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Professional pharmacy manpower in British Columbia : an exploration of selected topics and issues Polglase, Elaine Hadfield 1979

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PROFESSIONAL PHARMACY MANPOWER IN BRITISH COLUMBIA: AN EXPLORATION OF SELECTED TOPICS AND ISSUES by ELAINE HADFIELD POLGLASE B.S.P., University of British Columbia, 1956 A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE in THE FACULTY OF GRADUATE STUDIES (The Department of Health Care and Epidemiology) We accept this thesis as conforming to the required standard THE UNIVERSITY OF BRITISH COLUMBIA April , 1979 © Elaine Hadfield Polglase, 1979 In presenting this thesis in partial fulfilment of the requirements for an advanced degree at the University of British Columbia, I agree that the Library shall make it freely available for reference and study. I further agree that permission for extensive copying of this thesis for scholarly purposes may be granted by the Head of my Department or by his representatives. It is understood that copying or publication of this thesis for financial gain shall not be allowed without my written permission. Department The University of British Columbia 2075 Wesbrook Place Vancouver, Canada V6T 1W5 >E-6 B P 75-51 1 E i i ABSTRACT The rapid and accelerating growth of the College of Pharmacists of British Columbia between 1974 and 1976 led to concern in the profession for what growth might reasonably be expected in the future. It was known that recent entrants had experienced difficulty in obtaining pharmacy employment in B.C. and this aroused anxiety about the capacity of the system to absorb future growth. As an extension of its work in employment information, employment relations and pharmacy economics, the B.C. Pharmacists' Society established a committee to focus on the manpower supply and demand balance of the profession. In order to address these concerns a study was designed in three parts. The first consists of a general review of supply and demand problems common to all types of health manpower. The system of pharmacist supply in B.C. is outlined, as are demographic characteristics of the register. Details of the employment system are also explored. The second part of the study is devoted to developing a method for projecting future growth of the number of pharmacists. From a complex model which illustrates the flows of manpower in and out of active licensed status, the main elements of supply and loss are identified. Trends surrounding these individual factors are analysed, and several projections for growth are made under i i i varying policy assumptions. The third phase of the study presents the findings of a survey of individual pharmacists to determine their employment situation in 1977 and 1978. Several estimates of total retail prescription demand in British Columbia are. made, using data from the responses of individual dispensing pharmacists and community pharmacy managers. The staffing patterns in community pharmacies to meet this demand are examined. Prescription workloads of community pharmacists are compared to norms previously developed by the profession, and time distributions, use of auxiliary personnel, and computer aids are determined. For the hospital pharmacy field, the staffing levels are compared to standards of the Canadian Society of Hospital Pharmacists, and estimates of pharmacist time spent in drug utilization review are compared to the recommendation of the federally funded 1975 Working Party on Standards for Institutional Pharmacy Service. TheVindings of the study lead to conclusions that the profession has a capacity for growth of its manpower supply that is as large, and perhaps even larger than the growth of the population i t will serve by 1990; but i t will not likely grow at the very high rates experienced in the mid-1970's. On the demand side the conclusions are basically similar to those of the Royal Commission on Health Services in 1966: viz . , in hospital pharmacy there are too few pharmacists. This is no longer due to a lack of attractiveness i v of the field, nor to a large disparity in its wage rates, but rather to the lack of an official provincial policy on institutional pharmacy services and staffing levels. In the field of community pharmacy there is s t i l l a drug dispensing overcapacity due to large numbers of relatively small outlets. While l i t t l e work was done to explore costs, the wide variation in pharmacist dispensing loads indicated that there were likely extreme cost pressures on pharmacies with low prescription volume. Among the recommendations arising out of the study are proposals that these data be given careful consideration by the College of Pharmacists of B.C., the B.C.Pharmacists' Society and the Faculty of Pharmaceutical Sciences in their role as planning agencies. The maintenance of a data base will continue to be important, and further research should be done on the growth and age distribution of the manpower supply, the economic base of community pharmacy, and the staffing and services in institutional pharmacies. V TABLE OF..CONTENTS CHAPTER ABSTRACT TABLE OF CONTENTS LIST OF TABLES LIST OF FIGURES ACKNOWLEDGEMENT PREFACE PART I: THE BACKGROUND OF THE STUDY INTRODUCTION I AN OVERVIEW OF PROFESSIONAL PHARMACY MANPOWER IN B.C: TO 1977 1.1 Need and Demand Problems in Pharmacy Manpoer 1.11 General Problems in Measuring Demand for Health Professionals 1.12 Historical Measurements of Demand for Pharmacists 10 1.13 Defining the Product of Community Pharmacy 18 1.14 Estimates of Prescription Demand in B.C. 21 1.15 Need and Demand for Community Pharmacists 24 1.16 Pharmacare: The Development of a "Super Client" 25 1.2 Recent Influences on Pharmacist Supply in B.C. 34 1.21 Pharmaceutical Sciences Enrolment Concerns 1965-1970 36 1.22 Pharmaceutical Sciences Curriculum and Enrolment 1971-1977 42 1.23 College of Pharmacists of B.C. 46 1.24 The Pharmacy Act of 1974 49 PAGE i i v xi xxi i xxi i i xxv 1 1 8 8 8 vi CHAPTER PAGE 1.3 The Pharmacist Register 52 • . . / 1.31 Growth and Distribution'of the Manpower Supply 52 1.32 Sex of B.C. Licensed Pharmacists 58 1.33 Age of B.C. Licensed Pharmacists 59 1.34 :Place of Education 64 1.35 Level of Education 67 1.36 Distribution by Practice Field 68 1.37 Geographic Distribution 70 1.4 Pharmacist Employment in B.C. 75 1.41 Number of Pharmacists in the Labour Force 1974-1977 77 1.42 Employment Status Reported by New Registrants, 1974 to 1977 78 1.43 The Pharmacist Full Time Equivalent 81 1.44 Full Time Equivalence of B.C.Pharmacists 1975, 1977 83 1.45 Pharmacist Unemployment and Placement Statistics 84 a) Canada Employmet and Immigration Commission 85 b) B.C. Pharmacists' Society Placement Information 86 : 2 RATIONALE AND OBJECTIVES OF THE STUDY 87 2.1 The General Concerns 87 2.2 The Specific Research Objectives 89 2.3 The Significance of the Study 93 3 METHODOLOGY 95 3.1 The Model of the Supply of Pharmacists in B.C. 96 3.2 The Survey of B.C. Pharmacists, 1978 97 3.3 The Use of Supplementary Data 102 CHAPTER vii PAGE 3.31 College of Pharmacists of B.C. 102 3.32 The B.C. Health Resources Survey, 1968 102 3.33 Faculty,' of Pharmaceutical Sciences, UBC 102 PART II: PROJECTING GROWTH OF THE MANPOWER SUPPLY 103 INTRODUCTION 103 4 THE DEVELOPMENT OF A METHOD FOR FORECASTING GROWTH 105 4;1 Modelling the Full Dynamics of Supply 105 4.2 The Forecasting Model 108 4.3 Developing the Forecasts 108 5 THE INDIVIDUAL FORECASTS 114 5.1 Forecasts Based on Thirty Annual Out-of-Province Entrants 115 5.2 Forecasts Based on Twenty Annual Out-of-Province Entrants 117 5.3 Forecasts Based on Zero Out-of-Province Entrants 120 6 THE APPENDICES ON FORECASTING SUPPLY 123 6.1 Appendix 1: The "Active Register" of Pharmacists 123 6.2 Appendix 2: UBC Enrolment: Second Year 127 6.3 Appendix 3: Attrition: Second to Third Year 131 6.4 Appendix 4: Attrition: Third to Fourth Year 133 6.5 Appendix 5: Attrition: Fourth Year to Graduation 134 6.6= Appendix 6: New Registration: UBC Graduates 136 6.7 Appendix 7: New Registration: Out-of-Province Graduates 137 6.8 Appendix 8: Attrition from the Profession: With-drawal from Active Status 142 6.9 Appendix 9: Attrition from the Profession: Deaths of Active Members 146 6.10 Appendix 10:Attrition from the Profession: Reactivation of Licence 147 CHAPTER vi i i PAGE PART III: THE PHARMACIST SURVEY 151 7 THE CURRENT MANPOWER CONCERNS -1.53 7.1 Unemployment and Underemployment 153 7.11 Employment/Unemployment; 1978 154 7.12 Part Time Employment Choices; 1978 156 7.13 Unemployment; 1977 157 7.14 Return to Employment 161 7.15 The REcent U.B.C. Graduates; 1978 status 162 7.16 The Recent U.B.C. Graduates; Unemployment, 1977 165 7.2 Recent Demand for Pharmacists in B.C. 168 7.3 Staff Recruiting Problems 172 7.4 Participation of Male and Female Pharmacists 176 7.41 Retention of Active Status by U.B.C. Graduates 177 7.42 Expected Duration of Career 180 7.43 Full Time Equivalence of Male and Female Pharmacists 181 7.5 Career Attitudes of B.C. Pharmacists 185 7.51 Pharmacy as a Career Choice 1968, 1978 185 7.52 Satisfaction with Current Field of Practice 186 CHAPTER ix PAGE 8 COMMUNITY PHARMACY PRACTICE IN B.C. 191 8.1 Estimates of Total Retail Prescription Demand for B.C. 192 8.11 Estimates from Individual Pharmacist Workloads, 1978 192 8.12 Estimates from Pharmacy Weekly Volumes, 1978 193 8.13 Estimates Based on 1977 Annual Volumes 194 8.14 Estimates Based on Pharmacare Billing 194 Statistics 8.2 Community Pharmacy Outlets in B.C. 197 8.21 Prescription Statistics, 1977 198 8.22 Prescription Volume and Pharmacist Staffing, 1978 202 8.23 The Use of Pharmacy Assistants 206 8.3 Staffing Patterns in Relation to Prescription Demand 211 8.4 Community Pharmacists in B.C. 217 8.41 Weekly Prescription Loads 218 8.42 Hourly Prescription Workloads 221 8.43 Aids to Productivity 225 8.44 Patient Records and Patient Counselling 227 8.45 Activity Patterns of Community Pharmacists 233 9 INSTITUTIONAL PHARMACY IN B.C. 241 9.1 Staffing Patterns in B.C. Hospitals 242 9.11 Ratios of Beds per Pharmacist 243 9.12 Ratios of Pharmacist Hours 244 9.13 Pharmacy Assistant Staffing 245; X CHAPTER PAGE 9.2 Drug Distribution Systems in B.C. Institutions 245 9.3 Activity Patterns of Institutional Pharmacists 246 9.4 Prescription Workloads of Institutional Pharmacists 247 CONCLUSIONS AND RECOMMENDATIONS ;250 BIBLIOGRAPHY 258 APPENDIX A: THE SURVEY METHODOLOGY 261 xi LIST OF TABLES TABLE TITLE PAGE 1.1-1 Number of persons eligible and total benefits paid by Pharmacare 1976 - 1977 (March year end) 28 1.1- 2 Number of community pharmacies in B.C., 1961-1977; showing estimated population per pharmacy. 29 1.2- 1 Number of new pharmacist registrations with the College of Pharmacists of B.C. , 1949-1976; Showing number and percentage U.B.C. graduates 37' 1.2- 2 Undergraduate enrolment, Faculty of Pharmaceutical Sciences, U.B.C. 1970-1977 45 1.3- 1 Ratios of census population per pharmacist for British Columbia, 1961-1976 51 1.3-2 Percentage growth of population and numbers of licensed pharmacists in B.C. , 1961-1976 56 1.3-3 Number of licensed pharmacists in B.C. , 1962, 1974, 1977; showing sex of pharmacists 59 1.3-4 Percentage of pharmacists in two age categories, 1962-1977 60 1.3-5 Number of licensed pharmacists in B.C. , September 1977, by age and sex 63 1.3-6 Number of licensed pharmacists by age in 1977 projected to 1987 64 1.3-7 Province of basic pharmacy education, B.C. licensed pharmacists, September 1977 65 1.3-8 Number and source of new out-of-province registrants, College of Pharmacists of B.C. , 1974-1977 66 1.3-9 Number and percentage of B.C. pharmacists reporting apprenticeship or degree training, 1977 67 1.3-10 Major fields of employment reported by B.C. licensed pharmacists, 1968. 68 1.3-11 Major fields of employment reported by B.C. licensed pharmaci sts ,1975 and 1977 69 xii TABLE TITLE PAGE 1.3- 12 Number of pharmacist FTE per 10,000 population and percentage of elderly in the non-metropolitan regions of B.C. showing FTE deviation from mean and from age adjusted population 72 1.4- 1 Number arid percentage of B.C. licensed pharmacists reporting residence outside B.C. , 1974-1977 7 7 1.4-2 Number and percentage of B.C. licensed pharmacists reporting pharmacy employment, 1974-1977, showing major field of employment 78 1.4-3 Increase in number of pharmacists licensed and reporting pharmacy employment, 1974-1977; showing major field of employment 79 1.4-4 Number and percentage of new registrants reporting employment, 1974-1977 80 1.4-5 Number and percentage of new registrants reporting employment, 1974-1977; showing sex of pharmacist 80 1.4-6 Number of new registrants reporting employment, 1974-1977; showing region of employment 81 1.4-7 Level of employment reported by non-owner respon-dents, B.C.P.S. Survey 1975, 1976 82 1.4-8 Full time equivalence of B.C. pharmacists 1975,1977 83 1.4-9 Full time equivalence of B.C. pharmacists 1975, 1977; showing field of pharmacy employment 84 TABLE TITLE xi i i PAGE 4.3-1 Summary of ferti l i ty and migraiton assumptions underlying Canadian population projections, 1972-2001 111 4.3-2 Projected total population of B.C. , 1978, 1983, 1988, 1990 112 4.3?3 Projected percentage population growth in B.C. , 1983, 1988, 1990; indexed to 1978 113 5.0- T Summary of migration, enrolment and withdrawal assumption underlying the individual projections for growth 114 5.1- 1 Projected number of actively licensed pharmacists to 1990, assuming 30 annual out-of-province registrants 115 5.1- 2 Projected growth (per cent) of the number of actively licensed pharmacists to 1990, indexed to 1978 (based on projections 1 - 4 ) 116 5.2- 1 Projected number of actively licensed pharmacists to 1990, assuming 20 annual out-of-province registrants 118 5.2- 2 Projected growth (per cent) of the number of actively licensed pharmacits to 1990 indexed to 1978 (based on projections 5-8) 119 5.3- 1 Projected number of actively licensed pharmacists to 1990, assuming zero out-of-province entrants 121 5.3-2 Projected growth (per cent) of the number of actively licensed pharmacists to 1990, indexed to 1978 (based on projections 9-12) 121 6.1-1 Registration statistics of the College of Pharmacists of B.C. , 1971-1978 (February 28 year end) 125 6.1-2 PHARMFILE: practising pharmacist totals, September 1974-1977; showing number of male and female pharmacists 126 6.1-3 PHARMFILE: estimate of mid year register totals 1974-1977 126 xi v TABLE TITLE PAGE 6.2- 1 Number of students enrolled in second year, Faculty of Pharmaceutical Sciences 1970-1978 127 6.3- 1 Number of students enrolled in third year, Faculty of Pharmaceutical Sciences, 1974-1978; showing number and percentage attrition from second year 131 6.4- 1 Number of students enrolled in fourth year, Faculty of Pharmaceutical Sciences, 1971-1978; showing number and percentage attrition from third year 133 6.5- 1 Number of Bachelor of Science (Pharm.) degrees conferred at U . B . C , 1972-1978; showing number and percentage attrition from fourth year 135 6.6-T Annual number of U.B.C. graduates newly licensed by the College of Pharmacists of B.C. , 1974-1978; showing number and percentage attrition from number graduated 136 6.7- 1 Annual number of out-of-province new registrants with the College of Pharmacists of B.C. , 1971-1978 138 6.7- 2 Annual number of out-of-province new registrants with the College of Pharmacists of B.C. , 1960-1977; showing place of training of pharmacist 138 6.8- 1 Number and percentage of non-renewals for all causes among active pharmacists, 1971-1978 143 6.8-2 Number and percentage of withdrawals among active pharmacists, September 1974-1977; showing sex of pharmacists 143 6.8-3 Number of withdrawals among male pharmacists, September 1974-1977; showing age of pharmacists 143 6.8-4 Number of withdrawals among female pharmacists, September 1974-1977; showing age of pharmacists 144 6.8- 5 Number of withdrawals among pharmacists in two age categories, September 1974-1977; showing percentage of mid-year register 144 6.9- 1 Annual number of deaths of actively licensed pharmacists, September 1974-1977; showing percentage of mid-year register 147 X V TABLE TITLE PAGE 6.10-1 Annual number of reactivations of licensed status, September 1974-1977; showing sex of pharmacist 148 6.10-2 Total number of relicensed pharmacists, September 1974-1977; showing age and sex of pharmacist 149 6.10-3 Number and percentage of relicensed pharmacists reporting pharmacy employment, September 1974-1977; showing sex of pharmacist 149 7.1-1 Employment status 1978, reported by respondents to B.C.Ph.S. survey 154 7.1-2 Number of not employed pharmacists reporting efforts "within last three months" to return to pharmacy . employment, 1978 155 7.1-3 Level of employment reported by respondents in active pharmacy(and related)practice, 1978 156 7.1-4 Pattern of part time employment reported by B.C. pharmacists, 1978 157 7.1-5 Number of pharmacists reporting choice/no choice in part time employment, 1978 157 7.1-6 Number of pharmacists reporting weeks of unemployment in 1977; showing duration of unemployment 158 7.1-7 Number and percentage of pharmacists reporting weeks of unemployment in 1977; showing sex of pharmacist 159 7.1-8 Number and percentage of pharmacists reporting weeks of unemployment in 1977; showing age of pharmacist 159 7.1-9 Number and percentage of pharmacists reporting weeks of unemployment in 1977; showing field:-;of practice 160 7.1-10 Number and percentage of pharmacists reporting unemployment weeks in 1977; showing geographic region of practice 161 7.1-11 Employment status 1978, reported by respondents with weeks of unemployment in 1977 162 7.1-12 Number of pharmacists reporting choice/no choice part time employment, 1978; showing number reporting weeks of unemployment in 1977 162 xvi TABLE TITLE PAGE 7.1-13 Employment status 1978, reported by 1974-1977 U.B.C. graduate respondents; showing year of graduation 163 7.1-14 Number and percentage of pharmacists reporting choice/no choice part time employment, 1978; showing 1974-1977 U.B.C. graduates 163 7.1-15 Number of 1974-1977 U.B.C. graduates reporting choice/no choice part time employment; showing year of graduation 164 7.1-16 Employment status 1978, reported by 1977 U.B.C. graduate respondents 164 7.1- 17 Number and percentage of U.B.C. graduate respondents reporting weeks of unemployment in 1977; showing year of graduation 165 7.2- 1 Number and percentage of pharmacy managers reporting hiring a pharmacist "during the past year"; showing practice field, 1978 168 7.2-2 Number of pharmacists hired "during the past year"; reported by community pharmacy managers, 1978 169 7.2-3 Number of pharmacists hired "during the past year"; reported by institutional pharmacy managers, 1978 169 7.2- 4 Number of pharmacists hired for business expansion positions "during the past year", as percentage of total employment, 1978; by field of practice 170 7.3- 1 Number and percentage of pharmacy managers reporting "any difficulty in finding a pharmacist" to f i l l a vacant position in the last year; showing practice field, 1978 172 7.3-2 Number of community pharmacy managers reporting "any difficulty in finding a pharmacist" to f i l l a vacant position in the last year; showing geographic location, 1978 173 7.3-3 Number of community pharmacy managers reporting "any difficulty in finding a pharmacist" to f i l l a vacant position in the last year; showing type of pharmacy organization, 1978 173 TABLE TITLE xvi i PAGE 7.4-1 Number and percentage of male and female UBC graduate pharmacists retaining active status in February 1977, in 5 year groups by year of f irst registration 178 7.4-2 Number of active/non-active status changes among male and female UBC graduate pharmacists between February and September, 1977, in 5 year groups by year of f irst registration 179 7.4-3 Expected duration of practice, pharmacists under age 35 years, by sex 181 7.4-4 Expected duration of practice, pharmacists age 35 and over, by sex 181 7.4-5 Employment status and full time equivalence (FTE) of B.C. pharmacists, September 1977; showing sex of pharmacists 182 7.4-6 Employment status reported by respondents to BCPS (1978) survey, showing sex of pharmacists 183 7.4- 7 Number of pharmacists reporting choice/no choice in part time employment showing sex of pharmacists 183 7.5- 1 Number and percentage of pharmacists indicating their choice of pharmacy/not pharmacy as a career, 1968 and 1978 185 7.5-2 Number of B.C. pharmacists indicating alternate career choice, 1968 and 1978 186 7.5-3 Satisfaction/non satisfaction with present field, number.:and percentage of pharmacists 1978 187 7.5-4 Reason for dissatisfaction with present field of pharmacy, number and percentage of pharmacists,1978 7.5-5 Reason for dissatisfaction with present field of pharmacy, number and percentage of pharmacists, 1978; showing field of practice 189 xv i i i TABLE TITLE PAGE 8.1-1 Mean weekly prescription load reported by B.C. community pharmacists, 1978 192 8.1-2 Mean weekly prescription volume reported by B.C. community pharmacy managers, 1978 193 8.1-3 Total billing to Pharmacare plans A and C, 1976 to 1978 (estimated); showing average price per prescription and estimated number of prescriptions 195 8.1- 4 Estimates of total retail prescription volume for B.C. , 1977 and 1978 196 8.2- 1 Number of community pharmacy responses, 1978; showing type of pharmacy organization 197 8.2-2 Annual prescription volume reported by B.C. community pharmacies, 1977 198 8.2-3 Prescription sales as a percentage of total sales reported by B.C. community pharmacies, 1977; showing type of pharmacy organization 199 8.2-4 Percentage of prescriptions billed to Pharmacare in 1977, reported by B.C. community pharmacies, showing type of pharmacy organization 200 8.2-5 Percentage of prescriptions billed to Pharmacare in 1977, reported by B.C. community pharmacies; showing prescriptions as a percentage of total sales 200 8.2-6 Percentage of prescriptions billed to Pharmacare in 1977, reported by B.C. community pharmacies, showing geographic location 201 8.2-7 Summary statistics of weekly open hours, pharmacist employment and weekly prescriptions, reported by B.C. community pharmacies, 1978 202 8.2-8 Weekly prescription volume reported by B.C. community pharmacies, 1978; showing type of pharmacy organization 203 8.2-9 Number of pharmacists on staff (including manager), reported by B.C. community pharmacies, 1978 204 8.2-10 Weekly pharmacist hours reported by B.C. community pharmacies, 1978 205 xix TABLE TITLE PAGE 8.2-11 Pharmacy assistants per pharmacist, 1978, reported by B.C. community pharmacy managers 207 8.2- 12 Pharmacy assistant hours per pharmacist hour, 1978 reported by B.C. community pharmacy managers. 