosting pharmacies.
 
The Pharmacy Guild is possibly the best health lobbyist in Canberra, so it is surprising to see it let one of its state presidents off his leash. This is not the discipline for which the Guild is known, especially for what can only be described as an uninformed rant.

Five-minute medicine? Turnstile operations? Where did they come from?
 
Is the Guild feeling pressure from its own members, the large pharmacy chains or from the public? Or, most importantly, is the Guild reading the tea leaves and seeing that the next pharmacy agreement might not occur? Is it time to allow everyone to compete in the pharmacy space?
 
I don’t have time to talk to my patients about signing a petition every time the rules look like changing. There are times when my patient has a straightforward diagnosis. But I see my patient in a holistic light – not just their presenting symptoms, but the rest of their health, in their context. Not in a crowded shop that lacks any privacy.
 
My principal driver is to keep my patient healthy. I want to decrease the number of medications my patients are on, and ensure that when they are on a new medication it is necessary and evidence-based.
 
The closest thing I see to a turnstile in healthcare is at the cash registers of the pharmacy.



general practice Pharmacy Guild



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John Black BPharm   13/02/2019 8:33:07 PM

Now children please stop fighting. An adult question, why are there more overseas trained GPs working in Australia than Australian trained GPs and what is the RACGP doing about this absurdity? The answer to the question in the title is that during my pharmacy training we were never taught perfume dispensing.


Dale van der Mescht   14/02/2019 8:10:06 AM

This is play ground nonsense.

Let them say what they like. When we start little comments about perfumes and things aren’t we just becoming as pathetic as they are. We all have degrees in our respective fields. We need them as much as they need us.

Let them push their probiotics and multivitamins at the the end of the day we live in a capitalist society. The end goal for privately owned anything... even general practices is PROFIT.

I think as a college we shouldn’t keep defending ourselves. Surgeons, paediatricians and cardiologists don’t do it...

LETS STOP SINKING TO THE LEVEL OF WELL WRITTEN, EDUCATED NAME CALLING.

We are better than that.


andrew hodson   14/02/2019 9:05:32 AM

I find this response inflammatory and counter productive. Sometimes no response at all is a safer strategy when representing an organization rather than allowing previous negative personal experiences override the gravitas of one's postion


Tan Letran   14/02/2019 9:22:16 AM

Good on you Harry for speaking out the truth about the greediness of the Pharmacy Guild and its members whose main interest is to protect its monopoly on pharmacy ownership


Linh doan   14/02/2019 9:26:14 AM

I am an ex pharmacist turned GP. I never envisioned the difficulties that doctors face and the financial strain they are constantly under to provide good medical and holistic care under an outdated Medicare and hospital systems- it is no longer ok to say take 2 panadol and i’ll see you in the morning. We are practising in a time when medical research has burgeoned and translating that into practice is no easy task, staying up to date an impossible task. I never would have thought that 3 colleagues might suicide in Medicine or that i would be training in an environment where my colleagues are so time poor that only the very few are available or capable of teaching. I never could have imagined the complexity of working in health care teams relying on the wisdom, expertise and leadership of senior doctors in a hierachical system and had no idea how poorly remunerated GPs are for the amount of responsibility they take and time taken outside of paid consulting hours to complete their work unpaid or take care of their patients, finding out what services are available or upskilling in an area they are less familiar. I don’t know any doctor who is not worried about the state of healthcare resources in the future as we see funding cut or simply not increasing with the cost of providing care. I implore our allied health professionals to back general practice rather than pointing the finger with blame. General practice has been cut at its knees and i don’t blame my colleagues for wanting a fair wage and “easy patients” because the truth is that most of the time it is hard and our society has failed to recognise there is a funding shortage for general practitioners. Out hands are tied. We want more skills but we need to pay for our own training with time and expense. We want to spend more time with patients and achieve the corrext diagnosis first time but Medicare does not reward us for comprehensive care nor do our patients realise that there is a cost to complex care- every minute spent talking to a patient requires the same time documenting after a patient has left. To point blame is short-sighted. In order to leave a reasonable healthcare system to our children we need to reverse the decline in real wages for general practice so that GPs can achieve the skills and provide their expertise without rushing. Patients see only that our waiting rooms are full and that they have to wait but there is drama and complexity within each consultation. God help us when we are in need of a good GP if that doctor needs to forego his or her house, car or marriage to do his or her job properly. A robust health system cannot rely on the goodwill of GPs alone. We need solid monetary support extending beyond keeping up with rising inflation. We need the dollars to rise with complexity of assessing diagnosing managing and counseling patients and keeping up to date with changes in medical practice.


Dr Peter Robert Bradley   14/02/2019 3:15:11 PM

Well said, Linh. And please keep spreading that gospel, as the more that do, the better the chance of someone in a position to act, and actually do something, might listen, actually hear, take heed.

Because like you, I came from an allied health background, being a fully qualified hospital scientific officer before I went to med school. I completely agree when you say that the experiences and understanding of the different roles of allied health and those of a GP are poles apart, but are indeed complementary, and it is destructive to turn the situation into turf warfare. We need to work together.

