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Bernie McKone: global challenges
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New Zealand may be on the other side of the world, but the challenges
its pharmacists are facing are remarkably similar to those being faced
by pharmacists in Britain. New Zealand pharmacy has seen new rules around
the regulation of pharmacists, modernisation of its professional and
regulatory body, extended role development, deregulation of pharmacy
ownership, even a “vision” for pharmacy. These are familiar
issues in Britain but all of them have been tackled in slightly different
ways.
Perhaps the single most important change for pharmacy in New Zealand
took place on 18 September. On this date, the Health Practitioners’ Competency
Assurance Act came into force. It put an end to self-regulation
of health professionals and, consequently, the Pharmaceutical Society
of New Zealand split.
Until then, the regulation and representation of pharmacy was carried
out by the PSNZ in a similar way to the Royal Pharmaceutical Society
in Britain. But the New Zealand government decided that this could no
longer continue. The PSNZ was divided into the Pharmacy Council to regulate
pharmacy, and PSNZ (Inc) for the representative and professional roles.
Bernard McKone, who was the president of the PSNZ and is now the first
chairman of the new PSNZ (Inc), explains that the decision stemmed from
two cases of poor practice in medicine, the second of which involved
a pathologist who misread a large number of cervical cancer slides. This
case, four years ago, prompted the health minister to draw
up the Health Practitioners’ Competency Assurance Act.
“It was a hugely ambitious piece of legislation that affected every
health profession,” Mr McKone says. He explains that the government
perception of the PSNZ’s self-regulating role was of a conflict
of interest. “Despite
the fact that the society had a very good record in the way that it handled
discipline, the government perception was of an old boys’ club,” he
says. The new legislation aims to create a transparent process of regulation.
But the effects have implications way beyond regulation. Mr McKone points
out that pharmacists’ roles had been constrained by having to work
within the previous legislation, which was drawn up in 1970. “So
it represented a good opportunity to modernise the legislation for pharmacy.
Hopefully in
future people will look back and say that the new legislation is enabling
and allowed the profession to move forwards.”
Preparing for the changes
Pharmacy in New Zealand has had a year to prepare for implementation
of the Health Practitioners’ Competency Assurance Act since a
bill that would lead to the act’s implementation was passed in
September 2003. One of the first steps taken by the health minister
was to appoint a transitional PSNZ council. Rather than allowing scheduled
PSNZ council elections to go ahead, she asked a number of people on
the existing PSNZ council to stay in post and appointed some additional
members.
The minister also had to appoint the new regulatory Pharmacy Council.
In October 2003, she selected two existing PSNZ council members, two
past presidents of the Society, one academic pharmacist and two lay members
to form the new Pharmacy Council. The Pharmacy Council acted as a shadow
council with limited roles while the PSNZ continued to function more
or less as normal during the past year. The Pharmacy Council then took
over regulatory functions from the PSNZ on 18 September.
Disciplinary issues involving pharmacists are now dealt with outside
pharmacy altogether. The Pharmacy Council determines whether a case is
a competency issue, in which case it addresses it, or if it is a disciplinary
issue. Disciplinary issues are referred to the Disciplinary Tribunal.
This organisation deals with disciplinary issues for all health professions,
not just pharmacy. The tribunal is chaired by an appointed barrister,
has three lay members and three members of the health profession to which
the person whose case is being heard belongs. “The concern is that
this will slow down the disciplinary process,” comments Mr McKone. Deregulation threat
In a parallel with the recent Office of Fair Trading report into control
of entry in the UK, community pharmacists in New Zealand also faced
the threat of deregulation. But in their case it was a consequence
of the Health Practitioners’ Competency Assurance Act. Although
ownership of pharmacies is covered in the previous legislation, it
had no place in the modernised act, which is about the regulation of
health professionals — not premises. The result of the act superseding
the old legislation would have been the immediate end to the regulation
of premises.