208 8.3- 1 Weekly pharmacist hours reported by B.C. community pharmacies, 1978; showing weekly prescription volume 211 8.3-2 Pharmacist/Pharmacy assistant staffing mix in B.C. community pharmacies, 1978; showing weekly prescription volume 212 8.3-3 Weekly pharmacist hours reported by B.C. community pharmacies with weekly volumes of 300 or fewer prescriptions, 1978; showing pharmacy assistant use 214 8.3-4 Weekly pharmacist hours reported by B.C. community pharmacies with weekly volumes between 301 and 600 prescriptions, 1978; showing pharmacy assistant use 214 8.3- 5 Weekly pharmacist hours reported by B.C. community pharmacies with weekly volumes of more than 600 prescriptions, 1978; showing pharmacy assistant use 214 8.4- 1 Number and percentage of B.C. community respondents pharmacist involved in dispensing, 1978 217 8.4-2 Weekly prescription workloads reported by B.C. Community pharmacists employed four or more hours per week, 1978; showoing position of pharmacist 219 8.4-3 Number and percentage of B.C. dispensing community pharmacists reporting part time/full time weekly hours, 1978; showing position of pharmacist 220 8.4-4 Weekly prescription workloads reported by B.C. community pharmacists employed 35 or more hours per week, 1978; showing position of pharmacist 220 8.4-5 Summary statistics of mean usual weekly prescription load, weekly hours and prescriptions per hour for B.C. community pharmacists, 1978, showing position of pharmacist 222 8.4-6 Hourly prescription workloads of B.C. community pharmacists, 1978; showing position of pharmacist 222 X X TABLE TITLE PAGE 8.4-7 Hourly prescription workloads of B.C. community pharmacists, 1978; showing type of pharmacy organization 224 8.4-8 Use/non use of pharmacy assistant reported by B.C. Community pharmacists, 1978 226 8.4-9 Hours of use of pharmacy assistant reported by B.C. community pharmacists, 1978 226 8.4-10 Use/non use of computer records reported by B.C. community pharmacists, 1978 227 8.4-11 Use/non use of patient record plan reported by B.C. community pharmacists, 1978 229 8.4-13 Estimated percentage time spent in review of patient records and medication counselling reported by B.C. community pharmacists, 1978; showing position in practice. 230 8.4-14 Mean "time budgets" of B.C. community pharmacists, 1978; showing position in practice 236 8.4-15 Estimated charge-off of pharmacist wage cost per prescription, showing position in practice 238 8.4-16 Mean "time budgets" of B.C. community pharmacists, 1978; showing hourly prescription workload 238 8.4-17 Estimated charge-off of pharmacist wage cost per prescription at varying prescription workloads, showing percentage of pharmacists reporting use of pharmacy assistant, computer records 239 9.1-1 Bed/pharmacist ratios calculated for 60 BC hospitals, 1978 243 9.1-2 Weekly pharmacist hours/beds x 7 calculated for 54 BC hospitals, 1978 244 9.241 Drug delivery systems "mainly used" in 68 B.C. institutions, 1978 246 9.3-1 Estimates of percentage time spent in drug use review, B.C. institutional pharmacists, 1978 247 xxi NUMBER TITLE PAGE A- 1 Number of responses to the B.C. Pharmacists' Society Survey 265 A - 2 Survey respondents and total in-province registrants, May 1978; showing sex of pharmacist 267 A - 3 Survey respondents and total in-province registrants, May 1978; showing age of pharmacist 267 A - 4 Survey respondents and total in-province registrants, May 1978; showing place of pharmacy education 268 A - 5 Survey respondents and total in-province registrants, May 1978; showing region of residence and/or practice 268 A - 6 Survey respondents and total in-province registrants, May 1978; showing principal field of employment 269 A - 7 Survey respondents and total in-province registrants, May 1978; UBC graduates by year of graduation 1974 to 1977 269 xxi i LIST OF FIGURES FIGURE TITLE PAGE 1 Components of Pharmacy Service 20 2 Registration of UBC graduates with the College of Pharmacists of B.C., 1949 to 1976 (5 year total by sex) 39 3 Number of New Pharmacist Registrations in B.C. 1971 to 1978 48 4 College of Pharmacists of B.C. Indexed Growth, 1971 to 1978 55 5 Age and Sex of Licensed Pharmacists, 1974-and 1977 61 6 Scattergram of Pharmacist FTE per 10,000 Population by Percentage of Persons over age 65 for the Non-Metropolitan Regions of B.C. 74 7 The Model of the Supply of Pharmacists in B.C. 106 8„ The Forecasting Model 109 xxiii ACKNOWLEDGEMENT No one stands alone. My first expression of gratitude must go to my academic committee who spent many hours bringing their individual skills to this project, and even more hours helping me to organize my thoughts. Mr. D.A. Earner, my thesis Chairman, has contributed enormously to the methodology of the study, and Dr. Anne O.J. Crichton has brought to i t her wide knowledge of the Canadian health care system. Dr. Finlay A. Morrison and Dr. B.E. Riedel have contributed generously of their knowledge of previous Canadian studies in this area, and of pharmacy education. Although they were not members of my academic committee, I would be remiss i f I did not thank Dr. R.G. Evans and Dr. D.O. Anderson for their assistance. A huge debt of gratitude is also owed to individual pharmacists for their thoughtful responses to the survey and to the pilot study which preceeded i t . The high rate of response was a constant source of encouragement to me. The funds for this study were provided by the B.C. Pharmacists' Society, a voluntary organization of practising pharmacists. I would like to express my appreciation not only for the funding, but also for the assistance of the executive, committee members, and staff throughout the development of the project. I am deeply grateful to the President, Mr. F.M. Archer, for his open door and for the many long discussions we had concerning pharmacy practice in B.C. xx iv This study would not have been even remotely possible without the very active assistance of the College of Pharmacists of B.C., its executive and staff. Mr. L.C. Fevang, who was Registrar until 1978, assisted me with many of the intricacies of adapting the model, designed by Mr. Earner, to pharmacy. Access to annual licensing statistics was permitted by the College, and special thanks are owed to ;the staff of the Health Manpower Research Unit at U.B.C. for the enormous amount of useful material which was generated. Several messy drafts of surveys and of this thesis have been deciphered and typed by Mary Sayler and Celine Gunawardene. I am grateful for their help, and for their efforts throughout the production of the final draft. Many friends and fellow students have offered their encouragement during this long process. To them, and to my family, I tender sincere thanks for their gracious support. X X V PREFACE Since the late 1960's Canada has had a joint federal -provincial system of public financing of medical and hospital care which has endeavoured to interfere as l i t t l e as possible with the traditional modes of organization of that care. It has been an insurance type scheme founded on four main principles. The first of these requires that access to all care deemed necessary by a physician be provided to patients without financial limit. The second principle, that of universal coverage, recognizes the right of all citizens to care, and the third guarantees the portability of these benefits. Thus care cannot be denied i f a person is out of the labour force or moving to other parts of the country. Finally there exists a requirement for public accountability of its administration. The costs of drug therapy for hospital patients have been absorbed by the public financing system, but retail prescription drug costs for most of the population have remained a direct individual responsibility. Public access to hospital and medical care has definitely improved through redistributive taxation, although some geographic problems of access s t i l l remain. On the other hand, the distribution of pharmacy service is decentralized to the extreme, but for ambulatory patients the main barrier to care has been price. Throughout the 19701s there have been public demands for improved access to health education and to health care. Pharmacy xxv i has not been excluded from any of these demands. The voluminous amount of detail in the text which follows has been left in for several reasons; f irst , because it is the only written account of the profession and its response to policy changes in the 1970's. Secondly, the assessment of its capacity for growth may serve as a basis for future recruiting policies; and, finally, the description of the demand system may serve as a point of reference for the development of data collection which will serve as a tool in improving its efficiency and public accountability. At the outset it is important to state that a complete analysis of the economic base of the profession was well beyond the scope of the current project. It has performed no review of the current or future role of the pharmacist, nor any sophisticated task analysis of the practising pharmacist, all of which would be necessary before judgements concerning efficient manpower allocations could be made. As the t it le of the thesis suggests, several topics of concern to the profession of pharmacy have been selected for review. Generally stated, they centre around the rapid and unpredictable growth of the number of pharmacists in B.C. between 1974 and 1976, and a realization that there was l i t t l e in the way of a statistical information base about the system of practice in the province. The project has thus confined itself to gathering and reporting in a non-sophisticated way, fairly basic data on a wide xxvi i range of topics. Some of this information will likely stimulate the maintenance of a selective data base, and indeed public demands for more accountability from all professions will make this step essential. To orient the reader, the study consists of three main sections. Part I provides a review of the recent health manpower literature and of the studies which have dealt more specifically with pharmacy in Canada. Three topics which relate to recent and important policy changes concerning the principle of access have been included in the section. First, the expansion of the local training programme to improve the access of British Columbia students to pharmacy education is explored. Second the changes in the Pharmacy Act which restrict the automatic access of a professional to current licensed status are reviewed briefly, and third, the development of Pharmacare, a programme designed to improve public access to pharmacy service is presented. Part I also includes an outline of the recent growth and demographic characteristics of the pharmacist register, and information on the employment system of pharmacists. Two short chapters outline the objectives and methodology of the rest of the study. Part II offfers a concise, but fairly technical discussion of the development of a method for projecting growth of the pharmacist register. The method goes beyond the more usual techniques of projecting past net growth rates, and involves an analysis of the separate factors of growth for their likely future contributions to a growth rate. This type of component analysis allows growth xxvi i i projections to be made under varying policy assumptions. In Part III, data from a 1978 survey of individual pharmacists are presented quite simply as frequency or percentage tables, with l i t t l e in the way of statistical tests. The main objectives of the survey were to obtain employment status information, and general data of pharmacy practice, l i t t l e of which had ever been gathered for British Columbia. A summary of findings, general conclusions and recommendations arising from the study are also included. 1 PART I: THE BACKGROUND OF THE STUDY INTRODUCTION In his annual report to the College of Pharmacists in June 1976, the Registrar, Leroy Fevang noted that the total membership of the College had grown at a rate of six per cent in each of the two previous registration years. Every investor knows that this rate of growth sustained over a twelve year period will lead to a doubling of his capital. In this case the investment is human capital in the form of pharmacists who are educated at considerable cost in terms of duration of education, tuition expense and foregone income. Mr. Fevang called for an early assessment of growth because "a detailed study of our manpower requirements has not been undertaken".^ The College of Pharmacists is regulated by the provisions of the Pharmacy Act (1974). This legislation details the process of registering and licensing pharmacists, but in common with legislation regulating other professions, i t gives no mandate for actual control or limitation of numbers within the profession, and manpower planning was not considered to be within the legislated role of the College. St i l l almost every conceivable health occupation in the province has been put under the manpower study process. Nursing has been examined for shortages, medicine for maldistribution, and dentistry for both these problems. How has pharmacy, which is the third largest 1 College of Pharmacists of B.C. , "Annual Reports 1976-76," p.6 2 health occupation in B.C. , escaped this kind of scrutiny? Several reasons, besides the lack of jurisdiction of the College of Pharmacists, are immediately apparent. First, there has been no perceived lack of drugs or drug distribution services, except in the most remote regions of the province where all types of health services have been in short supply. The establishment of even a very small population centre in B.C. has been followed quickly with the opening of a community pharmacy. A stable regional payroll and a nearby physician have been reliable attractions for the pharmacist-entrepreneur. Secondly, the payment for prescription drugs has traditionally been a private sector expense in British Columbia. Despite the conviction in the courts of a group within the B.C. Pharmacists' Society on charges of price regulation, and a ban on prescription drug price advertising by the College, the costs and efficient provision of drugs at the retail level have not become a matter of political debate within the province. The public, at least in the urban centres, has had a choice of suppliers providing a convenient neighbourhood service. And, as often as not, the prescription service has been coupled with a low cost discount image; an image which has tended to obscure the connection between health service and drug supply behind the promotion for garden hose. Even where government has been involved in payment for prescription drugs there have been multiple agencies involved, not all 3 of which have had a health focus. The provision of drugs in institutions, and for some specific patient groups has been under the control of the Ministry of Health, but the payment or subsidy of prescriptions at the retail level has been very fragmented. The federal government has paid for several programmes involving status Indians and veterans, and the provincial Human Resources Ministry has been responsible for prescriptions for the elderly and for welfare recipients. These programmes, concerned with supply of drugs to labelled population groups have, in the past, been based on income redistribution principles, with the health services aspect being a secondary benefit. A third major reason for the lack of any interest in pharmacy manpower planning is that pharmacy education has not become a political issue. The demand by qualified resident students for pharmacy education has, in most years, been more than satisfied. This situation is vastly different from medicine and dentistry where the numbers of student applications have traditionally been in the range of eight to ten times the number of places available. Nor have the costs of pharmacy education been perceived as excessive. Individual student expenses for tuition, books and equipment are in the same range as those of general science programme students. More important though, is that the public costs associated with pharmacy education have not been at issue. While pharmacy students in B.C. have received a more clinically oriented education since 1971, this experience does not require, as i t does for medical education, an immense public 4 investment in personnel and teaching hospital facil it ies. What then, are the problems in pharmacy manpower, i f demands for service are being met at an acceptable price, i f distribution of service is adequate, and i f provision of education for the profession is not a public issue? A primary concern is that a policy of expansion of the local production of pharmacy manpower stock to give British Columbia residents more opportunity in the profession may have proceeded too far too fast. In terms of manpower ratios, B.C. has always been well supplied with pharmacists, but by the late 1960's it was importing more than i t trained within the province. In an overview of the find-ings of a provincial inventory of health personnel, Dr. Donald 0. Anderson raised what he considered to be: " a policy question of the greatest importance: Will British Columbia commit itself to providing an educational opportunity with exists in Canada as a whole?" (HSRD, 1975, p. 10) This question had come under discussion in the profession of pharmacy almost ten years earlier; and in 1971 in response to demands from prospective employers, and from prospective entrants, the Faculty of Pharmaceutical Sciences developed its policy of enlarged access to professional education. Since 1974 there has been rapid growth in the number of persons registered with the College of Pharmacists, and while this 5 has been coupled with even higher growth among pharmacists who report "pharmacy employed" status, there is mounting evidence that full time employment is becoming increasingly scarce for new registrants. Pharmacy is , of course, a very specialized health occupation which involves a long lag time between the recruitment of students, completion of the formal education process, acceptance by the licensing body, and finally employment. Because of the large investment incurred by the student, and also by the tax supported education structure, i t would appear that there must be a firm obligation to assure that those new registrants trained within the province have an opportunity for full time employment. Baker (Reinke and Williams, 1972, p. 179) has stated, and the emphasis is his, that health manpower planning is: "the process of trying to make sure that we shall have enough health workers to meet, but not exceed, the future effective economic demand for their services -that is , to fu l f i l l perceived needs backed by willingness and ability to pay." In February of 1979 the President of U . B . C , Douglas T. Kenny spoke to the Vancouver business community about the role of the University . He noted that "sixty cents of every dollar we spend in our academic enterprise goes toward giving young people marketable skills of a professional or vocational nature," and that "British Columbia needs people trained in these professions and vocations." 2 Douglas T. Kenny, "Legends I Live With: Myths About Higher Education", an address to the Vancouver Kiwanis Club, February 8 1979. 6 While admitting that his "views on the value of education may be old-fashioned", he stated his belief that "all students should get a broad, liberal education, then let them go on to specialize i f they wish." The university has been reluctant to put any ceiling on enrolment beyond that forced by space and budget limitations. The argument has been that i t is the traditional obligation of the institution to respond to the demand of qualified students for education in the discipline of their choice. The argument is similar to that used by Bowen (Moore, ed., 1975, p. 238) that education should not serve parochial, immediate and specific needs but "education - even strictly vocational education - has wide applicability and produces flexible and versatile people", with better outcomes for society and the economy deriving from the "free choices of students." Over the years the Faculty of Pharmaceutical Sciences has observed that the demand for pharmacists has been cyclical in British Columbia. In addition they have reminded the critics of generous admission policies that a large proportion of female graduates, who represent nearly half of the enrolment, will never seek full time or long term employment, and for this reason the total enrolment must be larger than i f only a small proportion of graduates were female. Finally there is a feeling that the current crops of graduates have been reluctant to search for opportunities in fields of pharmacy 7 other than community or hospital practice, or in areas other than the Greater Vancouver core. Another major concern among pharmacists is that the previously fragmented clients of pharmacy - the individual retail consumers, and the various third party payment agencies are becoming organized and directly by one "super-client", namely government. Government has always been the source of funds for the hiring of pharmacists in institutions, and for the money to pay for several retail prescription programmes. As the funding agency, i t has thus been in a position to control levels of remuneration for service. And there is evidence that "super-client" has begun to look very critically at its pharmacy purchases, not just in terms of price, but in terms of the contribution of this purchase to health outcomes. The implications for institutional pharmacies are becoming clear: further expansion of pharmacy service will depend on contri-butions of that service to patient care, and importantly, to reductions in cost of patient care. For community pharmacists the implications seem to be that government, by organizing all payment mechanisms, is putting itself in a position to control not just the payment terms, but the actual content of community pharmacy services. 8 CHAPTER 1: AN OVERVIEW OF PROFESSIONAL PHARMACY MANPOWER IN B.C. TO 1977 1.1. Need and Demand Problems in Pharmacy Manpower 1.11 General Problems in Measuring Demand for Health Professionals In an article on health manpower planning first published in 1966, Baker outlined several methods for estimating demand for health workers, none of which, he thought was completely adequate. (Reinke and Williams ed., 1972, p. 187). The first method involves determining the numbers of health workers required from the "basic biological need" of a population. Baker recognized the "seductive appeal" of this "scientific appraisal" but felt that i t was generally an impractical approach because so many alternate solutions to health problems are often available. Kriesberg et al (1976) noted that agreement on health needs was difficult to obtain, and that the detailed data collection and computation techniques were likely to be costly. The main danger they thought was, that i f standards were set too high, the manpower needs would be over-estimated beyond the financial capability of the community to pay for them. This would result in unemployment i f supply programmes were geared to this high standard. For example, should more dentists be trained to repair cavities, or could dental auxiliaries provide less costly repair of minor cavities? Or should preventive measures be stressed which would involve fluoridation of public water supplies. 