Never have we collectively wanted to seal the door to a year so firmly and decisively as 2020. I suspect most people will remember last year for its unpredictability and destabilization. Yet amidst the anxiety and instability, the overstretched hospitals, and the restrictions and closures in primary care, I will remember how pharmacy kept the pace and demonstrated its remarkable commitment and support for patients and health systems.

Sandra Hanna

As an essential service for communities, a cornerstone of local public health infrastructure and a steadfast partner for government, pharmacy has proven itself unwavering. While the world rubs its eyes and shifts its gaze to 2021 with tempered hope and cautious optimism, the Neighbourhood Pharmacy Association of Canada (Neighbourhood Pharmacies) is assured that pharmacy can meet the diverse needs of patients in virtually every community across the country.

For our part, Neighbourhood Pharmacies has five priorities heading into 2021:

• Creating capacity in public health.
• Creating capacity in primary care.
• National pharmacare.
• Pharmaceutical supply.
• Cannabis.

Despite the trust and accessibility pharmacists have, their scope varies across the country. We support expanding pharmacists’ scope of practice to ensure community pharmacies can leverage their accessibility and infrastructure to support the primary care and public health systems.

Pharmacists should be empowered to work to their full scope of practice in all provinces, ensuring every Canadian has equitable, universal access to the full range of services pharmacists provide. This includes the ability to administer medications by injection; initiate, renew and adapt prescriptions; diagnose and treat common ailments; and deliver testing and immunization ­services.

According to a recent poll conducted by Neighbourhood Pharmacies, 88% of Canadians are confident in the quality of care they receive from their pharmacists. Many pharmacies open early and stay open late (with some open 24 hours), making pharmacists the most accessible health care provider in Canada. The convenience and accessibility of pharmacies make it easy for Canadians to rely on their trusted local pharmacist as their first and most frequent point of contact with the health care system. In the early months of the pandemic, many health care providers closed their doors. Pharmacists and pharmacy operators stepped up to demonstrate resilience, commitment to patients and an unmatched infrastructure of accessibility to fortify local health care systems. Pharmacy solidified its effectiveness as the first line of defense during a crisis and is well positioned to continue in the year ahead.

Creating capacity in public health

Pharmacy’s role in supporting public health is often unrealized and underreported. In 2019, approximately 50% of Canadians received the influenza vaccine at a community pharmacy, and this number continues to grow year after year. Pharmacies are also involved in COVID-19 testing initiatives in Canada and the United States — with extensive pharmacy testing programs in the U.S. In both countries, pharmacies stepped up to increase testing capacity in areas of need and can do even more, not only testing for COVID-19 but also for monitoring and screening other health conditions.

Leveraging pharmacies’ accessibility and the relationships built between pharmacists and their patients means fewer visits to physicians’ offices and emergency rooms. Pharmacist interventions correlate with better health outcomes, increased vaccination rates and improved return on investment for every dollar spent. They also contribute to a reduced burden on local health care resources already under stress. Canadians rely on pharmacists to provide credible health information and to navigate the plethora of misinformation. Research confirms pharmacies as the preferred destination for immunization services. Eighty-one percent of Canadians feel that pharmacy is a safe place to be vaccinated.

Pharmacy can further contribute our expertise to support critical public health vaccination programs and respond to other public health crises like the opioid crisis. In terms of vaccination programs, this includes a COVID-19 vaccine, seasonal immunizations, and routine child and adult immunizations.

Recent data also indicates one-third of Canadian parents cancelled or postponed scheduled vaccinations for their children due to the pandemic. School-based public health programs were also delayed or paused due to public health capacity. Ninety percent of Canadians trust the quality of care provided by pharmacists, and 80% of parents support pharmacists administering vaccinations for communicable ­diseases.

While we continue to tackle COVID-19, we are fighting an ongoing, and in some cases, worsening opioid crisis. Pharmacies are poised to support in response to this crisis. Opioid overdoses in Canada account for 11 deaths and 13 hospitalizations daily. Pharmacists are on the front lines of the crisis, ensuring safe supply, managing opioid therapy, providing access to opioid dependence therapy and facilitating access to naloxone programs. During the COVID-19 pandemic, pharmacists acted under temporary legislative exemptions under Section 56(1) of the Controlled Drugs and Substances Act to enable pharmacists to prescribe controlled drugs and substances to ensure continuity of care. We have seen further opportunities to support patients with this exemption, which was to expire in September 2020, and subsequently extended to September 2021. We encourage government to make the change permanent so that pharmacies can continue to play a critical role in fighting this devastating public health crisis.