Mr McKone comments that both the PSNZ and the Pharmacy Guild of New
Zealand, which is the representative organisation for contractors,
lobbied the
government hard over this issue. The result is new legislation that allows
pharmacists to own up to five pharmacies with a 51 per cent shareholding
and an unlimited number with a 49 per cent shareholding. It also means
that
licensing of community pharmacies now
falls to the government; the PSNZ has lost its right to license pharmacies. Dividing the resources
Dividing the PSNZ’s roles also meant dividing its financial assets. “Much
of the past year has been spent working out what to do with resources
and what belongs to whom,” explains Mr McKone. One of the biggest
debates was whether or not the PSNZ’s assets should be used to
fund the Pharmacy Council. Some pharmacists said that since
the Pharmacy Council is a government-appointed body, it should not receive
PSNZ funding but others said that since it was being established for
the benefit of pharmacy it should
be funded.
“If the Pharmacy Council had no money then its only way of operating
would have been through the registration fee. So the PSNZ took the view
that
if we gave it nothing then on day one pharmacists would have faced a
big increase in fees to cover the set-up costs of the Pharmacy Council,” says
Mr McKone. “We consulted with the profession and they didn’t
want increased fees.”
Once the principle of funding the Pharmacy Council was established, the
next debate was around how to divide the PSNZ assets between the Pharmacy
Council and PSNZ (Inc). First, certain funds that were solely connected
with professional issues, such as the benevolent fund, were separated.
Next the society’s share in its headquarters building was sold
to the guild. PSNZ (Inc) now leases space from the guild and the Pharmacy
Council is housed in a new building. Once the building was sold, the
PSNZ had cash assets. One-third of this went to the Pharmacy Council
and the remainder was moved to the new organisation — PSNZ (Inc) — to
protect it. “If it hadn’t been moved it would have automatically
gone to the Pharmacy Council on 18 September,” says Mr McKone.
In addition to headquarters
assets, the PSNZ also had to deal with the money held within the branches
of the PSNZ across New Zealand. “If not, they, too, would have
lost their funds on 18 September.” Mr McKone adds: “I think
we have resourced the Pharmacy Council well. It has been able to set
up and operate until 31 December this year without having to ask for
additional fees from pharmacists.”
This year’s retention fee was NZ$695 [about £260] plus tax. “We
expect next year’s registration fee with the Pharmacy Council to
be in the region of NZ$300–350 plus tax,” says Mr McKone.
On top of that, pharmacists can opt to become members of the new professional
organisation, PSNZ (Inc). “We expect that pharmacists will be able
to join it for less than the difference between the old and new registration
fees,” he adds. New professional organisation
“The formation of the Pharmacy Council has been successful,” says
Mr McKone. “But it has been the easy bit because its roles are
clearly set out in law. Setting up the voluntary organisation has been
much harder.”
PSNZ (Inc) was officially launched on 15 September, and getting to that
event has not been without its problems. It was decided that all pharmacists
would remain members of PSNZ (Inc) until 1 January 2005 to retain the
benefits of the entire year’s retention fee for 2004. “The
success of PSNZ (Inc) will depend on whether pharmacists decide to join
it on 1 January,” comments Mr McKone. He says that an encouraging
sign is that when all pharmacists were asked earlier this year whether
their membership of PSNZ could be transferred to PSNZ (Inc), 98 per cent
responded. “Altogether, 90 per cent said yes and 8 per cent sent
their forms back without ticking the ‘yes’ or ‘no’ box,” he
says.
The formation of the voluntary professional organisation has been a hot
topic in New Zealand this year. “About six months ago, the guild
started questioning the need for more than one representative body in
pharmacy,” explains Mr McKone. In other words, it asked whether
PSNZ (Inc) was needed in addition to the guild. The PSNZ held roadshows,
which established that pharmacists wanted the two organisations to merge.
However, it was recognised that forming one representative organisation
would take time so it was decided that PSNZ (Inc) still had to be established
to protect the PSNZ
assets in the short term. But the waters got muddied and the profession
got the impression that PSNZ (Inc) was trying to compete with the guild.
This was followed by concerns that the new representative body would
be sector-led and therefore not be to the benefit of all pharmacists. “There
was a deep suspicion that the proprietor group would take over,” Mr
McKone explains. “The challenge is to form one organisation that
incorporates all sectors.”