9 to reduce the incidence of dental disease? If hypertension is used as an example several problems become obvious. First, the morbidity statistics in a population are difficult to establish; and second, the symptoms are often not sufficiently uncomfortable to motivate a person to seek treatment. In addition the treatment of hypertension may take many forms involving different types of workers, not all of whom are readily described as health personnel. Recently weight loss, meditation and even hypnosis have been tried as treatment methods. Where a more traditional type of therapy involving drugs is prescribed, there are several accepted regimens, but for many patients the side effects and high costs may discourage compliance. The result will be that there will be no effective economic demand for treatment. The second method for estimating health personnel requirements, and the one described by Baker as the most common, is that of the status quo. Here the "existing professional to population ratios are enshrined as norms", and are used as an unquestioned basis for future projections. A variation on this is the "comparative method" where ratios from other areas or countries would be imposed on the area of study. While this method according to Kriesburg et a l , is "quick, cheap, easy to do and understand, it may be dangerously simplistic" in that it may fail to determine the suitability of a ratio; and as well, impose i t across all sectors of the population regardless of demand as influenced by demographic characteristics, income levels, or differences in utilization of professionals. 10 Where the private sector is largely responsible for payment of medical costs, Baker felt that measuring "effective economic demand" for health workers was the most suitable method. In this approach, patterns of demand are measured by survey techniques. Kriesberg et a l . , (1976) noted that while this method relates "to job opportunities, preventing the overstatement of requirements which may result from other approaches"; i t is valid only from the perspective of existing insti-tutions and current staffing patterns. A method described by Baker as "The Russian System" would estimate demand for health workers using observed norms of practice and allocate them on the basis of population. He considered the method to be based on a vast amount of paperwork, and to have its main application where government was the employer, an opinion shared by Sorkin, (1977). Kriesburg et al . (1976) thought that the normative or "service targets" approach was particularly relevant because i t "focuses on manpower utilization and the organization of the delivery system." The difficulties with the method were considered to be those of definition of the output unit to be measured, and the fact that final estimates for manpower might be unrealistic in terms of the "felt needs of the community" and its economic base. 1.12 Historical Measurements of Demand for Pharmacists All of the above approaches, population ratios, service targets, population need, and effective economic demand have been used, often in combination, in studies to determine pharmacy manpower needs. 11 In some European countries pharmacy openings are government regulated and are authorized on the basis of proximity to other services in the community and community need. In their discussion of this type of regulation Wertheimer and Grogan (1976) recognized the possibility for cutting down the duplication of expensive inventories and high cost personnel resources i f the numbers of community pharmacies were reduced in North America. Accompanying such regulation would be a need for government control of prices and service levels as well as a philosophical and political acceptance of such controls. Because of the division of the United States into 50 jurisdictions, the authors felt that such a move, even i f pol i t i -cally feasible, would almost be impossible to co-ordinate. In Canada, like the U.S.A., the distribution of pharmaceuticals is firmly entrenched in the free enterprise system though the trend has been to increase government involvement at all levels. The federal government has taken steps to control the pharmaceutical manufacturing industry, and the provinces have been active in manipulating large portions of retail prescription payment and service mechanisms. As well, some municipal health boards have established pharmacy services as part of community health centres in remote areas. St i l l the actual control of pharmacy openings by government in a manner that goes beyond price manipulation is not politically acceptable in Canada in 1978. The Commission on Pharmaceutical Services (CPS) study published in 1971 made projections on the basis of population per pharmacist ratios which were averaged across the provinces, in spite 12 of very different patterns of pharmacist utilization in eastern and western parts of Canada. At that time the ratio of population per pharmacist was about 3000 in Quebec and the Atlantic provinces, 1700 in Ontario, and 1500 in British Columbia. The prairie provinces were in the range of 1600 and 1500 persons per pharmacist. Yet the Commission recommended an "average" population per retail pharmacist ratio of 2300 (CPS, 1971 p. 350) in order to avoid shortages "which will quickly build up wage rates in the retail field making i t even more difficult for other areas to attract highly competent pharmacists." In his 1962 study of pharmacy manpower commissioned by the Royal Commission on Health Services, Thomas M. Ross (1966) measured the effective economic demand for pharmacists across Canada. At that time the costs of prescription services were borne almost completely by private individuals. For the year of the study, which was 1962, Ross estimated that community pharmacy managers in British Columbia would have hired 111 more pharmacists, had they been available, for the 484 retail pharmacy outlets in the province. Then the current ratio of population per pharmacist in B.C. was 1425, one of the lowest in Canada, and the estimated average productivity in terms of prescriptions dispensed was 5500 per year. Ross opened the study, and indeed concluded,it, in the firm belief that there were too many small community pharmacies competing for skilled labour, and that this was creating an artif icial demand for community pharmacists, as well as a shortage 13 of practitioners in other sectors of the profession. He felt that the "proliferation of pharmacies", especially in the urban areas, had "led to less than optimum utilization of the professional services and facilities offered by each." (Ross, 1966, p.2) In a final evaluation of supply and demand, the maintenance of the 1962 community pharmacist population with no growth to 1970 was viewed as the best course. This would have produced an estimated population per retail pharmacist ratio of 2650 which could in "no way be considered inadequate from the point of view of service to the public." In fact the limitation was viewed very positively as a means to "encorage (sic) the more logical location of pharmacies", and to allow the pharmacist to spend a greater proportion of time in the more professional aspects of practice. (Ross, 1966, p. 107). In his work for the Royal Commission study group, Finlay A. Morrison emphasized that "there are only so many prescriptions written," and that increases in prescription volume come only at the expense of other pharmacists. (Morrison, 1963, p. 387). He went on to remind the Commission that despite government, educational and professional association appeals, the dual aspects of commercial enterprise and professional activity were unlikely to disappear from the Canadian "corner drugstore" in the near future. In his analysis of the Commission survey data he found that pharmacists employed in establishments with a low ratio of prescriptions to total sales spent a greater proportion of their time managing cash and managing 14 front store stock and a smaller proportion of their time managing dispensary stock and accumulating information regarding new developments in pharmacy. He felt that consideration of time distribution was important because of its potential for influence on: "the type of training a pharmacist is to receive, the number of pharmacists required and recruited, and perhaps even the job satisfaction derived from working in a retail pharmacy." (Morrison, 1963,p.385) Despite the concerns of the Royal Commission about low productivity, an over-abundance of small inefficient retail outlets and sub-optimal utilization of the community pharmacist's time, Ross in his final statements recommended "vigorous recruitment" policies by the universities. He went on to argue that a large pool of pharmacists would allow encouragement and diversion of students to hospital practice, an area of the profession which "demonstrates a real public need." (Ross, 1966 p. I l l ) A similar argument was made by the Commission on Pharmaceutical Services (1971, p. 350) which concluded that: "Constriction of the size of the manpower pool in retail pharmacy can have, therefore, serious con-sequences on the availability of staff for other areas of pharmacy. In addition shortages will quickly build up wage rates in the retail field thus making i t even more difficult for other areas to attract highly competent pharmacists. In view of these considerations, i t is important that the over-all ratio of population per phar-macist remain fairly stable until sufficient restructuring of drug distribution occurs to change these considerations." There has been a general acceptance that the services of a well trained hospital pharmacist can effect substantial economies 15 in institutional drug costs; and as well, influence more rational therapy for patients. Standards for hospital staffing have been well developed for some years, but as Sorkin pointed out "what ought to be" does not always result in demand for personnel. (Sorkin, 1977, p.154) Considerable expansion of pharmacy services in provincial institutions has occurred, largely as a result of the acceptance of the uti l i ty of pharmacy services in smaller hospitals; but neither the standards of the Canadian Society of Hospital Pharmacists (C.P.S., 1971), nor those developed by the Working Party on Standards for Institutional Pharmacy Service (Bachynsky, 1976) have been fully adopted as policy in British Columbia. Community pharmacy on the other hand, has suffered from an inefficient proliferation of services. At the time of the Royal Commission study no recommended service targets were established in the profession. From the 1962 survey data on Canadian pharmacists, Ross estimated that the average hospital pharmacist was dispensing 26,200 prescriptions per year or about 12 per hour, but the average retail practitioner was dispensing just 5000 per year or 2.2 prescrip-tions per hour. The study recognized trends in health care which would likely increase retail prescription demand and increase the time a pharmacist might spend in record keeping, but "it must be conceded that the average retail pharmacist is capable of performing more professional services than he is , at present, required to accom-plish". (Ross 1966, p.106) The report of the Commission on Pharmaceutical Services 16 concluded that by 1968 "the underutilization of retail pharmacists which existed in 1962 has been overcome in large part and more efficient use is being made of pharmacists." (C.P.S. 1971, p. 345) The average workload was estimated to be 8300 (6700 in B.C.) prescriptions per pharmacist per year for the study year of 1968. The Commission recognized that prescription demand was increasing, and concluded that pharmacists would have to increase their productivity to meet rising prescription demand, to maintain better records and to monitor prescription and non-prescription drug use. Unfortunately there were no firm recommendations made for productivity in community pharmacy, though under "ideal conditions" the Commission felt that a pharmacist "should be able to dispense between 80 and 120 prescriptions per day." (C.P.S. 1961, p.238) Using a daily average workload of 100 prescriptions, based on a five day week and a 48 week year, this represents an annual productivity level of 24,000 prescriptions. To allow for part-time pharmacists and lesser productivity of managers the Commission felt that an upper limit on productivity would be in the "range of 10,000 to 15,000 even with non-professional assistance." (C.P.S. 1971, p.358) However the projections for pharmacy manpower were ultimately made "assuming a standard average workload for a pharmacist of 10,000 prescriptions per year." In terms of the 48 week year and 5 day week, this figure becomes 42 prescriptions per day, or about 6 per hour, a level of productivity which is so close to breakeven point for hiring non-professional assistants, i t would preclude their use by all but the largest outlets. 17 This final target for productivity appeared to be in basic contradiction of the statement of the Commission (C.P.S. 1971, p. xxi) that: "Health care cannot be delivered in an economical mannerwhile highly educated persons continue to perform simple tasks and to make insufficient use of modern labour saving technology." In Ontario, Duncan (1975) reported that "by negotiation be-tween the Ontario Pharmacists' Association, and the Ministry of Health, i t has been decided that i t takes 8 minutes to f i l l a prescription properly." This service target of eight minutes per prescription was to include actual f i l l ing , checking patient records, checking for pos-sible drug interactions, patient counselling and paper work. However, no provision was made for the impact of pharmacy assistants or computer-ized records. This level of productivity based on a seven hour day, five day week and 48 week year implies a productivity level of 7.5 prescriptions per hour or 12,600 per year, which is just half that considered "ideal" by the Report of Commission on Pharmaceutical Services. The "health needs" combined with individual "service targets" approach was rejected by Evans and Williamson in their evaluation of policy options for Pharmacare and Denticare f irst prepared for the Ontario Economic Council in 1976. They stated that: "The relationship between the stock of pharmacists available and the volume of prescriptions f i l led in a given region is subject to even more slippage than is typical of health personnel magic ratios in general, so that i t is the least reliable of all such unreliable measures." (Evans and Williamson, 1978, p.66) 18 The slippage was attributed f irst to the part-time involvement of pharmacists in dispensing in combination with management activities which result in lowered productivity. Secondly i t was attributed to the therapeutic revolution, which by the 19401s put most of the compound-ing and quality control functions of the pharmacist in the hands of the large manufacturers. Thus the technical and manipulative role of the pharmacist has largely been diminished to selecting, repackaging and labelling already prepared items. As of the 1970's much of this technical function could be reduced further with the introduction of prepackaged and pre-labelled specialties and unit dose packaging. This leaves the door open for delegation of many tasks to lesser trained assistants who can greatly increase a pharmacist's productivity. 1.13 Defining the Product of Community Pharmacy Target productivity in terms of "numbers of prescriptions dispensed" has been an issue that has been ducked by community pharmacy for many years. According to the "ideal conditions" standard of the commission on Pharmaceutical Services study, the annual output of a pharmacist should be in the range of 24,000 prescriptions. When this is compared to the 1967 estimated median output per pharmacist of 7100 prescriptions (C.P.S. 1971, p. 153) i t would seem obvious that the capacity of the system was between two and three times that actually required. Much of the thrust of the CPS study was aimed at defining a new role - and hence a new "product" - for the community pharmacist: a role which would see the pharmacist more involved in drug use control. 19 In this function he would be required to keep records of individual patients' drug consumption, and to become the drug knowledge specialist of the "health team". The Commission concluded that "the pharmacist has a clear responsibility to provide appropriate product information to his customer; and to prevent, as far as possible, the misuse of drug products which he offers for sale." As well i t recognized that some kind of payment incentives would have to be built into the system. The problem of remuneration, or payment for a wider definition of product, was more bluntly stated by the American Association of Colleges of Pharmacy Study Commission (1975, p. 44) some years later: "Not only is there no economic incentive to communicate with the patient, there is the reverse incentive not to communicate." In their analysis of policy choices for government in regard to community pharmacy, Evans and Williamson (1978) also considered the definition of "dispensed drug" to be incomplete. They recognized that the "professional component" of drug and patient information ser-vice was likely to be a benefit to the consumer i f properly done, but felt that the fragmented and competitive structure of the profession, as well as pharmacists' dependence on the good will of physicians, mitigated against any large scale move to drug use control. It was the same argument as that used by Freidson in his discussion of the pressures on the small fee for service medical practice: "the major pressures of the system are directed toward increasing the number of services and decreasing the professional quality of those services." (Freidson 1970, p. 73) Like the solo medical practitioner, the "corner drugstore" pharmacist (Morrison 1963j p. 385), faces a "duality" in 20 actual practice. As well as offering services which are defined "by the ideological leaders of pharmacy", the pharmacy must become integrated into the community and in the process, conform very largely to lay standards i f i t is to survive. It was these lay criteria of "convenience/ambience", or time-saving access and personal contact, supplied by a small nearby pharmacy that Evans and Williamson (1978) defined as the third component of pharmacy service. FIGURE 1: Components of Pharmacy Service DRUG DRUG INFORMATION PATIENT INFORMATION PRESCRIPTION CONVENIENCE AMBIENCE Their proposal for rationalization of pharmacy service in-volved exposing the public to much more open prescription price signals, including price advertising, in an effort to encourage consumers to make their own choices about the amount of professional service and convenience for which they were willing to pay. They did not feel that this would lead to a complete consolidation of dispensing capacity into large dispensaries,butrather -to a multi-level market, where price conscious shoppers would frequent the low-cost, few-frills dispensaries, 21 and consumers who valued convenience would pay for it at a higher rate in their own communities. Evans and Williamson recognized that any rationalization would take some time because large segments of the population are simply not motivated by price differences, especially i f they are price sub-sidized. St i l l they thought that free consumer choice of service was a more appropriate control over community pharmacy than more direct government regulation of the elements of service and allowed price. 