The Irish System Of Community Pharmacy Needs A Rethink And A Fresh Vision For Its Future, Writes Ultan Molloy.
I hadn’t realised that pharmacist numbers on the PSI register have increased by 90 per cent in the last 20 years to over 6,000 at this stage. Yet there is a shortage of available pharmacists to fill full-time positions in community pharmacies throughout the country. We can see from the B&A IPU-commissioned survey on this that over 80 per cent of pharmacists charged with arranging cover for pharmacies (owners and superintendent pharmacists) consider a shortage of pharmacists to be a significant issue, although it’s becoming clear that the issue is more complicated than this, given the pharmacist numbers on the register.
Why has employment in community pharmacy evolved to become a progressively less attractive career option?
Other career options may give pharmacists:
- Greater flexibility around working hours (not necessarily tied to retail hours which can run later, and usually includes some weekend commitment), and breaks, etc.
- Greater remuneration in some situations, such as working as a locum, where job security isn’t a priority in the present market for some pharmacists. Just 22 per cent of locum pharmacists are prepared to work more than 30 hours per week in the recent IPU B&A survey, with almost a third indicating that they work less than eight hours per week, and the median being 13-to-16 hours per week. Females make up c. 65 per cent of pharmacists and c. 70 per cent of pharmacists are 45 years old or younger, so many will be working two ‘jobs’ as such, where we have family to take care of, and are also working as a pharmacist.
- Less managerial, administrative, regulatory and additional service responsibility. Why would you want it, if you don’t enjoy it, and can avoid it? However, someone still has to look after these things now and into the future.
- More employment incentives with some other contracts, ie, maternity benefits, sick pay, health insurance, supplemented pension. I understand that every employer has to give a pension option to employees, but does not have to supplement it, and paid sick leave is in the pipeline also as a requirement in all employment contracts. Putting these in place as a more standard arrangement could be a way forward, although how they would be paid for in many pharmacies is a significant consideration. Would they just be for pharmacists then, or for all staff, and what’s fair and reasonable for the team to expect?
Other frustrations after what has been a demanding couple of years for all of us include:
- Excessive bureaucracy and paperwork (HSE/PCRS, PSI and now FMD).
- Lack of support staff, although a wage budget which leaves a pharmacy financially viable is obviously finite.
- A ‘lack of respect’ from the public and other stakeholders (colleagues, doctors, regulators, employers, etc).
- Feeling like ‘no matter what you do, it’s not enough for some people’.
The role of the community pharmacist appears to have evolved to become, in many cases, untenably complex and laden with unreasonable expectations. We also have a new generation of ‘Gen-Z’ pharmacists coming through, with their own expectations, in tandem with soul-searching from our present workforce around work-life integration, and where one’s priorities lie. Gen Z, in broad terms, prioritise work-life balance and personal wellbeing.
They look for benefits such as paid time off, mental health days, or activities that create a sense of community, as well as being pragmatic and financially-minded, and they’re prepared to walk in order to get what they want. Whether others consider some of these to be reasonable, who’s entitled to what, and what the expectations are of each party, is something that will have to find its own level in time. The available workforce is just that, the available workforce, and everything that comes with it.
What the above fails to comprehensively address is what motivates and drives us. Autonomy (the right or condition of ‘self-government’), mastery (comprehensive knowledge or skill in a particular activity), and purpose (the reason for which something is done). Also, the idea that ‘meaningful struggle’ is a source for our own self-fulfilment. Many of us are struggling, although finding the meaning in said struggle can be the more difficult aspect of this paradigm.
The proportions of each of these three elements available to oneself varies depending on one’s role within community pharmacy. For example, a locum role may offer high levels of autonomy, but perhaps lower levels of the others. The joy in my own role as a pharmacist comes from sorting out customers who are appreciative, reasonable, and value the relationship and the time that we invest in looking after them. It can feel some days, of course, like these are few and far between, and the more challenging ones can take up more time and energy than they deserve.
Anyway, it is clear that the whole community pharmacy model needs a rethink, and a vision for its future. Thinking through the various stakeholders, and our experience in recent memory, it is difficult to get a sense of inspiration around what that might look like. As things stand, and having inherited what they have, the Irish Pharmacy Union executive frustratingly has limited influence on primary care policy, pharmacy and pharmacist involvement in primary care, and influence over many of the forces bearing down on us all. We have no Chief Pharmaceutical Officer in the Department of Health, and pharmacists have apparently been bypassed for the last two decades due to a lack of relationships and influence at the top table.
Pharmacy payments come in under the drugs budget in the HSE. Up to flu vaccinations, and more recently Covid-19 vaccinations, we have been unable to demonstrate clear value for money to our politicians, with massive cuts in payments to pharmacies made under FEMPI legislation back in 2010 still in place. ‘A conduit for the delivery of medicines?’
Why would our politicians, who are mainly middle-aged, relatively healthy people who pay for their medicines see us as anything other than sticking labels on boxes in a comfortable retail setting, when they know no different? We get an average of about €4 dispensing fee under Government schemes, and yet Plavoxid, which can be prescribed by pharmacists in other countries, gets a Hi-Tech fee because of drug interactions. What about everything else in the dispensary that we’re working with every day that have drug interactions? Ironically, a non-dispense fee for Plavoxid involves at least twice the professional intervention and work, as dispensing it would, for half the remuneration… go figure!
We don’t have patients knocking on politicians’ doors saying they can’t get a pharmacist, whereas it is the case that some can’t get a GP. Does it need to come to that? Maybe that’s why the GP contract has capitation fees, holiday pay, sick leave, locum cover fees, practice allowances, out-of-hours payments, superannuation, maternity leave, study leave, rural practice allowance, special fees for additional services, care home fees, EU patient fees, and a practice premises grant.
Clinic hours can be for set times on weekdays, with minimal weekend commitment. I still wouldn’t want that job, mind you, but they have a fairly comfortable contract arrangement with the Government as part of their primary care service.
We had a net negative change in the number of community pharmacies open in the country recently. Maybe more need to close. Ironically, community pharmacy is a highly functional part of the primary healthcare system, that yet has highly dysfunctional internal challenges, and relentless forces acting on it that are simply out of the control of community pharmacists and owners.
Clearly, this month’s article is about the landscape in which we presently operate. What needs to change in order to have a thriving and sustainable community pharmacy network as a primary care resource into the future, and an inspiring vision for this, is a more challenging proposition to tackle. One thing is for sure, and that’s if we keep doing what we’ve been doing, we’re going to get more of what we’re getting.