The process has been complex. The councils of PSNZ (Inc) and the guild
met in July. “After a day of difficult debate, we came to a unanimous
decision to move forward,” says Mr McKone. Five members of each
council were appointed to form an independent governance board and an
independent project manager was appointed to push through the formation
of the new body.
It was hoped that the new representative organisation could be in place
by January. “Unfortunately, on 9 September, the guild decided that
it could not carry on with the process,” says Mr McKone. “We
were disappointed and surprised that they decided not to proceed at the
eleventh hour.” The guild is now consulting its members again and
the process is on hold for three months. “With hindsight it is
clear that our January target was too ambitious,” he adds. “But
with a will, we will get there in the end.”
In retrospect, Mr McKone believes it was wise that PSNZ (Inc) was established.
Not only has it protected the PSNZ assets, but it will now operate as
pharmacists’ representative body until the new organisation is
formed. “To have no organisation to act as an advocate on behalf
of pharmacists at this time would have been bad for the profession,” he
explains. “And now PSNZ (Inc) can become a stronger advocate for
pharmacy rather than having to take a more tempered approach when, as
the PSNZ, it also had its statutory role.”
One of the first tasks for PSNC (Inc) will be to elect a new council.
The old PSNZ council became the PSNZ (Inc) council in September. It has
been four years since elections were held and some members of the transitional
council, including Mr McKone, want to step down. Challenges for the profession
PSNZ (Inc) already has its work cut out. The turmoil facing pharmacy
extends beyond regulation and representation. At the end of last year,
the government’s drug purchasing agency Pharmac decided to move
from move from one-month to three-month prescriptions. “Dispensing
fell by a third and this
resulted in a sudden drop in pharmacists’ income,” he says. “Doctors
were continuing to write monthly prescriptions that pharmacists couldn’t
dispense. At one point I was
returning 30 to 50 prescriptions a day to doctors for clerical changes.”
To make it worse, in the most recent contract negotiation, pharmacists’ pay
structure was changed so it consisted purely of a dispensing fee. Five
years before, the pool of money had been top-sliced so that pharmacists
were paid for clinical services plus dispensing fees. “But pharmacists
had been slow to take up services such as medication review so the guild
argued for the money to be moved back into an increased dispensing fee,” says
Mr McKone. The decision hit pharmacists who had restructured their practice
around clinical services. “So when the recent Pharmac decision
came it was a disaster. Small pharmacies closed and the number of intern
placements fell. Even the number of pharmacy students went down.”
Some concessions have been now made and pharmacists can dispense whatever
the doctor writes (even if that is a one-month prescription). But Mr
McKone warns that the full impact will not be felt until the end of the
financial year. “Pharmacists are experiencing between 2 and 20
per cent change in gross profit. No one can sustain that,” he says. “New
Zealand is rural and many pharmacies depend on dispensing for 90 per
cent of their income. The community pharmacy model has got to change.”
So the PSNZ decided to bring the whole pharmacy sector together to come
up with a strategic document based around expanded services for pharmacists. “We
must find other funding streams for pharmacy,” he says. “Sure,
pharmacists need to keep on the dispensing role but the profession is
capable of many more roles, such as medicines management.” The
resulting 10-year vision document has gained the support of both the
medical and nursing professions.
It is clear that advocating new roles for the profession will be the
main focus for PSNZ (Inc). And developing the role of pharmacists brings
Mr McKone full circle to the new Health Practitioners’ Competency
Assurance Act. “The new act is enabling,” he says. Through
it, pharmacists will be able to develop extended roles.
All over the world, pharmacists are facing many of the same issues. Mr
McKone comments: “Pharmacists have got to get their heads around
these changes and not just in New Zealand; the professional challenges
are the same in Australia, the UK and the US. But it isn’t recognised
at grassroots. Pharmacists keep making the mistake of saying that they
do all these clinical roles already. Taking a
patient into a separate environment and looking at their medicines in
depth, asking if they are appropriate and modifying them is an
entirely different process from dispensing. Pharmacists who say they
are doing this on a day-to-day basis as part of dispensing are
deluding themselves.” |
The
Pharmaceutical Journal