1.14 Estimates of Prescription Demand in B.C. The demand for pharmacy service is a derived demand based on the willingness of a physician to prescribe a course of therapy, the accessibility of that therapy - which usually means price in the case of drugs, and finally the compliance of the patient with the ther-apeutic regimen. While i t is likely that some estimate of the "health needs" of a population for prescription drugs could be made on the basis of morbidity statistics or physician visits, this type of approach is complex and paperwork intensive. The more usual method is to equate "need" with actual dollar volume of prescriptions demanded at the retail level. Traditionally prescription volume has been a secret to be closely guarded by pharmacy managers. One of the large chains does post aggregated volume across all stores in Canada, but l i t t l e information 22 is recorded on a formal basis for regions within B.C. or for the province as a whole. In Ontario an estimate of prescription demand was made by Duncan (1975) using data from the voluntary survey of pharmacy managers conducted on an annual basis by H.J. Fuller of the University of Toronto. While his methodology is not fully detailed, the calculation appears to be based on the average number of prescriptions for the reporting pharmacies projected across the total number of Ontario outlets. Based on 1973 data, the consumption in Ontario was estimated to be 4.64 pre-scriptions per capita per year. This same method cannot be used directly to estimate volume in B.C. because too few stores from this province participate in the Fuller surveys. However i f the same consumption rate of 4.64 prescriptions per annum is applied to the B.C. population of 1976 (2.467 million persons) an estimate of 11.4 million prescriptions can be made. The Annual Report of the Saskatchewan Prescription Drug Plan (1976) indicates an average consumption rate of 4.02 prescriptions per capita. The statistics from this plan were broken down by age, and show that consumption varied between 1.41 prescriptions annually in the age group 5 to 14 years and 10.18 prescriptions for persons 65 years and over. This plan subsidizes more people in the population, but does not provide f irst dollar coverage to the elderly, which may account for the lower consumption rate among this group than in B.C. where Pharmacare estimates i t to be in the range of 12 to 14 prescriptions annually. The overall consumption rate of 4.02 prescriptions applied 23 to the B.C. population for 1976 given an estimate of 9.9 million prescriptions. The Department of National Health and Welfare publishes data of health expenditures by individuals for each province. The most recent publication of 1975 contains data as of 1973. In that year the estimated per capita expenditure for prescription drugs was $23.38 in British Columbia.' In their estimates of prescription drug volume for Ontario, Evans and Williamson (1976, p. 71) considered that a 10 per cent inflation rate was likely for the period. Applying this to the 1973 estimate yields a likely per capita expenditure of $31.12 for 1976 in B.C. In April 1975 Pharmacare was paying an average prescription price of $5.38, close to the $5.50 average reported by Blue Cross in Ontario. As of 1976 the mid-year Pharmacare price was in the range of $5.90. This price would imply 31.12 * 5.90 = 5.27 prescriptions per capita. The toeal prescription volume would thus be 5.27 x 2.467 million persons, or 13.0 million prescriptions. From 1976 Pharmacare statistics, persons 65 years and over consumed $20.4 million dollars worth of prescriptions, and those eligible for Human Resources assistance (Plan C) received benefits totalling $4.7 million. This total of $25.1 million at an average price of %5.90 implies a consumption of 4.25 million prescriptions. A survey of community pharmacies conducted by the B.C. Pharmacists' Society indicated that Pharmacare was being billed for approximately 40 per cent of prescriptions dispensed in 1976. This would indicate a total of 10.63 million 2k prescriptions for the whole province. These estimates, using mainly borrowed statistics, range widely from 9.9 to 13.0 million prescriptions f i l led in B.C. during 1976, a spread of more than 30 per cent. 1.15 Need and Demand for Community Pharmacists Two main legal constraints influence the demand for community pharmacists in B.C. First a pharmacy must be licensed and "under the 3 bona fide management of a pharmacist." Secondly, "no pharmacy shall be open for business unless 4 a pharmacist is in the pharmacy" during all hours that an outlet is being operated as a pharmacy. Despite "lock and leave" provisions in the legislation, few pharmacies in the province have attempted to operate as sundry stores on a part time basis. More often there is a complaint by neighbouring retail merchants that the pharmacy operation is being used to disguise the extended hours of a small department store. Thus, by law, i f i t is in the economic interest of the pharmacy to be open, the effective economic demand for community pharmacist hours will be equal to the pharmacy open hours. Any further demand for pharmacist hours would be based on high levels of prescription demand, or some allowance for pharmacist involvement in management. 3 Pharmacy Act 1974, Sec. 19.1 (b) (i) 4 Ibid, Sec. 28.1 25 The policy of the large chain operations is to keep hours of "pharmacist overlap" to a minimum to reduce wage costs. There is no information to indicate the average weekly hours of community pharmacies in B.C. , but at an estimated 70 hours across 533 pharmacies (April 1978) the legal demand for community pharmacist hours would be: 533 x 70 = 37310 hours. On the basis of a 35 hour week this would be 1066 pharmacist full time equivalents, a figure very close to the 1037 FTE calculated by the Health Manpower Working Unit from the hours and weeks of employment reported by Community pharma-cists as of September, 1977. If the ideal service target of the Commission on Pharmaceutical Services (1971) of 80 to 120 prescriptions per day is averaged, the estimated prescription volumes for 1976 would have generated a "need" for between 413 to 542 full time community dispensing pharmacists in B.C. If the higher estimate of "need" is accepted this would indicate that 1050 - 542 = 508 of the FTE pharmacists actually demanded in 1977 were involved in supplying those other aspects of pharmacy service which were described by Evans and Williamson (1978) as drug/patient information and (or) neighbourhood convenience/ambience. 1.16 Pharmacare: The Development of a "Super Client" No single government agency has been solely responsible for pre-paid prescription drug supply programs in B.C. The Ministry of Health has had responsibility for institutional drug supply, and for a short time directed a prescription drug subsidy plan (PDSP) for low 26 income recipients. However the ambulatory patient drug programmes in the province have been generally treated as income transfer problems, and have not been viewed in the context of provision of health services. As of 1972, the largest group of eligible ambulatory patients were the 112,000 Human Resources Department welfare recipients who received $3.6 million in drug benefits. The Social Assistance Medical Systems (SAMS) operated under the policies and jurisdiction of the Human Resources Department, and for many years it appeared that SAMS was designed with a special view to producing maximum denial and minimum convenience to all involved. The main problem was a drug benefit l i s t which was outdated from the point of view of current therapeutic practices, pricing mechanisms and price levels. In his work with the Health Security Programme Project commis-sioned by the N.D.P. government after the 1972 election, Dr. Richard Foulkes recognized that the role of the hospital pharmacist was well defined, and that "pharmacists are themselves currently reviewing their role in the ambulatory sector." (Foulkes, 1973, IV-B-3-5) In his recommendation that government subsidized programmes for drugs, prosthetic appliances, etc., should be united under a single agency, he made a plea for expert design of the programmes "so that they do not merely pay the bil ls but are established so as to ensure the delivery of high quality services at lowest cost through the health and social system of the province." (Foulkes, 1973, IV-C-18-25) Specifically for pharmacy he recommended creation of a single government agency to improve the purchasing power of institutions and to oversee the combined SAMS and subsidy programmes. 27 Central to the ambulatory programme was to be a computer system "which would provide monitoring of prescribing habits, drug utilization, drug costs and patient profiles." (IV-C-18-6) Consultation with the profession was established early, and even before Foulkes reported formally to government, there was con-solidation of PDSP and SAMS into one agency - Pharmacare. Implementation of the new programme was set for January 1974 with benefits being given to social assistance clients and as well to all persons over 65 years of age. The entire mechanics of the previous plans were reworked to allow easier access for those who required service. The drug benefit l i s t was scrapped, and with i t went at least some of the irritating paper work. A cost plus dispensing fee payment, already general in the rest of the system, was negotiated. In 1976, status Indians, Workers Compensation Board claimants, some war veterans and patients classified in specific disease groups (e.g. cancer, tuberculosis, venereal disease, cystic fibrosis, chronic renal failure) were receiving prescription drug benefits too, though s t i l l through separate programmes. Pharmacare was by this time the largest agency with 242,105 persons over 65 and approximately 100,000 welfare recipients eligible for benefits. Table 1.1-1 shows the costs associated with Pharmacare for 1976, which were estimated to be between 37 and 40 per cent of the total retail prescription dollars in British Columbia. 28 Table 1.1-1 Number of Persons Eligible and Total Benefits Paid by Pharmacare 1976 - 1977 (March year end)  # Eligible Benefits Paid Price/Rx Plan A - 65+ 242,105 20,400,000 5.90 Plan C - Human Resources 100,000 4,700,000 5.90 SOURCE: P. Tidball, Director of Pharmacare Between 1974 and 1977 a maximum Pharmacare dispensing fee was negotiated between government and a committee of the B.C. Pharmacists' Society which represented all pharmacies with Pharmacare contracts. It soon became apparent that this negotiated fee which had climbed from $2.20 to $2.90 was narrowing the range of all fees,and was taking the private sector charges up the same steps. There were few incentives in the programme to encourage dispensing efficiency. A very low Pharmacare fee would have driven small inefficient operators to bankruptcy, yet it was government policy to retain the existing mode of community pharmacy organization to allow the elderly to shop for neighborhood convenience and service. Ross concluded that there was "an overabundance of retail pharmacies" (Ross, 1966, p. 88) especially in large metropolitan areas. Clearly there has been an expansion of pharmacy service to northern areas in B.C. , and large scale consolidation in the urban centres. One 37 block suburban Vancouver thoroughfare had four community pharmacies in 1978, 5 a considerable reduction from the eleven of the early 1960's. In his study of Canadian Pharmacy practice in 1962, Thomas George Fisher, private communication 29 This has meant that most outlets serve a large number of persons, and Table 1 ..1.-2 shows the number of pharmacies in B.C. since 1961 compared to numbers in the population. Between 1961 and 1974 the number of community pharmacies was relatively constant. However between 1975 and 1976 there was an increase of 33 outlets or 7.46 per cent in a two year period. In his TABLE 1.1-2 Number of Community Pharmacies in B.C. 1961-1977 Showing Estimated Population Per Pharmacy  # Pharmacies1 2 Population Pop/Phcy 1961 484 1629 3365 1966 478 1874 3920 1971 491 2185 4450 1974 486 2349* 4835 1975 496 2406* 4850 1976 520 2467 4745 1977 533 2519* 4725 SOURCE: ^College of Pharmacists of B.C. (Feb. 28) 2 Census Population (1000's) * Estimated (Linear regression) annual report to the College of Pharmacists, John Moran the. Deputy Reg-istrar, noted that "a number of pharmacists have been unable, for one of several reasons, to find employment. Some of these pharmacists have elected to open new pharmacies and therefore become self employed. It is reasonable to expect this trend to continue."^ J.W. Moran, "College of Pharmacists of B.C. Annual Reports 1976-77", p.6 30 While Pharmacare quite welcomed some surplus of pharmacists to keep wages down during the years i t was negotiating a fixed dispens-ing fee, the increase in the number of pharmacies was seen rather less benignly as evidence of high profit taking from dispensing. In 1976 the recently elected Social Credit government was committed to a policy to "contain the rate of escalation of health c o s t s . F o r Pharmacare there was a quick move to transfer some payment back to the consumer. Those preparations usually purchased by the general public as over the counter medications were declared to be non-benefit items. The main classes of drugs immediately involved were laxatives, antacids, analgesic, and vitamin preparations. Billing for these items had "slid" into the programme, and then had escalated rapidly among the elderly. For some months the wrangling over claims in this category was intense, and spilled over into the Legislature. To add to the confusion, the non-benefit l i s t changed almost daily. Finally Pharmacare agreed to accept some claims,but only those backed by a letter from a physician outlining therapeutic rationale. Though the responsibility for Pharmacare was not in his jurisdiction, the Minister of Health became involved in the theme of improper pre-scribing, and declared that "antibiotics are an excellent sample o of a segment of the health system that has gone mad." ^ R.H. McClelland, Minister of Health, "Manpower Planning: Provincial Government Perspective", Forum, Association of Canadian Medical Colleges Ottawa, IX:5, 1976, p.9. Ibid., p.10 31 Over a period of several weeks there were no further announcements. There was considerable fear among the elderly that their section of the plan would be scrapped for one which would put all persons on a partial reimbursement basis. Pharmacists too, waited "for the other shoe to drop", but no meetings were held with the profession to discuss the mechanics of implementing the programme. The profession was s t i l l reacting with anger toward their first encounters with the new government. The most recently negotiated dispensing fee increase had been held back pending "ministerial approval." Many pharmacists felt that these negotiations, conducted on a collective basis by the B.C. Pharmacists' Society were a failure and were demand-ing the right to set their own dispensing fee. And so the government "gave" i t to them. Actually Pharmacare had allowed this right for some time in the smallest segment of the programme which had been the old Prescription Drug Subsidy Plan (PDSP). Under the basic contract with Pharmacare, the dispensing fees charged to government were not allowed to be above those charged on a "usual and customary" basis. Pharmacare had found that PDSP, which was just five per cent of the total drug programme, could be used very neatly and very simply to discipline the other 95 per cent of the plan. In return for the "concession" of allowing a usual and customary dispensing fee,government demanded price disclosure to the consumer. Originally price-posting in pharmacies was negotiated, but the final proposal for the programme involved a display of the 32 drug cost, dispensing fee and total price on all official receipts. There was l i t t l e room, and even less time for argument i f pharmacists were to avoid censure for holding up implementation of the "universal" programme. The completed plan retained the same first dollar coverage for persons over 65 years and those covered by Human Resources. The small subsidy plan was scrapped, and coverage for individuals or family groups was on a $100 annual deductible with 80 per cent reimburse-ment on amounts over this amount. And so pharmacy prescription pricing returned to the market place in July 1977. There was an immediate escalation of the average fee by about ten per cent, followed by a much slower rate of increase during 1978 to a f irst quarter average of $3.25 to ^3.35 depending on area. A variation of 15 per cent above average was tolerated by Pharmacare, but obviously with full disclosure of drug acquisition cost and dispensing fee, there were price incentives to both suppliers and consumers. Aside from meeting the announced government intention of slowing the escalation of costs, one of the effects of price dis-closure was that many consumers soon learned to demand quantity increases on prescriptions to cut the frequency of paying dispensing fees. A decrease in prescription volume with a shift to higher drug cost per unit dispensed put those pharmacies with high wage and service costs at an immediate disadvantage. The opportunity for more than price incentives is also evident. As in medicine, pharmacy is organized into "a structure 33 of relatively segregated, small circles of practitioners, the extremes of which are so isolated from each other that the conditions necessary for mutual influence on behaviour are missing", (Freidson, 1970, p.101) with the consequence that "markedly different ethical and technical standards" are contained within the profession. Clearly, as the major "client", government is in a position to wield enormous social control over the profession, and there is evidence that the "problem of engineering a judicious set of corss-pressures into the structure of practice" is being attacked. (Freidson, 1970, p. 76) If the battle for price control was won mainly under the jurisdiction of the Human Resources Minister, the battle for social control is being waged under the banner of the Health Minister. Pharmacare has announced its intention to seek more accountability from doctors and pharmacists, and specifically has demanded better pharmacy-health related services. The goals are to reduce inappropriate therapy, to avoid drug reactions and to save hospital costs. The Social Planning and Review Council (SPARC) has surveyed lower mainland pharmacies concerning types of services provided to the elderly; and Pharmacare has hinted at a community pharmacy service rating system which as well as forming the basis for payment, would become a matter of public information. Appropriately, i t was the Health Minister who announced a pilot study, funded by the profession, of a label generated patient record plan. The new system was designed specifically to cut the steps in patient record keeping, and was aimed at encouraging low service, large volume dispensaries to keep 3h and use individual drug consumption records. While Pharmacare hinted at mandatory record keeping, persistent persuasion backed by committee work within the profession, has been the style of the Director, Patrick Tidball, since the inception of the programme. If in the future the chain pharmacies and large volume dispensing outlets adopt a system of patient record keeping much of the "better service" distinction claimed by the neighbourhood outlets would disappear. While the elderly, who do not have to face price signals would likely continue to shop for neighbourhood convenience, some segments of the market undoubtedly shop for price, especially where service across all pharmacies appears to be uniform. An increase in price sensitivity would force small pharmacies to increase their dispensing efficiency toward the norms set for staff by the large volume dispensaries, with the most inefficient forced into bankruptcy or a further round of consolidation. 1.2 Recent Influences on Pharmacist Supply in B.C. The lag time from the beginning of training to the actual employment of health professionals is longer than for most occupations in society, and any large scale increase or decrease in supply is likely to be influenced by long term factors. Kriesberg et al.(1976) classified these as institutional and economic factors. The institutional influences on supply were those of availability of training programmes, and the constraints or incentives to practice. The economic factors 35 were those of expectation of employment, income in proportion to time spent in training, opportunity for geographic mobility, good working conditions, as well as rewards of status in the community. In the short term there are other factors which might also be used to increase or decrease the supply of health workers. Using the same classification, the institutional licensing or creden-tial ing process can be manipulated to influence supply. Simplification of the credential!ing procedure or lowering the price of f irst registra-tion could be expected to increase the registration of already trained workers from other regions. Decreases in supply would be a likely result from increasing license fees or institution of a relicensing examination process. Where there are trained persons already in an area who are not active, an accessible and attractive retraining programme might be used to encourage participation. Another form of institutional manipulation of supply which can effect rapid increases in supply is the registration of lesser trained workers to perform some sub-set of tasks. Of the economic factors that can be brought to bear on the short term supply, several studies (Sorkin, 1977) indicate that raising wages and offering more attractive working conditions are reliable methods of bringing inactive persons, especially women, back into the labour market. (Kreisberg et a l . (1977) commented, though, on the "perverse economics of the health sector" which despite manpower shortages in rural areas and large concentrations in metro-politan centres, generally maintains the same price structures 36 across all areas. Thus in the health industry there are rarely wage differentials which might encourage workers to practice in more remote communities. The following sections detail some of the policies adopted by the provincial government, the university system and the College of Pharmacists which have affected the level of pharmacist supply on B.C. in recent years. The actual levels of pharmacist supply and changes in the characteristics of the register since 1974, including projections for future supply will be discussed in subsequent sections. 1.21 Pharmaceutical Sciences Enrolment Concerns 1965-1970 Concern about declining enrolments in the Faculty of Pharmaceutical Sciences at U.B.C. had been expressed in 1966 in an internal faculty memo detailing the new student enrolment between 1960 and 1965. Most of the other schools of pharmacy in Canada had experienced fluctuations in new enrolment in the 1960's; but almost all had managed to increase f irst year enrolment, or had at least had a surplus of qualified applicants, by the 1965-1966 academic year. The total student body at U.B.C. had grown, but the "marked downward trend" in new students entering pharmacy was "a cause for g concern." The reduction in numbers of U.B.C. graduates had actually begun some ten years earlier. While registration of new pharmacists with the College had held steadily between 1952 and 1966 the number and percentage of U.B.C. graduate registrants declined from 81.6 Faculty of Pharmaceutical Sciences, U.B.C. "A Survey of New Student Enrolments 1960-1965". 37 per cent to 64.3 per cent of new registration as shown in Table 1.2-1. The lowest percentage of U.B.C. registrants occurred in 1970 when the 28 U.B.C. graduates formed just 37.8 per cent of the total of 74 new pharmacist registrations. It was in this year that concerns surrounding the large numbers of out-of-province registrants began to be discussed at the policy level of the profession. The College by this time had experienced three years of sharply increased registration of pharmacists from outside B.C. and from outside of Canada itself. TABLE 1.2-1 Number of New Pharmacist Registrations with the College of Pharmacists of B.C. , 1949-1976; Showing Number and Percentage of U.B.C. Graduates  Year UBC Out of Province Total # % # % 1949-51 175 80.6 42 19.4 217 1952-56 195 81.6 44 18.4 239 1957-61 170 66.9 84 - 33.1 254 1962=66 160 64.3 89 35.1 249 1967-71 164 43.2 216 56.8 380 1972-76 388 68.8 176 31.2 564 SOURCE: College of Pharmacists of B.C. , Registration #1451-3354 In a memo prepared for the B.C.P.S. Employee-Employer Relations Committee Peter W. Bell (Executive Coordinator, B.C.P.S.) noted the committee's discussion "with respect to the possibilities of 'upsetting pharmacy's ecological balance in B.C. 1 due to increasing number (sic) of graduates from outside of B.C. being registered as 38 pharmacists in this province." This memo was also circulated to members of the B.C.P.S. Senate and the College of Pharmacists Council with a recommendation that a study of personnel needs be undertaken. Between 1967 and 1971 the increase in the number and percentage of women enrolled in pharmacy became an issue as well. For the f irst time the number of women exceeded men in some classes. The women's liberation movement was just beginning, and was considered to be a major factor in encouraging entry of women to the traditionally male professions. While it is obvious that the enrolment of women did increase, i t is the dramatic decrease in male enrolment at U.B.C. that has apparently been completely overlooked by the profession. Figure 2 illustrates new registrations with the College of Pharmacists of B.C. , for each sex between 1949 and 1976, and clearly shows the drop in male registration since the early 1950's. Rather than asking why there was such an increase in number of women, it might have been more appropriate to ask the question posed by the popular folksong: "Where did all the young men go?" It is impossible to determine the actual reasons for the drop in male enrolment but there are several likely factors. The main reason is undoubtedly the lack of occupational choice available to men at U.B.C. in the years immediately following the second world war. The nursing degree program had been established in the pre-war period, but pharmacy was the only traditionally male dominated health related 1 0 P.W. Bell , Executive Coordinator, B.C.P.S., Memorandum to Romeo Goulet and members Employee-Employer Relations Committe, Nov. 24, 1970. 