Creating capacity in primary care

Pharmacies ensure efficient, effective continuity of care close to home while alleviating pressures on other primary care services. As designated essential services, pharmacies are crucial links in the primary health care system, providing critical, uninterrupted care in a coordinated way with other health care providers. More can be done to leverage pharmacists and pharmacies’ role to create capacity and alleviate primary care ­backlogs.

Approximately 15% of Canadians do not have a family physician, and 78% are likely to visit a pharmacist to manage common ailments. A recent analysis of common ailments programs in Canada estimates these ailments account for 10% to 20% of physicians’ workload at a time when physicians face significant capacity strains. Pharmacists can prescribe, diagnose, assess and initiate medication therapy for common ailments and conditions in most provinces, and they have much broader prescriptive authorities in some. Pharmacists are poised to support our health system partners and to reduce wait times by helping patients receive the care they need — when and where they need it.

Heading into the new year, we continue to advocate for the enhanced role of pharmacies in point-of-care testing, which would also serve to strengthen the primary care system. By enabling point-of-care testing in community pharmacies, pharmacists can screen for communicable diseases and monitor chronic disease therapies with shorter turnaround times. Offering this testing in pharmacies allows expedited decision making and increases the efficiency of care patients receive. Pharmacists should also have access to laboratory results and electronic medical records to ensure continuity of care and promote collaborative care.

To support the training and infrastructure pharmacists need to continue delivering these services, we also stress the importance of fair, sustainable ­remuneration.

National pharmacare

COVID-19 has had an unprecedented impact on health care systems worldwide, and Canada is no exception. The ongoing fight against this virus is far from over, and our health systems will likely need to remain focused on minimizing the spread of the virus, implementing wide-scale vaccinations and dealing with the secondhand impacts of the virus for the near future.

The virus has exposed many shortcomings in Canada’s health care system and, as such, the next few years should be focused on fighting COVID-19 while also working to address system improvements needed in long-term care, seniors care and mental health.

Fortunately, there are certain areas of Canada’s health system that have remained strong and stable throughout the pandemic. While the strains on our health care system have been unparalleled in our lifetime, Canadians’ access to prescription drugs has remained almost untouched. Based on industry data, 98.5% of Canadians have maintained their drug coverage during the pandemic, and access to drugs across the country has remained stable.

Before the pandemic, more than 95% of the Canadian population, representing 34 million Canadians, had drug coverage through private, public or multiple plans. The remaining 5%, 1.9 million Canadians, did not have any access to prescription drug coverage.

We believe that any new national pharmacare plan must prioritize caring for the uninsured and underinsured and providing coverage to those who need it most, particularly those living with and needing medications to treat rare ­diseases.

While the federal government continues to consider the implementation of a national pharmacare program, we will continue to urge it to work with provincial governments across the country to identify ways to provide drug coverage to Canadians who need it most while ensuring continuity of coverage for those who have it. We cannot risk disrupting Canada’s stable drug supply system, especially during the ongoing COVID-19 pandemic.

Pharmaceutical supply

Drug pricing is a critical component of the pharmacy business model, and these prices are strictly regulated in the Canadian pharmaceutical market. Dispensing fees and markups are the main source of income for community pharmacies, and because markups are assessed as a percentage of the drug cost, reductions in drug prices have unintended consequences on pharmacy income. Over the past 12 years the pricing of generic drugs has decreased by approximately 28%, from an average prescription price of $26.38 in 2007 to $19.09 in 2019. Pharmacies are estimated to have lost almost $1.1 billion in markup income over that 12-year period.

Likewise, the price decreases to patented drugs as a result of Canada’s revised Patented Medicine Prices Review Board (PMPRB) regulations and guidelines, implemented January 1, 2021, will lead to an estimated $78 million in lost markup income in 2022 alone. Pharmacies have limited ability to offset these losses, since drug plans dictate markups. Patients who need expensive specialty medicines to manage complex conditions require a greater level of care to achieve the best outcomes. The patient support services and additional handling costs for specialty medicines are supported almost exclusively by the markups received on these medicines. Therefore, the impact of price reductions is disproportionally felt by pharmacies serving the most complex patients who require the most care.

