The Pharmaceutical Journal
Vol 268 No 7203 p870
22 June 2002

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Is history about to repeat itself?

By John Wilson

Pharmacists are always blaming governments for disregarding the profession: for not funding it adequately, for not caring about the valuable contribution we can make, and so on. However, how much of this is actually our own fault? Someone (I forget whom) once said, "History repeats itself — it has to, because no one listens the first time". Let us consider a number of scenarios from pharmaceutical history, both ancient and recent, and see if this can teach us anything.

Many years ago, a pharmaceutical wholesaler began to offer a small discount of, I think, about 2 per cent to customers spending above a certain amount each month. Other wholesalers quickly followed suit, and a sort of "discount war" ensued for a time. Eventually, the Department of Health realised that these discounts were going to pharmacists as extra profit and decided that it, too, would like to dip its fingers in the honey pot. Thus was the "discount clawback" introduced. Now, wholesalers are trapped into the discount system and have to operate on a small profit margin.

Some of our more enterprising and adventurous colleagues found that prices of many pharmaceuticals were often much lower at wholesalers in other European countries, such as Belgium, so they took their camper vans over to the continent, loaded them up and, using an apparent loophole in the Medicines Act, began to dispense these "parallel imports" and make additional profits. Some began to trade these with other pharmacists. Eventually the trade in parallel imports became regularised with the availability of parallel import licences under the Medicines Act and the setting up of companies selling parallel imports. Again, the Department showed excellent business sense as a monopoly customer in demanding a share of the additional profit. Now, few pharmacists can afford not to use parallel imports because of the clawback on prices.

Senior citizens often have difficulty in coping with the large numbers of different medicines, often on complex dosing schedules, that they are prescribed. By the same token, the staff in residential and nursing homes are often faced with difficult therapeutic regimens for perhaps 20, 30, 40 or more patients in their care. One large multiple, in an atmosphere of generosity and public-spirited concern for the welfare of the elderly, began to supply controlled dosage systems to such institutions. Soon, other pharmacists took part in this and, very quickly, practically all residential and nursing homes were provided with this valuable service at no cost. Numerous elderly patients living at home also began to receive their medicines in little plastic devices which held the day's tablets and capsules in easy-to-remember compartments based on meal times. In spite of much discussion on possible remuneration for this valuable service, the Department of Health has steadfastly refused to make any payments for it. After all, why use taxpayers' money to pay for something that is being provided free of charge?

These scenarios have one thing in common — the gaining of short-term commercial advantage at the expense of the long-term. I am not a businessman, but the end result of such activities seems even to me to have been entirely predictable. Let us therefore consider a further scenario, which I fear may come to pass if we are not careful. One of the major problems facing community pharmacy today is the apparent difficulty of persuading pharmacists to work in community pharmacies. I have written in this column before about the problems of a profession based largely on locums. One possible solution to this problem that has been mooted is the concept of the checking technician. I have a great deal of respect for the dispensers whom I meet in my current role as an occasional community pharmacy locum. Most are excellent. Having a nationally approved accreditation system for technicians may, indeed, seem to be the way forward in a situation in which pharmacies sometimes have to close when no pharmacist can be found. However, let us apply the lessons of history to this idea.

Community pharmacist managers can now command significant salaries. The Journal of 4 May has two advertisements offering £40,000, one offering £42,000 and one £50,000. Let us assume that these are exceptional and that the average salary for a community pharmacist manager is, say, £35,000. Let us, further, assume that an accredited checking technician is paid £15,000 (roughly the mid-point of the MTO2 scale in hospital, which is advertised in the same issue of The Journal as £13,549–£17,144). Could a situation come about that an accredited checking technician could safely be left in charge of a pharmacy, with a pharmacist on-call in some way to exercise some kind of long-range supervision while carrying out the "extended role"? Could one pharmacist then carry out such supervision for more than one pharmacy? We could reach the situation where pharmacy companies had one pharmacist "supervising" perhaps four, five or more pharmacies where the routine dispensing was being carried out by an accredited checking technician. The Department might then look at the economics of this and conclude that the dispensing fee and professional allowance were paid on the assumption that a pharmacist was present in the pharmacy. Assume than an average pharmacy dispenses 6,000 items per month. This is 72,000 items per annum at a fee of 94.6p per item (from April [PJ, 16 February, p197]), which will bring in a total annual "fee" of £68,112. (I have ignored additional income such as container allowances and Controlled Drugs item fees.) Subtract the pharmacist's salary (£35,000) and this leaves a surplus from the annual dispensing fee income of £33,112 to go towards the other running costs of the pharmacy (dispenser, counter staff, heating, rates, etc.).

The technician's salary of £15,000 plus a "supervision" allowance of, say, £7,000 to cover the part of the pharmacist's time brings the professional staff cost to £22,000 instead of the £35,000 if a pharmacist were to be employed full-time. The annual fee income of that pharmacy could therefore be reduced to £55,112 and still leave £33,112 towards general running costs. This would allow the dispensing fee to be reduced from 94.6p to 76.6p, which would make a considerable saving to the Department.

Do you seriously think that it could not happen? Consider the scenarios outlined earlier in this article, and think again. I believe that it is imperative that we retain the direct personal supervision role, even if it makes life difficult for us. Remember that our biggest argument against doctor dispensing (which seems to have fallen off the agenda of late) is that the doctor cannot be said to be exercising supervision just by being elsewhere in the same building or out on a house call. We are in danger of allowing a situation such as I have described to happen by default in our rush to develop a checking technician role to alleviate the "shortage" of pharmacists. The only winner will be the Treasury. The losers will be the pharmacy profession and the patients.

Please destroy this article after you have read it, in case it falls into the hands of the men from the ministry!