39 Figure 2 200 REGISTRATION OF U.B.C. GRADUATES WITH THE COLLEGE OF PHARMACISTS OF B.C. 1949 TO 1976 (5 YEAR TOTAL BY SEX) 1 8 0 - SSSSSS MALE FEMALE 1 6 0 -co O 140 2 O 120 I I i 0£ z 1 0 0 -8 0 -6 0 -4 0 -20 I I I 1949 51 1952 - 1957 56 61 YEAR ko school established at U.B.C. by the mid 1940's. The f irst class of 47 persons registered with the College in 1949,and was composed of 42 men and 5 women. Enrolment in pharmacy and the entire university burgeoned in the immediate post-war period. There was a huge demand for education by returning veterans whose career choices had been postponed by their wartime service; but at U.B.C. the health sciences choices were meagre. For female students the choice was nursing or pharmacy; for males i t was pharmacy, or seek education elsewhere. Medicine was not established at U.B.C. until 1952, and was followed s t i l l later by dentistry in 1964. During this decade there was also rapid expansion of careers in physics, organic chemistry, pharmacology, biochemistry and computer sciences. These new choices naturally competed with pharmacy for enrolment. Throughout the 1960's in B.C., price competition initiated by the department stores and large chain pharmacies forced closure and consolidation upon the small pharmacist-entrepreneur. It may be that prospective pharmacy students, especially men, saw that their chances of store ownership were being reduced, and they were not willing to enter a profession where they would have only employee status. Finally, by 1970, just 10 male and 18 female U.B.C. graduates were newly registered by the College of Pharmacists to practice pharmacy in B.C. Another factor in loss of total student enrolment may 41 have been the lengthening of the pharmacy curriculum to five years commencing with the f irst year class of September 1960. As was previously noted, the number of women entering pharmacy in B.C. since 1949 grew steadily but not spectacularly until 1971. Since the expansion of the Faculty of Pharmaceutical Sciences enrolment for both sexes has increased at a similar rate. It would appear however, that male enrolment has been more responsive to com-petition from other career choices, perception of future opportunity and increasing curriculum requirements. Even prior to Peter Bell's request for a study of personnel needs, Dr. B.E. Riedel had asked for an evaluation of pharmacy manpower. In a letter to G.B. Hewitt, Director of Continuing Education in Pharmacy, Dean Riedel proposed that considerable demographic and employment data be obtained from pharmacists and that this material be related to the number of pharmacies and regional population data. 1 1 At least some of the material which he proposed be gathered "with some thoroughness" as the "first phase only of developing a requirement picture" was already available and could have been extracted from the 1968 B.C. Health Resources Survey. This questionnaire had an excellent response from pharmacists (76 per cent), but suffered from lack of funding for the analysis process. Ten years later, in 1978, the raw questionnaires were s t i l l intact; but very early, before any reports were written, the computer cards had gone astray. 1 1 B.E. Riedel, Letter to G.B. Hewitt, February 3, 1970. The tables which had been drawn did not provide the information required by Dean Riedel, and funds were not available for further data processing. Part of the problem with the Health Resources Survey was undoubtedly due to bad timing. The Commission on Pharmaceutical Sciences had sent out its questionnaire in 1968 as well. It was this study, sponsored by the Canadian Pharmaceutical Association, and conducted on a prestigious national basis, which was being anxiously awaited by the profession and its educators. Hewitt noted that while the "value of the Health Resources Survey data as the baseline for further study" was "very high", the "pressure towards further analysis" was reduced by publication of the Commission study. (Hewitt, 1971, p. 7) Writing from his perspective of responsibility for continuing pharmacy education,Hewitt concluded that the pharmacy manpower supply in B.C. was an aging one which would soon be affected by lower participation among a large proportion of its new female recruits. While he realized he had insufficient data for any prediction of manpower requirements, he did predict an increasing demand for services; a demand which would grow more in response to changing technology and broadening of the role of the pharmacist, rather than in response to population growth. 1.22 Pharmaceutical Sciences Curriculum and Enrolment 1971-1977. The team approach to patient care, which did not have great appeal for physicians and their educators, was received with enthusiasm in professions such as nursing and pharmacy. The expansion 43 and diversification of the professional role in these fields was viewed very positively. The planning for an overhaul of the pharmacy curriculum at U.B.C. had begun in the 1960's. The emphasis on, and extension of; clinical type teaching was innovative, in that the traditional apprenticeship or internship which tended to isolate the young pharma-cist in just one small setting was scrapped. Instead the final academic year was to be comprised of a compressed academic load, and a series of rotating clerkships in several types of pharmacy settings. The model was almost identical to the fourth year of medical education at U.B.C. While many employers were reluctant to see a period of intense supervised experience disappear, at least they could see the economic advantage of being able to employ a young pharmacist who was fully licensed immediately following graduation. Unlike the response to plans for change in medical education there was no dissent from the profession at large. The proposed emphasis on a clinical approach to education readily attracted new faculty applications to U.B.C. By 1971 the requirements of the university curriculum review committees had been met, and to complete this new prescription for pharmacy education an expansion of research facilities needed to hold faculty interest was finished. At the opening of this addition to the physical plant in 1971, Dean B.E. Riedel stated that the Faculty of Pharmaceutical Sciences had been "given space, staff, research funds and equipment" to handle a total of 300 undergraduate students and 35 graduate students. By the 1971 - 72 academic year the undergraduate enrolment stood at 227 and was approaching a total of 300, a limit set by space availa-12 bi l i ty , "where we expect to level off for a period of some years." This proposed total of 300 undergraduate students allowed for a graduating class that was in the range of 75 to 80 students. Though this was more than twice the number of graduates in previous years, the number closely approximated the average total number of new registrations with the College between 1967 and 1970. The breakdown of the enrolments by year is shown in Table 1.2-2. This expansion to 300 students clearly met the demands of the economic self interest group in the province for a reversal of the trend to licensing a large proportion of out of province graduates. It also addressed the concern for the aging of the labour force expressed by Hewitt, and a demand for younger mobile pharmacist employees expressed by employers in remote areas. By 1973-74 the total enrolment had increased to 345 and the graduating class size had grown to approximately 90 persons. In June of 1974, Dean Riedel reported that the demand for pharmacists "is continuing at a suitably high level and must be met by increasing 1 2 Dean B.E. Riedel, "Report of the Faculty of Pharmaceutical Sciences, U.B.C. to the Annual Meeting of the Pharmaceutical Association of B.C.", June 1972, p. 32 h5 the student numbers." Renovations were made to the physical plant to allow another expansion of undergraduate enrolment. TABLE 1.2-2 Undergraduate Enrolment, Faculty of Pharmaceutical Sciences, U . B . C , 1970-1977  YEAR 1970-71 1971-72 1972-73 1973-74 1974-75 1975-76 1976-77 1977-78 First 62 57 68 58 59 57 70 73 Second 69 94 90 101 102 125 119 115 Third 55 78 94 94 99 83 106 87 Fourth 35 48 75 92 94 95 80 98 TOTAL 221 227 327 345 354 360 375 361 SOURCE: Dr. B.E. Riedel, Annual Report to the College of Pharmacists Part of the impetus behind this further growth was undoubtedly due to changes in provincial government health and education policies. The NDP government, which had assumed power in 1972, had moved quickly to work with the profession to develop a new third party payment pro-gramme. While most pharmacists were wary of government intervention in the marketing of drugs, they recognized that an overhaul of the systems of prescription drug subsidy was long overdue. The resulting Pharmacare programme freed the elderly from price constraints and allowed them to shop in their own neighbourhoods. The increased prescription volume in smaller pharmacies increased the demand for community pharma-cists. 13 Dean B.E. Riedel, "Report of the Faculty of Pharmaceutical Sciences U.B.C. to the Annual Meeting of the College of Pharmacists of B.C.", June 1974, p. 27. 46 The new government had also questioned the enrolment policies of the universities, and urged all institutions to become more responsive to student demand. In addition the major professional schools at U.B.C. were requested to examine their selection processes for evidence of discrimination, elitism and unnecessary emphasis on academic achievement. However by 1975, after a series of embarassing budget over-runs, the government was closely monitoring provincial finances, and a general budget cut was imposed at U.B.C. This cut put limitations on the hiring of new staff by Pharmaceutical Sciences, and the size of a planned expansion to the f irst and second years was reduced though "the number of applications we received far exceeded the 14 number of students we could accept." 1.23 College of Pharmacists of B.C. The College of Pharmacists of B.C. is in a monopoly position in that i t is the only body in the province which registers pharmacists. However, under the provisions of the Pharmacy Act (1974) i t has no mandate to restrict the number of pharmacists who register. The regulations and the costs of registration have changed several times, but no quota has every been imposed on the Dean B.E. Riedel, Report of the Faculty of Pharmaceutical Sciences, U . B . C , "Annual Reports of the College of Pharmacists of B.C." June 1976, p. 13. hi numbers of out-of-province trained pharmacists accepted in B.C. 15 in any one year. The barriers to entry are those of examination of credentials, an initial registration fee, a forensic examination, and, unless a pharmacist can produce evidence of recent practice, a practical examination. One of the most important policy changes concerning out-of-province registration was the adoption in the late 19601s of the Pharmacy Examining Board of Canada (PEBC) examination as the main credential!ing standard for graduates by most jurisdictions in Canada. This has allowed pharmacists with PEBC registration to consider their skills to be more portable across Canada. It has also simplified the credential 1ing of graduates from outside Canada and has undoubtedly facilitated the immigration of foreign trained pharmacists. While a PEBC registration may be "purchased" by pharma-cists licensed prior to 1963 through the provision of a grandfather clause, the B.C. requirement for evidence of recent practice will likely discourage the registration of older semi-retired graduates. This could contribute, though likely in a small way, to a lowering of the age structure of the profession. The numbers of out-of-province registrants as well as those from U.B.C. are shown in graph form in Figure 3. Some Leroy C. Fevang, Registrar, College of Pharmacists of B.C. , private communication. 48 Figure 3 NUMBER OF NEW PHARMACIST REGISTRATIONS IN B.C. 1971 - 1978 1971 1972 1973 1974 1975 1976 1977 1978 YEAR Source: College of Pharmacists of B.C. 49 of the fluctuation of the numbers of registrants from the low of 26 in 1973 to the high of 50 in 1976 is likely related, with some time lag, to information concerning provincial economic conditions. The decline since 1977 is also likely related to the enlargement of the provincial training programme, as well as to the efforts made by Mr. Fevang since 1976 to inform would-be entrants that they should assure themselves of employment before they entered the province. The College has become more active in the process of examining new U.B.C. graduates since the mid-1970's when the requirement of a period of internship or apprenticeship prior to f irst licensing was dropped. A Panel of Examiners chosen from practising pharmacists has been established, and each graduate is required to pass a set of practical examinations. Initial failure rates have been variable, with the highest occurring in 1978 when one-third of the 97 graduates failed the f irst panel. By the end of the licensing year 90 persons 16 had completed the examination process, and this number was expected to increase to the average of other years. Between February 28, 1974 and 1978 just seven of 424 U.B.C. graduates (1.65 per cent) did not obtain licensed status with the College for various reasons which would include failure of Panel Examinations on five separate occasions. 1.24 The Pharmacy Act of 1974 An important and new provision of the Pharmacy Act (1974) 16 Norman S. Thomas, Registrar, College of Pharmacists of B .C. , private communication, March 28, 1979. 50 was one which empowers the College to examine pharmacists for competence on a regular basis, and also when an individual applies for reinstate-ment of a lapsed license. Prior to 1974, a pharmacist who wished to return to active licensed status, even after a protracted period of retirement, merely paid the then-current license fee, and was free to resume practice. Since the new Act has been proclaimed i t has been the policy of the College to re-examine those persons who have not held current licenses for more than two years. In the period close to the passage of the new legislation it is apparent that many licenses were reactivated and many retirements were reconsidered. This is reflected in the crude attrition rate for the profession which averaged 3.25 per cent between February 1971 and 1974, but fell to 0.61 per cent for the year of February 1975 to 1976. Between 1976 and 1978 these crude attrition rates were 2.59 per cent and 2.27 per cent; and likely reflect the lowered age structure of the profession, as well as the incentive in the Act for retention of active status. After three years of discussion the College of Pharmacists' Task Force on Continuing Competence developed a "Statement of Competencies" for licensed British Columbia pharmacists. The competency categories are those of dispensing of prescriptions, compliance with legal require-ments, and knowledge of non-prescription medications removed from public access. 51 As well, an assessment programme was developed to evaluate the standards of performance of pharmacists in the above categories. In November 1977 an open-book self-assessment paper was mailed to all licensed pharmacists as a means of examining competence. Under the authority of the Bylaws of the Pharmacy Act, all pharmacists were required to participate in the assessment programme as a condition of relicensure in 1978. While pharmacists who did not meet competency standards were s t i l l eligible for relicensure in 1978, they were expected to seek upgrading of their skills in the areas in which they were deficient. They were then to come under further evaluation either by the re-examination process, or by a Peer Review Committee evaluation. By early January of 1978 approximately 40 persons had notified the Registrar of the College that they did not wish to par-ticipate in the assessment and wished to be placed on the Retired Register. A further 30 persons had not participated, but had not given any indication of their re-registration intentions. It is thus likely that the competency examination require-ment will eliminate from the annual licensing process at least some of those pharmacists who do not intend to participate further in professional activity. The result will be that the number of currently licensed pharmacists will more closely reflect the number of pharma-cists who actively participate in the work force. 52 1.3 The Pharmacist Register The Registrar of the College of Pharmacists of B.C. is charged under the provisions of the Pharmacy Act with the responsibility for maintaining various College membership registers. These include registers of graduates from other jurisdictions who are proceeding through the credential!ing process, students, honorary and provisional members, as well as non-practising and retired members. The official registration document of the College is a handwritten ledger which contains the names and dates of registration of all qualified "ever-registered" pharmacists in B.C. For the purpose of this study the active pharmacist register of the College is defined in the same way it appears in the Registrar's Statistical Report to the College. The following membership categories have been used: i) Pharmacists holding current practice licences i i ) Provisional members i i i ) Qualified honorary members 1.31 Growth and Distribution of the Manpower Supply The classical guide to manpower supply is the relationship between the number of pharmacists and the population." (CPS, 1971, p. 318) It was observed by the Commission on Pharmaceutical Services that this relationship had varied very l i t t l e in Canada from 1955 to 53 the time of the Commission report which included 1968 data. There was recognition that not all registrants would be available to participate in the workforce because of age, illness, marital duties or an actual change of occupation of province of residence. More importantly the Commission recognized a distributional imbalance of pharmacists in Canada which reflected different patterns of utilization of personnel. In Ontario and the western provinces the population per pharmacist ratio ranged between 1200 and 1700 for the years between 1955 and 1968. During the same period this ratio was in the range of 3000 to 4000 in Quebec and the eastern provinces. (CPS, 1971, p. 319). The population per pharmacist ratio in British Columbia has always been one of the lowest in the western provinces. For his report to the Royal Commission on Health Services, Ross (1967, p.10) calculated the ratio as being between 1392 and 1476 for the years which included 1955 and 1962., Following Ross the population ratios have been calculated for the census years 1961 through 1976. The registration totals used are those of the College of Pharmacists end of fiscal year, and will tend to produce a downwards distortion of the ratio for all years. This distortion is likely quite small, because the bulk of new pharmacist registration occurs in May and June. 54 Table 1.3-1 Ratios of Census Population per Pharmacist for British Columbia, 1961 - 1976 Year Population Licensed Pharmacists Population/ (1000's) Pharmacist 1961 1629 1168 (Feb. 28, 1962) 1395 1966 1874 1290 (Feb. 28, 1967) 1453 1971 2184.6 1466 (Feb. 29, 1972) 1490 1976 2466.6 1850 (Feb. 28, 1977) 1333 Source: Census Date (June 1) College of Pharmacists of B.C. Between 1961 and 1971 the population per pharmacist ratio in British Columbia increased as is shown in Table 1.3-1, and the year end registration totals of the College indicate that the change to a higher ratio was a gradual one. By the 1976 census year this ratio was down to 1333 persons per pharmacist, a clear reversal of the previous trend. In Table 1.3-2 the percentage growth in the number of pharmacists for the five year intercensal periods is compared with growth in the pharmacist register for the same years, to illustrate the mignitude of the change. Between 1971 and 1976 the number of pharmacists grew at almost twice the rate in the previous period, and this 26.2 per cent growth was double the growth which occurred in the population served by the profession. In Figure 4 growth in the register is shown to February 28, 1978, when the number of actively licensed pharmacists was 1903. This growth has been indexed using the 1971 total of 1434 pharmacists in 1971 as the base year. Clearly there has been a recent and dramatic Figure h Source: College of Pharmacists of B.C.; Canada Census Data 56 shift in the pattern of pharmacist supply in British Columbia, and most of the growth in supply has occured since 1974. Table 1.3-2 Percentage Growth of Population and Numbers of Licensed Pharmacists in B.C. 1961-1976 Period Population Licensed Pharmacists % Growth % Growth 1961-66 15.0 10.4 1966-71 16.6 13.6 1971-76 12.9 26.2 Whilst i t has always been possible to trace! the net growth of the College of Pharmacists in B.C. from its annual audited totals of paid current licenses, there was l i t t l e information to indicate the actual sources of growth. The age, sex and educational qualifications of individual registrants, as well as their major practice fields and geographic distribution were also uncertain. Specific concerns stemming from the lack of this information had been expressed by Hewitt (1971) who was in the position of planning for the continuing education needs of what he considered to be an aging workforce. He also recognized that the increasing proportion of female registrants at UBC could quickly change the sex structure of the profession. The increasing number of women entering training was a cause for concern among those endeavouring to predict the size and distribution of the workforce. In a study for the Ontario College of Pharmacy, Des Roches (1973) found that women had career patterns involving shorter 57 working hours, limited geographic mobility, and lower job stability than men. Carpenter (1977) examined the traditionally male dominated health professions, including pharmacy, and noted that women gravitated to the more formally organized work settings of the hospital and the large dispensing pharmacy; accepting more readily the role of employee, rather than that of employer or entrepreneur. In a study of attitudes reflecting competitiveness, willingness to accept responsibility, and career committment Hornosty (1974,p.57) found significant differences between male and female pharmacy students who were registered in 1962 and 1972. He concluded that "the present cohort of females is destined for a more passive, technical role in the profession," and speculated that i f differences in career orientation were "inextricably linked to sex role differences" i t might be "necessary to discriminate on the basis of sex in order to affect (sic) changes in the practice of the profession." (p.51) For his projections of Ontario pharmacy manpower Duncan (1975) indicated that female pharmacist participation would be considered to be 0.75 times that of male participation. He based this on the Des Roches (1975) study which concluded that one half of female pharmacists were employed part time. If this relationship between male and female participation is similar in British Columbia, and enrolment of women continues to be nearly equal to that of men, the actual growth in the labor force will be smaller than projected. 