Kris Kristofferson wrote some great songs, and which include some iconic one-liners. Two come to mind re this business. One is to suggest "you've been reading my mail", in that I could have just about written what you just did word for word, yet sadly, I'm at the end of my career, and although I've been banging on pretty much along the lines you suggest for decades re the need for massive change in GP, especially the remuneration model, thus far, nothing substantial has changed. So, I have to admit at times I got discouraged, but... to quote from the same song again, "To Beat the Devil", and which is why the message must be carried on...

...."And you still can hear me(you) singing
To the people who don't listen
To the things that I am saying
Praying someone's gonna hear
And I guess I'll die explaining how
The things that they complain about
Are things they could be changing
Hoping someone's gonna care"...

Hang in there,
Pete B


Wayne Shipley   14/02/2019 4:37:42 PM

Good work Harry, I feel you are trying a new approach just like the guild has done for years that has been very successful for them to win back public support and political backing.

Being a silent, patient college has worked so well for us in the past....I believe most pharmacists are hard working colleagues that do not want to encroach on GP specialist territory, rather it is a vocal few in the guild. Politicians and the public unfortunately no longer respond to respectful lobbying or restraint. We are in the new age of Trump, Facebook, Twitter and short attention span readers.

We are in an age profit, increased tertiary care and corporate growth, we need to accept that and work hard to advocate for our members accordingly. It is the “easy” consults that pharmacists/ nurse practitioners want that help fund the time draining longer consults and allows GPs to keep viable.

It’s up to the government to put a stop to this ongoing fights of territory and strain on GPs. They simply need to stop encroachment from all sides, any proposed savings will be short term as medical students leave the General Practice specialty in droves and go towards the safer other specialties that don’t have to keep loosing status or funding or keep justifying their worth to the public and governments. Well meaning MBS reviews will always try to cut easily visible costs but by doing this they will only serve to hasten the demise of the old fashioned GP specialist with great service and even the much loved bulk billing will drop accordingly, as GPs have to source funding elsewhere and we will go closer and closer to the more expensive specialist and hospital dominated healthcare system such as in the US.

Difficult times calls for new tactics even if it makes some of us uncomfortable as we all prefer to be reserved, but in the end it may help save the quality and esteem of our specialty.

It is very hard to regain what is lost, so let’s fight hard to support each other, just look at the fight our Obstetrics GPs are having after the continual erosion of shared care/ GP hospital based services.

Unfortunately people listen to the guild and we have to defend our side of the story in a public way to.


Dr Kate   14/02/2019 6:33:31 PM

Linh, I would like to see what you wrote being read aloud as part of the submissions from our Colleges to the Government to support our push for the changes General Practice so desperately needs. Or maybe on a billboard in every city and town in our country. I could not have said it anywhere near as well, maybe I am too disillusioned and tired to spend the time wording my thoughts quite so eloquently. Sadly, if your message gets out too strongly, there may be even fewer young doctors choosing GP as their career path - despite the huge personal rewards and satisfaction we get from treating our patients (and indeed their families with them) from cradle to grave, the costs to our own health and morale are often greater than we like to admit, and how many of the next generation of doctors will want to sign up if they hear the truth in your assessment?


Dr Tosan Ajuyah   14/02/2019 10:18:37 PM

Shame on anyone who is having a go at our president Harry for standing up for GPs.
While I advocate for unity amongst health workers, it’s UNACCEPTABLE for any group to make such condescending and degrading remark about GPs. Enough of being quiet while we are continually ridiculed.
Well done Harry 👏🏽


Lisa Fraser   14/02/2019 11:07:06 PM

well said Linh


Sue McDonald   15/02/2019 1:01:17 AM

Very well said, Linh. Along with ex nurses, allied health are the first to stand up for GP's when the uninformed malign us. I have been in General Practice for 40years and it is harder and more complex everyday. If the nature of the game doesn't tip you over the hill, the endless forms, playing social worker and now listening to the "new"Chinese music on the woeful authority line will. I begged them to rotate the music after listening to the four seasons 10 times a day for over 20 years. It became pure water torture. I had no luck. Maybe an authority liner studied medicine and finally lobbied on our behalf!!
GP's have great RESILIENCE and are dogged in the face of adversity like a Jack Russell terrier.


Dr John Drinkwater   15/02/2019 6:55:46 AM

It does feel a bit like getting down in the gutter with the Guild. My local pharmacists are welcome members of our community health care team.


Alex   15/02/2019 6:22:11 PM

Disclaimer: I am a pharmacist. I apologize in advance for any misconceptions I may have about the practice of General practitioners

On a micro scale, location rules would make it seem like pharmacy is a monopoly in that you would have one seller (the pharmacy) and many buyers (customers). This is the case for prescriptions that are not subsidized by the government. This is evidenced by the rise of discount pharmacies taking an increasing share of the community pharmacy market.

On a larger scale, community pharmacy in Australia is a monopsony not a monopoly. i.e. where there is one buyer (PBS) and many sellers (community pharmacies). In this situation, the buyer has all the power of negotiation as they set the pricing of medications sold. This has been shown through ongoing price disclosures, where pharmacies are forced to report on the price of every single PBS medications that they buy and sell to the government, who can adjust the prices paid to the pharmacy accordingly. Therefore, it does not matter if there is 1 or 10 pharmacies in an area, they will all be paid the same price by the government, who can adjust the prices to whatever they want.

