Remuneration for services and the role of leadership
A meeting was conducted at the FIP congress in Vienna
in 2000, between the community pharmacy executive committee and seven
“successful” countries, ie, those with part or full remuneration
of pharmaceutical care or medicines management-related services. Countries
rewarded for services in 2000 were Australia, Canada, Ireland, South Africa,
Switzerland, the United Kingdom and the United States. By 2001, the group
included Austria, Denmark, Ethiopia, Italy and Portugal. Four countries,
Latvia, the Netherlands, Norway and Spain, indicated non-remuneration
for services.
Professor DICK TROMP, president of the Community
Pharmacy Section of FIP, briefly overviewed different remuneration systems.
Australian pharmacists’ remuneration comprises
of distribution (per pack + margin), basic services (validation of prescription,
advice and patient records), specific services (intervention, follow-up,
fee per service) and additional services (medication reviews, case conferences
with prescribers, dose administration aids, service package fee).
In Canada, service remuneration has been in place
for years but only 6 to 10 per cent of pharmacists apply. Fee guides have
been developed and differentiation of pharmacists and pharmacies is observable.
Phased dispensing services in Ireland, despite the
profession’s good relationship with the government, are also not
widely taken up by pharmacists although this has not deterred planning
of additional services.
Denmark runs yearly health promotion campaigns with
its smoking cessation services reimbursed.
Italian pharmacists book specialist examinations
and clinical tests directly in the pharmacy and this booking service is
compensated.
Portugal’s reimbursed service portfolio is
similar to that of the UK: methadone, needle syringe exchange, waste medicines
collection. In addition, Portuguese pharmacists provide a part compensated,
24-hour pharmacy service.
Reimbursed services in the US vary from state to
state, safety being the main driver. Drug therapy management (drug use
screening and prevention of medication-related problems), immunisation
administration and laboratory testing are reimbursed but pharmacists’
uptake of these is slow.
Swiss pharmacists’ negotiated payment before
service provision, in contrast to the norm of many countries that undertake
pilot studies and provide voluntary informal services, relying on pharmacists’
goodwill rather than on remuneration. A divided system has been created
and specific training is a contractual requirement. The formula for “success”
was multifaceted, requiring co-operation, strategic thinking, strong leadership
and negotiation.
Leaders — visionaries and thugs?
Professor CHARLIE BENRIMOJ, faculty of pharmacy,
University of Sydney, Australia, told the audience: “It’s complete
nonsense to say that economics is not a driving force. Job satisfaction
is not enough and glorious statements will not have effect unless there
is a direct financial structure. Community pharmacy is a retail environment
— that is the whole basis of the profession therefore we need to
focus on remuneration.” He emphasised competition with other health
professionals: “Role merging is a reality in some countries —
whoever does it better at lower cost will win.” Considering the decrease
in mark-up globally in real terms from 50 to 10 per cent, he suggested
that “remuneration models based on mark-up in Austria and Finland
are living in the past. Current models of pharmacy are not sustainable,
competitive, focused or professionally satisfying.”
Monopoly situations in some countries are anti-competitive
and he asked the audience to justify them. Professor Benrimoj called for
an urgent review of the undergraduate syllabus to prepare graduates for
future roles and pointed out that, where new curricula were practised,
graduates were more clinically focused at the outset but this reverted
after five to six years of community practice or when they owned a pharmacy.
Two types of leader drove changes in Australian remuneration — “visionaries”
who sold a dream and “thugs” who undertook the hard negotiations.
A watershed agreement reached recently allocated $A5,208m based on prescription
remuneration and $A416m in other payments. Pharmacists are paid $A2,500
to start a quality system and $A7,500 on completion. Medication reviews
generate $A1,400 per review and case conferences $A40 per item. Multiple
leadership with a common goal, quality and remuneration are integral parts
of the change process. This development has been incorporated into the
Australian undergraduate syllabus. The main problem in Australia is not
service remuneration but logistically delivering the goods.
Seven star pharmacists
Dr CARL TRINCA, board of pharmaceutical practice,
US, talking on leadership theory, outlined seven roles considered essential
for “seven star” pharmacists:
- Caregiver
- Decision-maker
- Communicator
- Leader
- Manager
- Life-long learner
- Teacher
He urged leaders of national pharmaceutical organisations
to reflect on the principles of effective leadership. These included:
- Creating strategic alliances
- Taking a long-term view
- Understanding stakeholder symmetry
- Encouraging dissent
Dr Trinca concluded by stating that learning is
the key to the future. “By learning as a leader we can create organisations
capable of coping with change and forging new futures.”
LARS-ÅKE SÖDERLAND, Sweden, discussed his practical
experience of leading 25 pharmacies in Sweden. He stated the importance
of role clarification, ie, ensuring everyone understands the mission and
the vision, team-working and balanced scorecard appraisals at regular
intervals. Having a mentor and time for reflection were two strategies
that made him a successful leader.
CHRISTINE GLOVER, Immediate Past President of the
Royal Pharmaceutical Society, UK, stated: “Integrity and trust are
key. The problem with pharmacy is that it is fundamentally introspective.
Leadership means looking outward, having perspective, vision, and understanding
what governments want from us.”
Dr TRINCA replied: “Pharmacists are also insulated
due to traditional education. Nurses are very effective at looking outward.
We need to take lessons from other health professionals.”
HELEN REMINGTON, a member of the Royal Pharmaceutical
Society’s Council suggested that clinical leadership needed to be
made more evident. “We don’t have enough of a research portfolio
in clinical/ patient outcomes. My clinical leaders in the hospital environment
are good innovative clinical practitioners.”