58 It was not until 1974 that a complete age and sex picture of the profession in B.C. was available. In that year, as part of the relicensing process, considerable information was obtained in a survey of individual members. The information was edited and stored on a dynamic computer based file appropriately named PHARMFILE. This f i le is regularly updated and edited by the Health Manpower Research Unit at UBC in cooperation with the College of Pharmacists as part of an ongoing project to establish a sound data base of health manpower in B.C. The PHARMFILE tapes which date from September 1974 contain the following types of information: 1. Personal biographic data 2. Registration status 3. Employment status, f ield, position 4. Location in province 5. Hours and weeks of employment 6. Narcotic singing authority 1.32 Sex of B.C. Licensed Pharmacists In the fifteen years between 1962 and 1977, the total number of licensed pharmacists has increased from 1164 to 1879 persons or by 61.4 per cent. During the same period the number of women who are actively licensed has almost quadrupled so that by September 1977 women comprised 28.5 per cent of pharmacists, as illustrated in Table 1.3-3. 59 Table 1.3-3 Number of Licensed Pharmacists in B.C. 1962, 1974, 1977 Showing Sex of Pharmacists Year # Male % # Female % Total 1962 1029 88.4 135 11.6 1164 1974 1189 74.8 400 25.2 1589 1977 1344 71.5 535 28.5 1879 Source: Registration Statistics, College of Pharmacists.of B.C. 1962 - Reported in Ross, 1966 1974-1977 - PHARMFILE Much of this growth has occurred since 1974 due to the enlargement of the Faculty of Pharmaceutical Sciences and to the sex composition of this enrolment which has had only a slightly larger proportion of males in most years. 1.33 Age of B.C. Licensed Pharmacists In his report on the 1962 survey of Canadian pharmacists for the Royal Commission on Health Services, Thomas M. Ross described the then current practitioners as "a rather youthful lot" (Ross, 1966, p. 49). Based on 674 responses or 57.9 per cent of the 1164 registered pharmacists in B.C. , the age data indicated that 45.0 per cent of pharmacists in the province were age 40 or under, and compared very closely to the 44.6 per cent in the total Canadian response. The 1968 Commission on Pharmaceutical Services study grappled mainly with issues surrounding the future role of the pharmacist. No tables survive to indicate the age of the manpower supply in Canada or B.C. 60 The best information from 1968 came from the B.C. Health Resources Council survey which drew a 76 per cent response rate from B.C. pharmacists. Unfortunately just one small table for age was drawn from the computer files instead of the more usual age and sex comparisons. A comparison with the data for 1962 is shown in Table 1.3-4. Table 1.3-4 Percentage of Pharmacists in Two Age Categories 1962 to 1977 40 41- N/S Ross, Canada 44.6 55.0 0.3 Ross, B.C. 45.0 54.4 0.6 to 39 40-B.C. Health Resources 1968 39.4 60.6 -PHARMFILE 1974 39.7 58.0 2.3 PHARMFILE 1977 45.6 51.5 2.9 Using age categories which differed by one year from those used in 1962, Hewitt (1971) reported that just 39.4 per cent of the 953 respondents were age 39 or under. He concluded that the profession in B.C.was facing the impact of a "large proportion of older pharmacists." (Hewitt, 1971, p.8) Table 1.3-4 also illustrates the age data for the same categories from the 1974 and 1977 complete PHARMFILE census. It is not possible to check the representativeness of the 1962 survey response to judge aging of manpower stock, but it is clear that in Figure 5 A G E AND SEX OF LICENSED PHARMACISTS, 1974 AND 1977 NUMBER IN EACH YEAR OF A G E Source: Pharmfile 62 the three years between September 1974 and 1977 B.C. pharmacists very definitely became much more of the "youthful lot" as described by Ross. A more complete illustration of the change in age and sex distribution in the profession is shown in Figure 5. There has been an increase in numbers in all age groups since 1974 due to in-migration. However the most dramatic change has occurred in the 25-29 year age bracket. Since the expansion of the U.B.C. graduating class to 90 persons the profession has l iterally experienced a youth explosion. The 25-29 year group which numbered 197 in September 1974 has grown by 167 persons to 364 in just three years for an increase of 84.8 percent. This would indicate that, i f the graduating class size continues to be in the range of 90 persons, each five year age group has the potential to reach 450 persons. Table 1.3-5 shows the detailed age and sex distribution as of September 1977. A very simplistic calculation would indicate that 90 graduates, each with a career l ife expectancy of 35 years could supply the expected retirements in a workforce of about 3000 persons. Since the register total was 1879 in 1977, this number of graduates could also be expected to support losses from younger age groups and some growth as wel1. 63 Table 1.3-5 Number of Licensed Pharmacists in by Age and Sex B.C. Sept. 1977 Age-24 25-29 30-34 35-39 40-44 Male 40 185 123 124 118 Female 55 179 84 66 35 Total 95 364 207 190 153 45-54 55-64 65-74 75+ Unkn. TOTAL Male 280 270 126 35 43 1344 Female 65 30 7 3 11 535 TOTAL 345 300 133 38 54 1879 Source: PHARMFILE In Table 1.3-6 a simple aging of the 1977 register by 10 years is shown. For this calculation all persons age 65 and above, and half of those between 55 and 64 in 1977 were dropped from the register. The other age groups remain unchanged to reflect the pattern of replacement of losses by in-migrants. Again the calculation is simplistic, but i t indicates that the profession has the potential for growth that is in the range of 30 per cent in ten years. Under assumptions of growth of this magnitude,and an equal number of female entrants to the training programme; women would comprise about 36 per cent of license holders by 1987. 64 Table 1.3-6 Number of Licensed Pharmacists by Age in 1977 Projected to 1987 1977 1987 -24 95 90 25-29 364 450 30-34 207 450 35-39 190 364 40-44 153 207 45-49 345 190 50-54 153 55-64 360 345 65+ 171 150 Unkn 54 54 1874 2453 The topic of growth in the profession and its relationship to growth in the general population will be dealt with more completely in Part 11 of the study; but given the 1977 age structure, i t appears that the problems facing the profession will be those related to youth rather than age, or even sex structure. 1.34 Place of Education Canada as a whole, is an importer of skilled labour, and in addition there is considerable movement of labour within the country. British Columbia and Ontario have always received a considerable portion of their supply of pharmacists from the prairie provinces. Here in British Columbia it has been traditional to speculate that 50 per cent of all pharmacy licenses and 75 per cent of positions of any importance are held by Saskatchewan graduates, with the rest of the Saskatchewan pharmacists arriving in time for retirement. 65 The actual figures shown in Table 1.3-7 do not support the full extent of my myth. Clearly B.C. trained pharmacists formed the vast majority of registrants, though Saskatchewan graduates formed the largest group of out-of-province trained pharmacists and comprised 10.5 per cent of the register in 1977. In 1968 the question asked in the B.C. Health Resources' Survey of 1968 was different in that it requested province of first licensing. At that time the percentage of Saskatchewan pharmacists in the response was only slightly higher at 11.2 per cent. Table 1.3-7 Province of Basic Pharmacy Education, B.C. Pharmacists Sept. 1977 # B.C. 1366 72.7 Alberta 101 5.4 Saskatchewan 197 10.5 Manitoba 58 3.1 Ontario 32 1.7 Quebec 3 0.2 New Brunswick 12 0.6 Other country 106 5.6 Unknown 4 0.2 1879 100.0 Source: PHARMFILE Between 1974 and 1977 it is clear that Saskatchewan and Alberta graduates formed the majority of Canadian pharmacists who entered the 66 province; as shown in Table 1.3-8. However, i t is also important to note the trend to decreased numbers of registrations of Canadian graduates during the period. Table 1.3-8 Number and Source of New Out of Province Registrants College of Pharmacists of B.C. 1974-1977 74-75 75-76 76-Alberta 13 8 5 Saskatchewan 18 13 3 Manitoba 4 3 1 Ontario 5 - 1 Quebec 1 - -New Brunswick 5 3 -Total Canada 46 27 10 Other country 10 17 16 Total 56 44 26 Source: PHARMFILE Though the 1974-75 total of new registrants may contain some persons previously registered but new to the computerized system, the reduction after 1975 is likely a reflection of depressed economic conditions in the province, and the increased competition from B.C. graduates for entry positions. 67 1 .'35 Level of Education The UBC degree programme has been the only route of entry to the profession within the province since the mid-1940's. However persons trained and credentialled under apprenticeship programs continue to hold licenses and to enter the province from other jurisdictions. As of September 1977 more than 80 per cent of registrants were University trained graduates. As well there were 304 persons or 16.2 per cent of registrants who had apprenticeship qualifications. Clearly many of these pharmacists were approaching retirement age and Table 1.3-9 shows that there was a loss of 51 persons or 14.4 per cent over the three year period. Table 1.3-9 Number arid Percentage of B.C. Pharmacists Reporting Apprenticeship or Degree Training Apprenticeship Degree # % # TOTAL 1974 355 22.3 1234 77.7 1589 1975 348 20.1 1383 79.9 1781 1976 323 17.7 1505 82.3 1828 1977 302 16.2 1585 83.8 1879 Source: PHARMFILE It was known that many pharmacists registered in British Columbia held higher degrees and also other types of qualifications. Even with computerized records it was not possible to gain access to this type of information in any systematic way. 68 Between 1970 and 1977 fifty-four persons entered the post-graduate hospital residency training program in British Columbia. Records of the entry of these persons to training, their subsequent certification and employment in the system have been kept at U . B . C , but as of 1978 their certification was not recorded formally on PHARMFILE. Thus i t was not possible to make an accurate estimate of the retention of these people. 1.36 Distribution by Practice Field The largest field of pharmacy employment has traditionally been community or retail pharmacy, and the Commission on Pharmaceutical Services (1971, p. 327) estimated that 85.4 per cent of Canadian pharmacists were employed in this field in 1969. Hewitt (1971) estimated that close to 90 per cent of B.C. pharmacists in employment were involved in some form of retail practice in 1968, with 7.2 per cent reporting their major field as hospital pharmacy. (Table 1.3-10) Table 1.3-10 Major Fields of Employment Reported by B.C. Licensed Pharmacists, 1968 Retail # 818 % 85.3 Hospital 69 7.2 Retail + hospital 40 4.2 Other 32 3.3 959 100.0 Source: B.C. Health Resources Survey, 1968. 69 The entire classification of employment fields as used for PHARMFILE is shown for 1975 and 1977 in Table 1.3-11. One small error of classification is immediately apparent. It shows as an overstatement of the number of persons employed in 1975 by the Association (College) and the Society (BCPS), and likely occurred as a result of change of name by both organizations. Table 1.3-11 Major Fields of Employment Reported by B.C. Licensed Pharmacists, 1975 and 1977 1975 1977 Retail 1244 1367 Hospital 192 202 Univ. or College 14 18 Fed. Govt. Hosp. 9 5 Prov. Govt. Hosp. 13 12 Phcy. Manufact. 19 18 Phcy. Assoc. Soc. 11 6 Other, Phcy. 31 30 Phcy. Wholesale 1 4 Armed Forces 1 7 Unknown 7 15 1542 1684 Source: PHARMFILE As of 1977 this distribution of persons in pharmacy employment shows that community pharmacy was s t i l l the largest field of practice with 81.2 per cent of practitioners. A direct comparison with the survey data from 1968 to judge diversification of practice fields would be misleading. St i l l the absolute and percentage growth of the hospital field should be noted. 70 1.37 Geographic Distribution The dispersion of health workers between metropolitan and rural areas of B.C. has always been uneven, and in 1975 the U.B.C. Division of Health Services Research and Development (HSRD, 1975, p.22) identified four Regional Hospital Districts as clearly deficient in manpower. The basis of the identification was a series of low health manpower rates per 10,000 population across 23 health occupations. The four districts were Stikine, Ocean Falls, Mount Waddington and Squamish-Lilooet. For pharmacy the first three districts plus Peace River-Liard were considered to be low in pharmacists when compared to with the average ratios across the other non-metropolitan areas. For the year 1977 there was an average of 5.37 licensed pharmacists per 10,000 population in the non-metropolitan areas as compared with 8.62 for the metropolitan areas of Greater Vancouver and Capital (Victoria). Calculated in the more traditional way, this was 1862 persons per pharmacist (non-Metro) and 1160 persons per pharmacist (metro) with the provincial average being 7.08 pharmacists per 10,000 or 1412 persons per pharmacist. (HSRD, 1977) Because there are some pharmacists who are not in the labour force, and a considerable number who work part time, a calculation based on hours and weeks of work was made to estimate the number of full time equivalent (FTE) pharmacists per 10,000 persons. This is shown for the non-metropolitan areas as Table 1.3-12. On the basis of one or more standard deviations (0.91) from the mean of 4.33 FTE 71 pharmacists per 10,000 population several areas were flagged as deviating significantly. The clearly deficient areas appeared to be Stikine with no pharmacy service and Ocean Falls for which two minus signs in the column headed "deviation from mean" indicate more than two standard deviations. In Cariboo, Bulkley-Nechako and Peace River-Liard the ETE pharmacist ratios were more than one but less than to standard deviations from the mean. Using the same comparison,four areas had significantly higher than average ratios. These were East Kootenay, Okanagan-Similkameen, Central Okanagan and Sunshine Coast. In his overview of the findings of Rollcall-75 (HSRD 1975, p.9) Dr. D.O. Anderson reminded planners that manpower supply ratios could not form the entire base for planning and recognized the influence of "entrepreneurial interests" among solo practitioners, as well as the policies and availability of employing health care facilities as important determinants of the "number, locations and functions of health care workers." In the case of community pharmacist ratios especially, these other factors are important. Some of the more obvious and readily measured ones include: 1. Ag e composition of the population 2. Per capita income in region 3. Number of communities in region 4. Population density 5. Number arid proximity of physicians 6. Number and type of hospital beds in region. 72 Table 1.3-12 Number of Pharmacist FTE per 10,000 Population and Percentage of Elderly in Non-Metropolitan Regions of B.C. Showing FTE Deviation from Mean and from Age Adjusted Population DISTRICT FTE/10,0001 <%0VER 3 DEVIATION DEVIATION 65 YEARS FROM MEAN AGE ADJUSTED 1 East Kootenay 5.51 6.16 + + 2 Central Kootenay 4.08 11.04 -3 Kootenay-Boundary 4.84 10.30 4 Okanagan-Simi1kameen 5.77 14.98 + -5 Columbia-Shuswap 4.50 8.08 6 North Okanagan 5.10 10.46 7 Central Okanagan 5.24 12.50 + -8 Thompson Nicola 4.79 5.23 + 9 Cariboo 3.00 3.85 -10 Squamish-Lilooet 3.83 4.03 + 11 Fraser-Cheam 5.28 10.70 + 12 Central Fraser Valley 3.97 9.46 -13 Dewdney-Alouette 3.81 9.36 -15 Sunshine Coast 5.86 13.11 + 16 Powell River 4.17 8.04 17 Mount Waddington 4.69 2.57 ++ 18 Ocean Falls 2.03 4.18 — 19 Skeena-Queen Charlotte 4.60 4.41 + 20 Kitimat-Stikine 3.94 2.80 + 21 Bulkley-Nechako 3.27 3.94 -22 Fraser-Fort George 3.81 2.84 + 23 Peace River-Liard 3.19 4.50 -24 Sti kine 0.0 2.59 — — 26 Cowichan Valley 3.65 9.32 -27 Nanaimo 4.79 11.22 -28 Alberni-Clayoquot 4.99 5.45 + 29 Comox-Strathcona 3.82 6.57 Mean 4.33 7.50 S. Deviation 0.91 3.60 Source 1 HSRD 1977 2 Census Data 1976 73 Persons over age 65 years have been identified as having higher than average hospital utilization rates, and high rates of use of prescription drugs. For Saskatchewan the overall consumption of prescriptions in 1976-77 was 4.02 per person per year. When persons over 65 years were separated out, their consumption rate was 10.18 per year or approximately two and one-half times the general rate. In B.C. the Pharmcare programme paid out $21,240,000 at the retail level in 1977 for prescriptions for the 241,405 eligible persons in this age group. At an average price of $5.90 this indicates a volume of 21,240,000 * 5.90 = 3.6 million prescriptions or an annual consumption rate of 14.9 pres-criptions per person over 65 years. When the prescriptions for social assistance clients are included i t has been estimated that Pharmcare is billed for 35 to 40 percent of the prescriptions f i l led at the retail level in B.C. While the proportion of elderly persons in the population will not be the sole factor in regional differences in manpower distribution, this group of citizens is s t i l l an important "indicator" group for pharmacy because of its high rate of use of drugs. For this reason a line (Slope = 2.31, Correlation = 0.585, Intercep. - 2.49) was drawn through the scatter plot of the pharmacist FTE per 10,000 population and the percentage of persons over 65 years as a simple form of population age adjustment. This is shown in Figure 6. In Table 1.3-12 the districts which deviated from this line by more than one standard deviation (0.91 FTE/10,000) were flagged for Figure 6 SCATTERGRAM OF PHARMACIST FTE PER I 1 1 1 1 1 r 2 4 6 8 10 12 14 % OVER 65 YEARS 75 comparison with the non-adjusted deviation from the mean. This shows that several of the non-metropolitan areas with average or lower than average pharmacist FTE per 10,000 population were actually staffed at ratios which were higher than expected when the low percentage of elderly in the region was considered. Aside from Stikine which had a total population of under 2000 persons, the regions identified as having lower than expected manpower ratios were in the sourthern part of B.C. Several of the northern regions, notably Peace River-Liard, Buikley-Nechako, Ocean Falls, and Cariboo fell within the expected range after the age adjustment, indicating that institutional and entrepreneurial factors were important influences on manpower ratios. While this population age adjustment is admittedly simplistic i t indicates that there is l i t t l e evidence of a shortage of pharmacists in northern regions of B.C. based on population need. There may::however be "shortages" which relate to staff turnover and reluctance of professionals to locate in the north, problems for which institutional and entrepreneurial type solutions will be most appropriate. 1.4 Pharmacist Employment in B.C. The number of current license holders or professional registrants in a given area is often a large understatement of the actual number who have been qualified or "ever-licensed". This is especially true in occupations which have a large proportion of female members; and, depending on institutional controls, the number of persons licensed can be a considerable overstatement of the numbers who are actually in 76 the workforce. The Commission on Pharmaceutical Services (1971, p. 318) noted that "some pharmacists do not reside in the province in which they maintain registration", that registration is often maintained after actual vocation change or retirement, and that there is generally a pool of qualified persons who are temporarily out of the workforce for various reasons. The number of B.C. licensed pharmacists who reside outside the province has never been large, but as shown in Table 1.4-1, there has been a sharp increase from 55 out of province residents in 1974, to 92 by September 1977. The reasons for the increase are not known, but the incentives of the 1974 legislation were likely important. The non-resident pharmacists have been included in the following sections, though a slightly lower percentage of this group report employment. The reporting of employment status and place of employment by individual pharmacists is not mandatory, but has always been encouraged by the College. Since computerization of the register in 1974 pharmacists have been asked at the time of first licensing, and on an annual basis thereafter, to indicate their type and level of employment. This information is stored on PHARMFILE, and while errors of under-reporting are likely, it has been assumed that these have occurred in all years. 