Community pharmacy: only innovation will deflect the disruptor beam

摘要

Is pharmacy at a crossroads, yet again? This phrase has often been repeated through the decades in different countries. This time though, it may be a question of survival. Traditionally, pharmacists were acknowledged for their expertise in the compounding of medicines. This special set of knowledge and skills in the methods of extraction and preparation of therapeutic products from their raw ingredients, often plants, was what defined us as a profession. In the post-Industrial era, pharmacists became distributors of medicines. The unique position of our forebears as the holders of knowledge was gradually eroded as industrial pharmaceutical companies took on manufacturing. Only the understanding that medicines are not ordinary goods of commerce protected the position of the pharmacy, and the pharmacist. Medicines present serious risks of harm, especially if used inappropriately. Accepting that assuring the safety of therapeutic products is fundamental to the delivery of high-quality health services (and to avoid diversion into illicit uses), is what has lead governments in countries with socialised healthcare systems to continue to fund pharmacies to distribute medicines, largely on a transactional cost basis. In most health systems the income generated by the ‘professional’ function of the pharmacy, the bit that has to do with having a special knowledge and skill set, is through the provision of medicines via the dispensing process or over-the-counter (OTC) sales. The question is, what value do funders and policy makers place on the medicines provision function and on the associated access to first contact primary health care? There is evidence from two successive community pharmacy contracts in New Zealand1, 2 that the funder here would like to disinvest in a volume-driven prescription dispensing model for community pharmacy services. The prevailing view among policy think tanks appears to be that disruptive technologies, some of which have already arrived in the guise of dispensing robots, electronic prescribing and transmission of prescriptions, universal health records, and telehealth consultations, will provide an opportunity to redesign the way medicines are safely distributed. This has important ramifications for how community pharmacy operates. One signal that funders' thinking has changed is the shift in the language used in their documents. The discussion now is about community pharmacist services rather than community pharmacy services.3 The predominant model of community pharmacy in the developed world is a blended business model, combining the role of health professional providing primary health care services with retailer. Elements of the retail operation may be medicines-related – OTC medicines or natural health products - but often a substantial proportion of the premises’ footprint is turned over to other merchandise. One may acknowledge that much of this is health- or wellness-related – for example, vitamins, ophthalmic solutions and sunscreens – but much of it is not, and one presumes it is only stocked because ‘that's what pharmacies sell’ or because it is necessary to cross-subsidise the other parts of the business. As reported by Scahill et al.4 in this issue, depending on the setting, the model flexes in terms of the proportion of retail to professional services. One pharmacy, predictably a mall pharmacy, is almost completely retail orientated and derives only 8% of its income from dispensing, while having no patients enrolled in the Long-Term Conditions service (a mandatory service under the current pharmacy contract). At the other end of the scale is a pharmacy that derives almost 90% of its income from professional services but relies on dispensing fees for one-third of that. Arguably, one provides little in the way of pharmaceutical services to its local community and the other is at significant risk of failing if the funding model moves away from paying for volume dispensing. Funders, internationall