MARSHALL DAVIES, President of the Royal Pharmaceutical
Society, reminded participants that an issue facing leaders is risk management.
Quoting Bismarck, he said: “Only fools learn from their own mistakes;
wise men learn from others’ mistakes.” He asked for clarification.
Dr TRINCA replied that a good leader will learn
wherever he can.
Mr SÖDERLAND urged everyone to be their own
leader and take responsibility for their own tasks, accepting that others
may have specialist knowledge.
MICHEL BUCHMANN, Switzerland stated: “It’s
important for pharmacists to be engaged in external political lobbying.
Very small numbers of pharmacists are actively involved in this.”
LINDA STONE, member of the Royal Pharmaceutical
Society’s Council replied: “There are many levels you can lobby
but you must represent the broader perspective first and then say ‘oh,
by the way, I’m a pharmacist and here’s what we can do for you’.”
Mr SÖDERLAND agreed. “You also need to
create new networks with customers, charities and non-governmental organisations.
It makes them understand the force of pharmacy.”
Is money a motivator?
In a panel discussion, pharmacy leaders discussed
remuneration as a motivator to change current pharmacy practice.
MITCHELL C. ROTHHOLZ, deputy executive director,
American Pharmaceutical Association, started the discussion. “If
we are effective, medicines use and drug costs should go up. With the
patient hopefully compliant, other costs are reduced. The difficulty is
in providing documentation.” He wondered what was the most effective
documentation system to put into place that was not a barrier to pharmacists
using it.
Professor TROMP asked: “Do you have proof that
payment for services works?”
Mr ROTHHOLZ replied pharmacists needed to move away
from a “having the evidence and then we’ll get paid” attitude.
It was not necessary always to have the evidence. “You have to define
how pharmacy can solve a health care problem. That’s the equation
that’s been successful in many countries.”
INGER DUUS NIELSON, of the Danish Pharmaceutical
Association, added: “The first hurdle is acceptance as a member of
the health sector instead of just a supplier. We were fortunate because
of a lack of human resources; the government decided we play a more active
part. We worked out a lot of free services in Denmark; we have been documenting
them a long time. Now we are trying to get payment for these.”
MARIE HOGAN, president, Irish Pharmaceutical Union,
stated, “It’s difficult to get people to act in a different
way. Most pharmacists are paid per dispensing fee: this encourages bad
practice. Mechanical efficiency equals lots of money.” In reviewing
the whole remuneration system Ireland hoped to develop more reward models
within the next 12 months. Education was the key to develop confidence.
“It’s difficult to get people to understand that a safe, mechanical,
dispensing process is not value; value is in the five minutes spent talking
to patients,” she said.
Mr DAVIES confirmed that England had a pharmacy
plan for the next 10 years, but “we are currently paid on an item
of service professional fee that is totally perverse — it works against
the plans. The government intends to revisit payment over the next 12
months and many pharmacists are worried about perceived added workload
and reduced payments.”
HERBERT CABANA, president, Austrian Chamber of Pharmacists,
told the audience that Austrian pharmacists offered a variety of additional
services, some paid by the patient, others paid by higher trade margins
on medicines. Even poor people could afford the services. “It puts
pharmacists in a strong position as margins adapt to economic developments.
Our pharmacists are highly motivated not by financial incentive but by
appreciation from patients and society. FIP guidelines on remuneration
for additional services could cause difficulties in countries like Austria.”
Professor TROMP asked about motivation. Was motivation
developed through education, remuneration or appreciation by patients
and society?
Mr ROTHHOLZ replied that motivation was on two levels:
pharmacy owner or manager and other staff. “There are lots of issues
so how do you make it work in the system?”
Dr ROSS HOLLAND, Australia, stated: “What we’re
looking at is a systems approach. Practice change is led at national level
but it needs to work in practice. Any practice change model has three
elements: environment, educational resources and motivation. We nearly
always forget about motivation. It’s not just extrinsic rewards but
also intrinsic satisfaction.”
A question was raised by a participant about whether
it was possible to provide services merely on the basis of financial reward,
without personal inner drive.
Mrs HOGAN replied that personal drive was required
but financial drive was also important. “We do need to make a living.
Nobody is going to make room for us, we need to secure our place in the
health care team.”
Mr HANS GUNTER-FRIESE, president of the German Federation
of Pharmacists (ABDA), commented: “Competition within the profession
brings quality. Customers vote with their feet for the best quality service.
That’s the drive we need.”
JEFF POSTON, director, Canadian Pharmacists Association,
said: “It’s a real issue as to who gets payment, the pharmacy
owner or the pharmacist doing the work. The UK primary care model is a
good example of how society values pharmacists’ skills.”
HEMANT PATEL, member of the Royal Pharmaceutical
Society’s Council, said that commissioners of services were trying
to identify health needs of the population. “The sooner pharmacists
get involved in needs’ assessment the better. Payment should be to
pharmacists via pharmacy owners.”
Mr CABANA repeated that motivation of pharmacists
was not a matter of money. “Many other things influence important
decisions. We have to stick to needs of the patient. It’s more important
than discussing reimbursement.”
Mr ROTHHOLZ pointed out that young pharmacists had
new skills but they were not trained in negotiating.
STEPHEN GREENWOOD, director, Pharmacy Guild of Australia,
responded: “It doesn’t mean they should not be paid for their
skills. The future depends on how we can be the solution to health care
problems and cost containment.”
Mrs HOGAN concluded the discussion, emphasising:
“We’ve spent too long discussing the services we can, do, and
should provide. We need to do more talking on remuneration.”
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