For payors and the health care system, achieving effective patient outcomes and protecting product integrity are critical to achieving the best value for money spent on pharmaceuticals. Throughout the coming months, we will continue to emphasize that any changes in government policy affecting drug pricing should include a dialogue with pharmacies.

Drug shortages have become an increasingly serious concern in the Canadian health care system. Over 1,000 shortages are reported to Health Canada every year. Pharmacies, wholesalers and pharmaceutical manufacturers protect and maintain the supply chain. They mitigate the worsening of long-standing shortages while preventing future ones from developing. Pharmacists dedicate hours to managing drug shortages for their patients. While necessary, it detracts from the time that pharmacists can spend on direct patient care. Drug shortages lead to an increase in harmful medication safety incidents. These shortages can confuse patients and lead to adverse outcomes — including noncompliance and incorrect medication use. One in four Canadians have experienced or know someone who has experienced a drug shortage in the last three years. In the past three years, 10% to 15% of Canadian drugs were in short supply at any given time. Patients rely on pharmacies for their medications and require timely access to medications — even when there are shortages. In response to the COVID-19 pandemic, Health Canada and provincial governments implemented various measures to manage the supply of ­medicines.

It’s clear that pharmacy needs to be included in government discussions on drug shortages at the earliest possible stage to address supply issues and identify alternatives. We also continue to be actively engaged in discussions relating to U.S. importation programs that threaten the supply of Canada’s medicines. Early identification of potential shortages, communication with stakeholders and equipping pharmacists with the scope to provide therapeutic substitutions will ensure quality and continuity of care as we head into 2021.

Cannabis

According to a recent survey conducted by Medical Cannabis Canada, systemic barriers in the legal medical cannabis system are pushing patients into recreational and unregulated markets without the support of a health care professional. Neighbourhood Pharmacies will continue to advocate for pharmacists’ inclusion as designated health care providers in the Cannabis Act. This change will allow pharmacists to prescribe and counsel patients on medical cannabis use — just as physicians and nurse practitioners can.

As part of our 2021 cannabis advocacy, we will also ask that the federal government amend the Cannabis Regulations so that pharmacists and pharmacies are authorized to distribute and dispense medical cannabis, just like hospitals and physicians are authorized to do. The timing of our advocacy campaign works well because Health Canada is required by law to begin a review of the Cannabis Act by October 2022. Early advocacy can help shape the terms of reference of this review and ensure that the voice of pharmacy is represented at all consultation tables.

Access to recreational, adult-use cannabis should not be more liberal than access to cannabis health products (CHPs). It is critical that the sale of CHPs meets standards of safety and efficacy similar to those of existing natural and pharmaceutical health products. Consumers, industry and association representatives report concerns with CHPs entering the market without oversight from regulated health care providers. Consumers prefer pharmacies as the ideal place for the sale of CHPs, compared to licensed retailers. Industry and association representatives also prefer a health care professional, such as a pharmacist, providing advice to consumers seeking CHPs, to support informed decision making. For these reasons, Neighbourhood Pharmacies invites government to work with pharmacy regulators toward aligning and integrating the regulations governing CHPs with those of the established national drug scheduling model developed by the National Association of Pharmacy Regulatory Authorities (NAPRA).

Regardless of whether a CHP is classified as a prescription, nonprescription or natural health product, we continue to advocate for the important role pharmacists have in providing clinical information to patients at the point of sale.

The year ahead

The extraordinary initiative pharmacists and community pharmacies demonstrated throughout 2020 unquestionably highlights our knowledge, versatility and, above all, our dedication to delivering accessible, uninterrupted patient care. Neighbourhood Pharmacies approaches the new year proud of our members for stepping up in every way to serve their communities. We are profoundly confident in pharmacy’s unique ability to innovate, collaborate and offer solutions in all areas of the health care system.

Our priorities — cannabis, national pharmacare, pharmaceutical supply, creating capacity in primary care, and public health — are foundational to guide our work heading into 2021. Public health is an area where pharmacy has contributed its resources and expertise over the last several months, working prominently to support our patients and partners in the health care system.

Pharmacies will continue playing a critical role in public health this year, deploying the COVID-19 vaccine in communities across the country. We will be instrumental in helping Canadians emerge from this pandemic and getting the economy and health care system back on track. We are equally prepared to leverage our flexibility and thought leadership. Pharmacy is ready to do what it takes to achieve progress and success in the highly anticipated months to come as we ride the wave of this surge and work together towards recovery.

Sandra Hanna is the chief executive officer at Neighbourhood Pharmacies.