77 Table.1.4-1 Number and Percentage of B.C. Licensed Pharmacists Reporting Residence Outside B.C. 1974 - 1977 Non-resident B.C. Resident Total % % 1974 55 3.5 1534 96.5 1589 1975 72 4.2 1659 95.8 1731 1976 80 4.4 1748 95.6 1828 1977 92 4.9 1787 95.1 1879 Source: PHARMFILE 1.41 Number of Pharmacists in the Labour Force, 1974 to 1977 With the expansion of the UBC graduating class to 90 and the subsequent growth in numbers of licensed pharmacists there have been concerns that the system cannot expand at the same rate to provide employment for the new registrants. An examination of PHARMFILE for employment status showed that just under 90 percent of licensed pharmacists between 1974 and 1977 reported some type of pharmacy employment. From Table 1.4-2 i t can be seen that growth in the register was 290 persons or 18.3 per cent for the period, and the number of persons reporting employment increased by 275 or 19.5 per cent. The total percentage reporting employed status increased slightly to 89.6 per cent. This would be expected given the change of age distribution of the profession. The new recruits were mainly young and would be expected to be in employment. 78 Table 1.4-2 Number and Percentage of B.C. Licensed Pharmacists Reporting Pharmacy Employment, 1974-1977 Showing Major Field of Employment 1974 1975 1976 1977 Community 1140 1244 1313 1366 Hospital 153 192 206 202 Other, Unknown 116 106 109 115 TOTAL EMPLOYED 1409 1542 1628 1684 TOTAL LICENSED 1589 1731 1828 1879 % EMPLOYED 88.7 89.1 89.1 89.6 Source: PHARMFILE Growth in the major fields of employment has not been even during the period. The number of persons reporting hospital employment increased by 25 per cent between 1974 and 1975. Much of this growth was due to increased hiring and establishment of new hospital pharmacies, but some can likely be attributed to the transfer of the Federal Veterans' hospitals to the provincial system and reclassification of already employed pharmacists. The lack of growth since 1976 reflects the change in government policies in B.C. and the subsequent freeze on all types of government subsidized employment. While i t is clear that the growth of numbers of persons reporting employment slowed by 1977, Table 1.4-3 shows that this growth closely parallelled growth in the register in all years. 1.42 Employment Status Reported by New Registrants, 1974 to 1977 It was not until new registrants with the College of 79 Pharmacists of B.C. were considered separately that any evidence of employment problems emerged. Again i t should be noted that the reporting of employment is not compulsory, and some under-reporting is likely. The assumption has been made that under-reporting will be similar for all years. Table 1.4-3 Increase in Number of Pharmacists Licensed and Reporting Pharmacy Employment 1974-1977, Showing Field of Major Employment 1974-75 1975-•76 1976-77 # % # % # % Community 104 9.1 69 5.5 54 4.1 Hospital 39 25.5 14 7.3 -4 -1.9 Other, unkn. 10 -8.6 3 2.8 6 5.5 Increase Employed 133 9.4 86 5.6 56 3.4 Increase Licensed 142 8.9 97 5.6 51 2.8 Source: PHARMFILE From Table 1.4-4 it can be seen that the percentage of persons reporting employment in their first year of licensing was 71.0 per cent in 1974-75. However this declined sharply to 50.0 per cent in 1976-77 and from Table 1.4-5 i t can be seen that this drop was general for males as well as females. The geographic distribution of new registrants reporting employed status is shown in Table 1.4-6, and while the number has declined in all regions, there was no information to indicate whether 80 Table 1.4-4 Number and Percentage of New Registrants Reporting Employment 1974-1977 1974-75 1975-76 1976-77 # Registered 159 138 106 # Employed 113 76 53 % Employed 71.0 55.0 50.0 Source: PHARMFILE Table 1.4-5 Number and Percentage of New Registrants Reporting Employment 1974-1977 Showing Sex of Pharmacist 1974-75 1975-76 1976-77 M F M F M F # Registered 104 55 83 55 54 52 # Employed 75 38 43 33 30 23 % Employed 72.1 69.1 51.8 60.0 55.5 44.2 Source: PHARMFILE there were positions in non-metropolitan areas which were not being f i l led because registrants preferred to stay in the metropolitan area; St i l l these data suggest that pharmacists of both sexes registered in 1976 and 1977 had diminished success in finding positions which suited them. 81 Table 1.4-6 Number of New Registrants Reporting Employment 1974-1977 Showing Region of Employment 1974-75 1975-76 1976-77 Non-Metro 49 24 25 Capital 14 7 2 Greater Vancouver 41 41 24 Out of Province 9 4 2 113 86 53 Source: PHARMFILE 1.43 The Pharmacist Full Time Equivalent In the previous section a simple "count of bodies" method was used to measure the numbers of persons in the labour force. One of the problems with this approach is that i t fails to account for differences in body weight, that is differences in work patterns. Many pharmacists work on a part time basis. The surveys conducted by the B.C. Pharmacists' Society in 1975 and 1976 indicated that more than 35 per cent of respondents with non-ownership status wereoin part time employment. This is shown in Table 1.4-7. The computerization of the College of Pharmacists of B.C. Register has allowed the development of a measurement of full time equivalency based on individual pharmacist reports of employment status, and hours and weeks of employment. The factors used to estimate the 82 Table 1.4-7 Level of Employment Reported by Non-owner Respondents, BCPS Survey 1975, 1976 1975 1976 # % % Part time chosen 194 32.6 191 29.8 Part time all available 27 4.5 53 8.3 Full time 374 62.9 397 61.9 595 100.0 641 100.0 Source: B.C.P.S. Employment Relations Surveys. full time equivalent (FTE)are: HOURS PER WEEK FACTOR WEEKS PER YEAR FACTOR 0 0 0 0 1 - 14 .2 1 - 14 .2 15-24 .4 15 - 34 .5 25 - '34 .7 35 - 47 .8 35 - 44 1.0 48+ 1.0 45+ 1.2 Source: Health Manpower Working Unit, UBC. The pharmacist equivalent is the product of these factors unless only one is available in which case that is used. The provincial average pharmacist equivalent is substituted for those pharmacists who do not indicate their hours and weeks of employment, but specify that they are employed in the field of pharmacy. 83 1.44 Full Time Equivalence of B.C. Pharmacists 1975, 1977 The information required to calculate the pharmacist FTE was collected for the years 1975 and 1977. From Table 1.4-8, i t can be seen that for 1977, 1684 persons in all types of pharmacy employment were working at an equivalence of 1406 full time pharmacists. This represents an increase of 74 FTE or 5.6 per cent over the 1975 totals. However,it should be noted that during the same period growth in the register was 8.5 per cent , and growth in numbers of pharmacists reporting employment was 9.2 per cent. This would indicate that some of this employment growth was of a part time or short term nature. Table 1.4-8 Full Time Equivalence of B.C. Pharmacists 1975, 1977 Change 1975 1977 FTE 1332 1406 74 5.6 # Employed 1542 1684 142 9.2 # Licensed 1731 1879 148 8.5 FTE/#Employed .863 .836 •FTE/#Licensed .769 .748 Source: PHARMFILE For Table 1.4-9 the employment and FTE totals were disaggregated to show what growth had occurred in the major employment fields. It shows that the major growth in numbers of pharmacists reporting employment occurred in the community pharmacy field. However, 84 Table 1.4-9 Full Time Equivalence of B.C. Pharmacists 1985, 1977: Showing Field of Pharmacy Employment Change 1975 1977 # % .COMMUNITY FTE 1080 1137 57 5.3 # Employed 1244 1367 123 9.9 HOSPITAL FTE 169 178 9 5.3 # Employed 192 202 10 5.2 OTHER, UNKN FTE 83 91 8 9.6 # Employed 106 115 9 8.5 Source: PHARMFILE the fu111 time equivalence of these positions,and those in the hospital field,indicate a real growth in hours and weeks of employment of just 5.3 per cent during a period when the growth rate in the register was 8.5 per cent and was comprised of mainly young registrants. 1.45 Pharmacist Unemployment and Placement Statistics A debate in the 1978-79 winter session of Parliament gave formal recognition to the fact that the official data of the Canadian Employment and immigration Commission (CEIC) concerning the number of persons unemployed in Canada were incomplete because they did not include information on the numbers of unregistered unemployed.,; It was felt that many persons had dropped out of formal job search procedures and should be counted as "discouraged seekers". In Canada government employment 85 agencies have not generally been used by established professionals unless they are seeking employment information from other provinces. Those persons with experience depend for employment information on the communication network which operates in any professional body...Such an unemployed group, also unregistered, could be termed "grapevine seekers." The following sections provide information concerning pharmacist registration with government agencies, and also a description of the professional employment "network" agency. a) Canada Employment and Immigration Commission During 1976 and 1977 the Canada Employment and Immigration Commission (CEIC),created from a re-marriage of Canada Manpower and the Unemployment Insurance Commission, reported increasing registrations among pharmacists. As of September, 1977, there were 45 persons or 2.5 per cent of inprovince resident licensed pharmacists receiving unemployment benefits. While exact comparisons for area of residence are not possible, i t appears that a disproportionally high number of claimants were resident in the metropolitan areas. The claim group consisted of 41 retail , 2 hospital and 2 industrial pharmacists who had been on claim for an average of 11 weeks. During the same month the placement branch of CEIC reported 52 registrants, most of whom were youmg. A spokesman for the agency was dismayed by the lack of willingness of applicants to relocate, and 86 felt that more pharmacists should write the PEBC examination to increase their chances for positions in other provinces. b) B.C. Pharmacists' Society Placement Information Under the terms of its Constitution the BCPS operates a Placement Bureau to centralize employment opportunity information. Listings of vacant positions are made available only to member employees. The names.of job seekers are supplied to all employers regardless of membership status, unless they are overt violators of the BCPS Employment Code standards. Since 1976 the placement service has been under increasing pressure from new graduates seeking full time employment.' However because of the relative informality of the service, and because of its nature which is informational only, an evaluation of its success is difficult. 87 CHAPTER 2: RATIONALE AND OBJECTIVES OF THE STUDY Three broad issues were of interest to the profession in B.C. These were: rapid growth of the number of pharmacists, a recent lack of employment opportunity and uncertainty about the future capability of the system to absorb the manpower stock. 2.1 The General Concerns The first rationale for the study relates to the concern expressed by the B.C. Pharmacists' Society and by members of the College of Pharmacists of B.C. over the large increase in enrolment in the Faculty of Pharmaceutical Sciences and the rapid growth of College membership between 1974 and 1976. It also relates to the lack of any method for predicting what growth in the numbers of actively licensed pharmacists might reasonably be predicted for the future. Secondly, there were concerns among many pharmacists that the traditional obligation of older professionals to assist new entrants to find satisfying employment in the profession could not be met. It was recognized that there will always be periodic fluctuations in the economy which will affect-employment opportunity, and that those first hurt in a downward trend would be inexperienced workers. St i l l there should be some certainty that the numbers of persons receiving specialty education in a given area would reasonably match the demand for their services. 88 The third rationale for the study relates to the broader obligations a profession has to society as a whole to provide a quality service in an efficient and accessible manner. Pharmacy, in common with many professions, has a legally supported monopoly over practice. Professions have generally sought to control numbers within their groups in order to maintain their exclusive status, traditional role and existing price structures. While an examination of the role of the pharmacist is not the objective of this study, there is a recognition within the profession that the traditional role of drug supplier must be modified to include better drug and patient information i f the quality of pharmacy service i;s to be improved. As well i t is becoming recognized that much of the drug supply role which pharmacists have claimed as their exclusive right, is composed of many simple tasks, some of which should be delegated to lesser trained personnel i f the obligation of cost efficient service is to be met. The temptation in a saturated labour market is for an occupation to hold fast to an old role and to search for expansion into other activities in order to maintain employment and price levels. The recent graduates have been trained to expect an altered role in pharmacy which will allow them to provide a service which incorporates more drug and patient information services. If the profession can not, and does not move away from the routine "counting and pouring", i t will not likely be able to hold t'he.interest of these young people; and their investment in the specialty aspects of a pharmacy education 89 will bring no return. 2.2 The Specific Research Objectives This study has attempted to illustrate the various components of pharmacy manpower supply, and to obtain information about the flow of persons into and out of the profession. It has also attempted to make projections of future growth under several policy options. While-iit was known that some of the recent graduates had had difficulty in finding pharmacy employment, there was l i t t l e data to indicate the extent of the problem. Ah attempt has been made to ascertain recent levels of employment and unemployment among B.C. resident pharmacists, and as well as document recent demand by employers for pharmacists. In addition the study has examined the employment choices of members, the differential participation of women and attitudes of pharmacists to their careers. There were few data sources to aid in estimating how many prescriptions are demanded at the retail level in British Columbia. The study has developed several approaches for estimating this demand. It has also related this demand to productivity standards developed by the Commission on Pharmaceutical Services (1971) to estimate a "need" for dispensing pharmacists. Individual pharmacist workloads, time allocations, and the use of auxiliary personnel and computer systems were examined for relationships to these productivity standards. The staffing patterns in community pharmacies at various levels of prescription demand were also compared. 90 For institutions the staffing levels were compared to standards developed by the Canadian Society of Hospital Pharmacists and those of the more recent federally funded Working Party on Standards for Institutional Pharmacy Service. 91 The following is a l i s t of the specific research objectives of the study: 1. To illustrate through the use of a model, the system'of the supply of pharmacy manpower in B.C. 2. To project what growth in supply might reasonably be expected to 1990 under varying policy options. 3. To provide data on recent employment levels, unemployment, and employment choices made by pharmacists resident in B.C. , with specific emphasis on U.B.C. graduates of 1974 to 1977. 4. To examine career attitudes held by pharmacists, their expectations of career duration, and differences in participation by women. 5. To estimate recent demand for pharmacists in community and institutional pharmacies in B.C. 6. To estimate the number of prescriptions demanded at the retail level in B.C. and to document the staffing patterns in community pharmacies at various demand levels. 7. To provide data concerning individual community dispensing pharmacist workloads in terms of prescriptions per working hour; to document pharmacist activity patterns including medication counselling, and the use of auxiliary personnel and computer systems as aids to productivity. 8. To estimate what staffing levels are general in B.C. institutional pharmacies and to compare them with established standards. 9. To estimate the percentage of time spent by institutional pharmacists in drug utilization review and the review of individual 92 patient therapy and.to determine what drug distribution systems are mainly used by institutional pharmacists. 93 2.3 The Significance of the Study This study is expected to provide benefits to: (1) The College of Pharmacists of British Columbia; (2) the British Columbia Pharmacists' Society; (3) individual pharmacists and pharmacist employers in the provice; and (4) pharmacy educators. (1) It is expected that the use of a model detailing pharmacist supply will be useful to the College of Pharmacists as a guide to the type of information they will need to record on a regular basis in order to predict growth in the profession. (2) This study will provide the B.C. Pharmacists' Society with information concerning recent ambulatory prescription demand in the province, and productivity levels of pharmacists. It will also provide information concerning the use of patient record plans which may assist the Society in the development and marketing of future systems. It is likely that the information concerning employment patterns of pharmacists and demand by employers will aid the Society in modifying and improving its employment service. (3) This study will provide individual pharmacists and employers with better comparative information concerning service and staffing patterns, as well as productivity levels of pharmacists in various types of practice organizations. (4) It is expected that information from this study will provide educators in the profession with a better understanding of the current 94 age structure of the profession, and with some indication of the differences of employment patterns of male and female pharmacists. It is hoped that some of the attitudes to their careers expressed by current practitioners will be useful in the planning of future enrolment levels and also curriculum content. 95 CHAPTER 3: METHODOLOGY In order to make judgements about the future growth of the numbers of licensed pharmacists in British Columbia a model was constructed to illustrate the entry of persons to the profession, and the losses from the profession. The use of a model, even on a restricted basis, was considered necessary to avoid the pitfalls of using simple projections of recent and accelerating growth of College membership which would have led to forecasts of doubling of numbers in the profession by 1984. A mailed questionnaire was developed and sent to all B.C. resident pharmacists in April 1978 in order to obtain a more current and complete picture of employment levels and patterns of unemployment. Additional information was obtained concerning career choices and attitudes, as well as workloads in terms of dispensed prescriptions, and distribution of working time. Those persons in pharmacy management positions were asked to provide information concerning pharmacy staffing patterns, recent hiring of pharmacists, prescription volume,numbers of nursing home or in-patient hospital beds served, and pharmacy open hours. Throughout this study the College of Pharmacists of B.C. has allowed generous access to its files and correspondence dealing with register growth, to its original Membership Register, and to PHARMFILE which is the dynamic computer based register of currently licensed pharmacists. 96 3.1 The Model of the Supply of Pharmacists The model of the supply of manpower was based on one developed by Don Earner during the course of his study of legal manpower for the Justice Development Commission of British Columbia in 1974. Modifications to the model were made with the assistance of Dr. B.E. Riedel, Dean of the Faculty of Pharmaceutical Sciences, and L.C. Fevang during his tenure as Registrar of the College of Pharmacists of B.C. It is illustrated in Part II as Figure 7. While the model is suitable for computer simulation techniques, this was not carried out because most of the data available were from a short time span, and had been influenced considerably by the Pharmacy Act of 1974. The expense of programming may be justified in time. Because of a. lack of data for some of the components of the model, and because the simulation was done by hand, a reduced version of the model was used to eliminate some of the more intricate calculations. This version of the model appears in Figure 8, and the assumptions behind the calculations are detailed in the various Forecasting Appendices. The data for the calculations included student registration statistics provided by the Faculty of Pharmaceutical Sciences at UBC, and the pharmacist registration statistics of the College of Pharmacists of B.C. The College material which dated from 1974 was recorded on 97 PHARMFILE and was obtained with the assistance of the Health Manpower Research Unit at UBC. 3.2. The Survey of B.C. Pharmacists, 1978 During the process of design of the survey of pharmacists several earlier studies were reviewed. One of the first major works which examined pharmacist functions was done for the Royal Commission on Health Services. In this questionnaire mailed to Canadian pharmacists in 1962, twelve different activity categories were used. (Ross, 1967, p.126) The question was subsequentlyvalidated in British Columbia by F.A. Morrison (1962) and N.C. Zacharias. Similar questions were used by the Commission on Pharmaceutical Services and the B.C. Health Resources surveys conducted in 1968. Common to all,these questionnaires was the broad activity category described as "filling prescriptions" or "dispensing prescriptions". In the period since these studies were conducted there has been greater acceptance of the principle of delegation of some pharmacy tasks to non-professional assistants.