I believe that General practitioners work in a monopsony environment too, with the bulk of the payments they receive mostly coming from a single provider (Medicare). Therefore, the challenges faced by pharmacists and general practitioners are similar, in that they receive a bulk of their payments from one provider, who does not have any real incentive to pay more . This is evidenced by ongoing price disclosures and Medicare freezes (5 years+). This has led to a real and nominal decline in profitability for both sectors and both sides seeing the grass being 'greener' on the other side.

In an ideal world, doctor's would be able to spend enough time with patients and be reimbursed appropriately and pharmacies would be viable just selling medications. In order to reach this goal, there needs to be major reform. In an ideal world, there would be a clinical pharmacist in a GP practice to help with medication reviews, device usage and anything within the scope of practice of a pharmacist. This will be paid by Medicare and funded through savings associated with better device usage, de-prescribing etc. the dispensing would stay the same, with safe script workload standards enforced.

In the article that was linked to support a removal of location rules, the productivity commission requests that ''eliminating unnecessary boundaries on locations now endemic in pharmacy planning rules'', but does not cite any evidence for this.

The vitamins market is approximately 5 billion dollars a year (http://www.cmaustralia.org.au/resources/Documents/Australian%20Complementary%20Medicines%20Industry%20snapshot%202018_English.pdf), with 41% of the volume being sold through pharmacy. Personally, I would like to see all AUST(L) products to be labelled with a sizable font on the front of the packaging the following: 'Listed medicines are assessed by the TGA for quality and safety but not efficacy. This means that the TGA has not evaluated them individually to see if they work.' This is my personal opinion as customers self-selecting will be more aware about the efficacy of the product they intend to purchase.

Disclaimer: I am a pharmacist. I apologize in advance for any misconceptions I may have about the practice of General practitioners


Dr Peter Robert Bradley   15/02/2019 8:38:32 PM

Sue, and others, why don't you adopt the protest tactic I did years ago, and trained my patients who need regular authority scripts to always come and request them when they pick up their last repeat, and I then mail them in, ticked (and circled) post to patient. I refused to waste so much time sitting there on music on hold. When many acute type meds have now gone streamlined, there are few meds one needs to give so urgently that phoning for them is necessary. Most are for extended supplies of a regular med that is above standard dose, (ridiculous), or S8 meds, which again can be planned for by educating the patient.


Ashok Chotai   16/02/2019 1:05:06 PM

I want to congratulate Harry in writing something that countless GPs have strongly felt but never put pen to paper. There have been many decisions in favour of pharmacists through lobbying. When they won the right to substitute a generic (knowing most patients will opt for a cheaper price if offered), they also increased profits due to generic marketing profit bonuses system (ie buy 10 get 2 free type of thing).

They are so resistant to accept "Generic Labelling" in the interest of reducing patient confusion because they do not see any profit. Most times when generic label is provided it is inconsequential small letters skipped by all but the most vigilant and diligent patients. Substituting generics is one of the biggest cause of patient confusion and medical problems associated with it.

Well done Linh also, here is one of their members acknowledging the work done by GPs

Good work often results is good outcome and goes unnoticed and is accepted by patients who are unaware of the good work and advice given by GPs.

A Royal commission in Pharmacy trade/business would be interesting.

Every profession is required to disclose if they derive additional benefit from the advice they dispense (think bonuses on generics) and you guessed it, the only profession which appears to be exempt are the Pharmacists. If they really wish to be professionals then they really need to divorce themselves from the "other business side and be subject to the same rules as any other other professional".

We all know of the 'financial advisers' who were getting additional kick-backs and similarly also the insurance agents. That appears to be cleaned up slowly at last.


Dr Peter Robert Bradley   17/02/2019 5:13:18 PM

has anyone else encountered the issue where emailed links to threads being followed, like this one) do not take you to that thread any more after logging in. Dr Drinkwater and and now Even Ackerman have both made several posts to this thread since that one above by Ashok Chotai, but they are not there - not to me anyway. What gives..? I've tried to alert the webmasters re this - no response so far.


Dr Peter Robert Bradley   21/02/2019 2:37:19 PM

Ok, so, for the benefit of anyone else who was as confused as I was, there were in effect two parallel threads both following on from the Presidents response to the NSW Pharmacy Guild's president's not very flattering remarks about GPs. So, we weren't mad after all.
The reason they appeared in parallel was because they were. One was accessed via the NewsGP board, which is apparently open to non-,members, so is moderated and (sigh) spam protected. The other was on the ShareGP board, which is a closed board for fellows and members only, so not moderated. Somehow, I, and maybe others, had got sort of astride the two of them, so sometimes found their way to the closed board, and sometimes to the open one. It was only when a window popped up requesting a new password, which I did, that it all began to become clear. Not sure why my original log-in worked sometimes on ShareGP, and sometimes not, but that was how the confusion occurred. So, for members & Fellows, new password needed.


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