^ n both community and hospital pharmacy settings. However not all tasks which comprise the large activity category called "dispensing" may be delegated. By definition of the Pharmacy Act (1974): '"dispense1 includes the preparation and release of a drug prescribed in a prescription and the taking of steps to ensure the pharmaceutical and therapeutic suitability of a drug for its intended use." 98 In setting the Limits of Involvement for pharmacy assistants within the dispensary, the Pharmacy Act (1974, Rule C-52) differentiates between the technical components of dispensing such as counting, pouring, typing and labelling which may be delegated; and the professional components of interpretation, communication and final checks which may not be delegated. Because of these regulations i t was fe.lt that some sub-division of the broad category of dispensing prescriptions was desirable. A work study of personnel activities in community pharmacies conducted by Rodowskas and Gagnon (1972) examined prescription department and front shop activities in 29 Ohio pharmacies. For this study the pharmacy activities were categorized as manipulative, consultative, clerical and supportive; and could be quite clearly related to the definitions and limitations of the B.C. Pharmacy Act. Some rewording and rearranging of the Rodowskas materials was required, before it could be put into questionnaire format as the basis of the time budget question for the pilot survey. This pilot was mailed to B.C. licensed pharmacists who were resident in other parts of Canada, and from the erasures and notations on the returns there was some indication that separation of prescription department activities was difficult. The extent of the problem became clearer after interviews were conducted with nine lower mainland pharmacists in diverse practice situations. 99 Those pharmacists in larger outlets or in mainly dispensing practices seemed quite able to estimate their time using the Rodowskas based categories; but several persons in more mixed practice settings-felt they could not relate the categories to their practice. In three of the nine cases the pharmacist would not attempt the question, and volunteered that observation methods rather than the questionnaire format would be more appropriate. The small mixed merchandise pharmacy forms the backbone of community practice in British Columbia, and while many pharmacists would likely benefit from a more detailed examination of how they spend their time, i t was felt that the validity of survey data based on Rodowskas' categories would be questionable unless confirmed by the more time consuming and expensive work study method. During 1977 the B.C. Pharmacists' Society ran a small trial of a modification of a uniform cost accounting system developed by Siecker. (1976). This trial was part of an effort to help pharmacists become more aware of their costs of dispensing. A simple time allocation sheet which apportioned blocks of pharmacist time to pharmacy management, prescription department duties, and non-prescription department duties was used with some success. While there was absolutely no breakdown to differentiate dispensary taks, the question had at least proved to be manageable for community pharmacists. It was decided to ask for estimates of time spent in counselling patients about their use of prescription and non-prescription medication in a separate section of the survey to further reduce the 100 difficulties in the time budget question. In 1976 Bachynsky reported on the recommendations of the Working Party on standards of Institutional Pharmacy Service. (Bachynsky, 1976, p. 179) This group of consultants made recommendations concerning staff activities and staffing levels in various types of institutions. It was recognized that the actual staff requirements would vary depending on the level of care provided in the institution; however the working party made the uniform recommendation that pharmacists in acute, rehabilitation and extended care institutions should "regularly review the drug therapy of individual patients and total use of drugs in the institution-1 and that "not less than 25 per cent of the pharmacists' time should be devoted to this function". Though the recommendations of the working party have not been adopted as policy in British Columbia, i t was decided that the wording of the question concerning the amount of time spent by institutional pharmacists in drug use review should reflect this recommendation for comparative purposes. It is recognized that a large weakness s t i l l exists in that the time distributions are based on each pharmacist's own interpretation of the categories and his/her own estimation of how that time was divided. No time observation studies were conducted to validate the response. Several questions in the 1968 Health Resources Council of B.C. survey probed pharmacists' attitudes to their current field of practice, and to the profession in general. Of 947 respondents 831 or 101 87.8 per cent foundtheir present field of pharmacy practice professionally satisfying to some degree. However 387 of 940 respondents or 41.2 per cent indicated that i f they could be given the opportunity of "starting all over to choose a career", they would not choose pharmacy. Just 336 or 35.7 per cent would have chosen "pharmacy and the particular field" in which they currently practised. The most common complaints about their field of practice (70 of 115 responses) centered on a lack of challenge and status. Fully 102 of the 962 respondents admitted to being frustrated physicians. In the ten years since this 1968 survey, there have been changes in the pharmacy education process in BC, as well as attempts to bring an attitudinal change to the way pharmacists view the services around drug supply. The BCPS Employment Relations surveys since 1975 had invited membership comment concerning employment problems, but no assessment of career attitudes had been attempted since 1968. Space limitations did not allow a complete duplication of the attitudinal questions from 1968. The three main areas of interest were the satisfaction of the pharmacist with his/her career choice, the satisfaction with his/her current field of pharmacy practice, and the expected duration of his/her pharmacy career. The survey and details of its administration and response are to be found in Appendix A. 102 3.3. The Use of Supplementary Data The main sources of secondary data were the College of Pharmacists registration statistics, the Faculty of Pharmaceutical Sciences student registration totals, and data from the 1968 B.C. Health Resources Survey of pharmacists. 3.31 College of Pharmacists of B.C. a) PHARMFILE: Detailed registration and employment data from 1974 was obtained with the guidance and assistance of the Health Manpower Research Unit at U.B.C. b) Registrar's Statistical Report: This annual report provided details of the number of paid current 1icenseholders. c) College of Pharmacists Register of Members: The handwritten original ledger of the names and dates of original registration of all pharmacists in B.C. d) Files and Correspondence: Correspondence and records of meetings of the B.C. Health Resources committee members was made available for this study. 3.32 The B.C. Health Resources Survey, 1968 The raw questionnaires and original computer printouts (UBC Computing Centre I.D.: BDBY) were released from the office of Continuing Education in the Health Sciences. 3.33 Faculty of Pharmaceutical Sciences, U.B.C. The student registration totals reported by Dean B.E. Riedel to the College of Pharmacists were used in all cases. 103 PART II: PROJECTING GROWTH OF THE MANPOWER SUPPLY INTRODUCTION Between 1974 and 1976 the actively licensed membership of the College of Pharmacists of B.C. grew at the unprecedented annual rates of 6.48 and 8.21 per cent. These accelerating growth rates led to speculation of doubling of numbers in the profession by the mid-19801 s. While the trend to growth was unmistakable, i t was not known whether these growth rates represented significant and stable trends for pharmacy in B.C. , or whether they were a transient phenomenon. The increase in enrolment in the Faculty of Pharmaceutical Sciences at UBC was a readily identifiable source of growth. Between 1975 and 1976 there were 90 new registrations of UBC graduates with the College, a threefold increase over the number registered in 1970-71. As well the number of new registrants from outside the province had increased substantially over a three year period. However it was felt that there were likely other important influences on growth that were less obvious. A new Pharmacy Act, proclaimed in September of 1974, contained clauses which encouraged the retention of license and also resumption of active status by pharmacists. Throughout this period surrounding introduction, passage and final proclamation of the Act a large number of petitions for relicensing came before the College. 104 While i t was considered that growth in the range of six to eight per cent might not be sustained because the expansion of the UBC school was nearing its final stages, there was no method for forecasting other than projecting past growth trends. Obviously future plans for enrolment and for employment of graduates hinged on what these forecasts might be. Because i t was thought that there were several recent influences on supply, some kind of improved tool for prediction which examined the changes in the underlying factors was needed. In these chapters an alternative approach to simple projection techniques has been used. The following sections document the dynamics of pharmacist supply in B.C. This has been done through the use of a large flow chart from which a forecasting model has been developed. From this several forecasts to 1990 were made using data which were available on the individual factors. The way in which the data has been used to arrive at the forecasts is outlined in a set of ten Appendices, one for each parameter of the forecasting model. For ease of reference these have been included immediately following the forecasts as Chapter 6. 105 CHAPTER 4: THE DEVELOPMENT OF A METHOD FOR FORECASTING GROWTH 4.1. Modelling the Full Dynamics of Supply In order to obtain a clearer understanding of the supply of pharmacists in the province a model was developed to detail entry to, and losses from the profession.^ This model is illustrated in Figure 7. Supporting each decision point or "block" of the supply model is a standard, a policy, a set of regulations or a personal decision controlling the flow of persons through the system. The personal decision points are those faced by each student in the training system and by each pharmacist concerning the value to that individual of maintaining an active registration status each year. Otherwise the blocks represent the University academic system and the full set of controls over new registration of pharmacists, reactivation of qualifications, and discipline of members that are contained in the Bylaws of the Pharmacy Act (1974). In the section of the model which details the University system, a student is required to meet certain academic criteria before we can be admitted to the Faculty either in first or second ^ The model is based directly on one developed by D. Earner for his study of legal manpower supply for the Justice Development Commission in 1974. Modifications to the model to make it suitable for pharmacy were made with the assistance of Dean B.E. Riedel, Faculty of Pharmaceutical Sciences and L.C. Fevang during his tenure as Registrar of the College of Pharmacists of B.C. 106 Figure 7 A p p l i c a t i o n s  | A p p r o v a l ? ] F i r s t Y e a r E n r o l m e n t A t t r i t i o n X R e p e a t • i — ^ | A t t r i t i o n ! S e c o n d Y e a r E n r o l m e n t THE MODEL OF THE SUPPLY OF PHARMACISTS IN B.C. -j T r a n s f e r s | | R e p e a t T h i r d Y e a r E n r o l m e n t J. A t t r i t i o n | R e p e a t — TOTAL PREVIOUS POPULATION F o u r t h Y e a r E n r o l m e n t A t t r i t i o n R e p e a t D e a t h R e t i r e d S u s p e n d e d S u s p e n s i o n T e r m i n a t e d G r a d u a t i o n P o p u l a t i o n A t t r i t i o n O u t - o f - P r o v G r a d u a t e s P r a c t i c a l T r a i n i n g • R e t u r n t o P r a c t i c e ~ 1 Non-Exam P r a c t i c a l T r a i n i n g F o r e n s i c Exam F o r e n s i c Exam A t t r i t i o n T h e o r e t i c a l Exam COLLEGE PANEL EXAMINATION A t t r i t i o n A t t r i t i o n E n g l i s h Exam A t t r i t i o n LICENSING P r o v i s i o n a l AVAILABLE PHARMACIST R e g i s t e r POPULATION 107 year depending on the extent of his previous education. Progress through each year to graduation is of course dependent on academic achievement and accumulation of required course credits. Before first licensing each new graduate is required to be examined by a panel of practising pharmacists. The regulations concerning admission of out-of-province graduates have been gradually streamlined by the College over a period of several years. As in most Canadian provinces, e l igibi l i ty for registration with the Pharmacy Examining Board of Canada must be demonstrated before the credential!ing process can begin. The requirement for a period of practical training is waived i f a graduate presents evidence of recent practice, however all applicants must sit legal and practical examinations. The pathways for return to practice are considerably more complex. The extent of the examination process and the requirements for retraining become more onerous as the length of time a pharmacist has been on the Retired Register increases. The model of pharmacist supply as illustrated is well suited to computer simulation techniques for predicting growth. This can be carried out using aggregated membership totals or on a more sophisticated age and sex specific basis. This may be valuable in time, but most of the data available on pharmacist supply is from a very limited time span and has been considerably influenced by the Pharmacy Act of 1974. 108 4.2. The Forecasting Model Because of the difficulty involved in obtaining data for all of the factors in the large flow chart of manpower supply, and because of the short time span of the available data; it was considered necessary to reduce the number of categories which would be used in forecasting the growth in pharmacist supply. As an example, there was no information available to differentiate the number of persons returning to active status on a non-examined basis from those who had returned via the several pathways involving practical training, forensic and theoretical examination, and finally panel examination. On a very practical note, the total number of persons returning to practice was in the neighbourhood of twenty-five persons annually; and it was considered unlikely that reliable trend data could be obtained from small and complex subdivisions of this group.. Figure 8 shows the main elements of supply on a simplified basis as they feed into the central College credentialling function and then flow into the pool of actively licensed pharmacists. The main supply factors are: the local training supply, out-of-province registrants, and persons who reactivate previously held qualifications. The losses are those of non-renewal of license (for various reasons), and deaths among active members. 4.3. Developing the Forecasts In addition to providing a method of forecasting a "best guess" estimate which takes into account several different factors, 109 Figure 8 U . B . C . S e c o n d Y e a r T h i r d Y e a r F o u r t h Y e a r G r a d u a t e d P o p u l a t i o n THE FORECASTING MODEL O u t - o f - P r o v i n c e G r a d u a t e s R e - a c t i v a t i o n A p p l i c a t i o n s P r o v i s i o n a l A p p l i c a t i o n s / f A c t i v e l y L i c e n s e d P h a r m a c i s t s B . C . R e s i d e n t N o n - B . C . R e s i d e n t T o t a l Number o f P h a r m a c i s t s ( f r o m p r e v i o u s y e a r ) • D e a t h s A = A t t r i t i o n C o l l e g e o f P h a r m a c i s t s R e g i s t r a t i o n E x a m i n a t i o n P r a c t i c a l T r a i n i n g U.B C. Out - o f -R e g . P r o v i n c e R e g . R e t i r e d L i s t R e - A c t i -v a t i o n no a model is useful for testing the effect on growth of variation in these factors. As was previously noted each block of the model represents a decision point, a policy, a regulation or a standard. Several policy options emerge as obvious targets for testing. Very broadly described, these involve control of numbers of new registrants and quality control of the current population. In the context of general population dynamics such topics are controversial in the extreme. However when they are given labels such as enrolment quotas, age limited retirement, competence evaluation, peer review and exami4 nation of outside graduates, they are considerably more palatable; and indeed, form the basis of the institutional controls on manpower supply in any occupation or profession. In the process of forecasting for the general population of Canada a component analysis method was used in which "each component of population change - mortality, fert i l i ty and migration (internal and external) - was projected separately" and then applied to the base population to generate future population. (Statistics Canada, 1974, p. 13). The methodology was complex and further complicated by subdivision of the population into age, sex and regional groups. For the estimates of mortality, which would be analagous to retirement from a profession, a considerable amount of long term trend data was available. The main problem areas in the forecasts for Canada as a whole were considered to be estimations of the likely birthrate and predictions of future immigration policy,* because "recent history provides ample evidence of unexpected I l l swings in- both fert i l i ty and migration levels", (p.84) The technique for dealing with these two swings (which parallel entry to a profession from a local training program and from other areas) was to develop several projections based on different ferti l i ty assumptions and on variations in the numbers of immigrants and inter-provincial migrants. Table 4.3-1 is presented as an illustration of the variation in some of the assumptions used to produce the individual projections for the general population. Table 4.3-1 Summary of Fertility and Migration Assumptions Underlying Canadian Population Projections, 1972-2001 Assumed Migration Assumptions Projection Title Fertility Rate International Gain Inter-Prov. Movement A: High Fertility 2.60 100,000 450,000 B: Medium Fertility 2.20 60,000 435,000 C: Low Fertility 1.80 60,000 435,000 d: Low Fertility 1.80 60,000 218,000 Source: Statistics Canada (1974) It shows that three ferti l i ty assumptions were used as well as two estimates of immigration, or net gain of population from other countries. In addition, there were three assumptions concerning movement of population between provinces. 112 Table 4.3-2 is shown to illustrate the actual variation in the total population projected from British Columbia for the years 1978, 1983, 1988 and 1990 as produced under these different assumptions. The projections were all produced using 1971 census data as the base year. The last column of the table is a simple linear projection of census population from 1961, and includes the 1976 census population of British Columbia. Table 4.3-2 Projected Total Population of B.C. 1978, 1983, 1988, 1990 YEAR PROJECTION TITLE* CENSUS + A B C D PROJECTION 1978 •2669.0 -2611.7 2591.1 2499.3 2575 1983 3105.6 2967.3 2901.3 2728.6 2857 1988 3561.1 3333.9 3217.8 2960.6 3140 1990 3741.6 3478.0 3341.5 3049.6 3253 Source: *Statisties Canada (1974) +Li.near Projection of 1961 - 1976 census population Table 4.3-3 presents the same projections on an indexed growth basis relative to the base year which is 1978. This serves to illustrate the potential for a growth rate which is built into each projection. During the process of developing forecasts for pharmacy in B.C. , swings have also been identified in fert i l i ty (the number of persons entering training), migration (the number of pharmacists 113 Table 4.3-3 Projected Percentage Population.Growth in B.C. 1983, 1988, 1990 indexed to 1978 YEAR PROJECTION TITLE* CENSUS + A B C D PROJECTION 1978 100 100 100 100 100 1983 116 114 112 109 111 1988 133 128 124 118 122 1990 140 133 129 122 126 Source: *Statisties Canada (1974) +Linear Projection of 1961 - 1976 Census Population relocating in the province), and mortality (the number of losses from the profession). The need to consider variation in these broad categories has led to a number of growth forecasts to 1990. In the following sections the assumptions used in each group of forecasts will be outlined. The growth trends will then be presented first as frequencies for each year, and then as an indexed rate relative to the base year of 1978. The way each parameter was estimated appears in detail in the appendices which form Chapter 6. 114 CHAPTER 5: THE INDIVIDUAL FORECASTS Twelve individual estimates of pharmacists supply have been made under varying assumptions of the annual number of entrants to the second year of the local training programme, withdrawal from the profession, and entry of out-of-province graduates. The estimates are presented in three groups on the basis of three migration assumptions. One of these migration assumptions is the hypothetical level of zero migrants. Table 5.0-1 presents the assumptions for enrolment in the second year at U.B.C. and the percentage withdrawal from the profession used in each of the forecasts. The detailed analysis which supports these assumptions is presented in the Forecasting Appendices. (Chapter 6) Table 5.0-1 Summary of Migration, Enrolment and Withdrawal Assumptions Underlying the Individual Projections for Growth. PROJECTION NUMBER U.B.C. ENROLMENT SECOND YEAR WITHDRAWAL FROM PROFESSION (%) Migration 0 20 30 #1 #5 #9 118 2.5 #2 #6 #10 118 3.5 #3 # 7 #11 100 2.5 #4 #8 #12 100 3.5 115 5.1. Forecasts Based on Thirty Annual Out of Province Entrants The following series of projections is based on the assumption that the annual number of out-of-province registrants with the College of Pharmacists will be t h i r t y J Table 5.1-1 presents the projected number of actively licensed pharmacists of 1990, based on the two enrolment and two withdrawal estimates summarized in Table 5.0-1. In Table 5.1-2 the projections are indexed to the February 28, 1978 base year total of 1903 pharmacists to show the percentage growth that would be sustained assuming an annual registration of 30 out-of-province graduates. Table 5.1-1 Projected Number of Actively Licensed Pharmacists to 1990, Assuming 30 Annual Out-of-Province Registrants. Feb. 28 Projection Projection Projection Projection Year #1 #2 #3 #4 1978 1903 1903 1903 1903 1979 1991 1972 1991 1972 1980 2064 2026 2064 2026 1981 2132 2075 2132 2075 1982 2198 2122 2188 2112 1983 2264 2169 2242 2148 1984 2328 2214 2295 2182 1985 2390 2257 2346 2215 1986 2450 2299 2396 2246 1987 2508 2339 2444 2276 1988 2565 2377 2491 2305 1989 2620 2414 2536 2333 1990 2673 2449 2580 2360 The analysis which supports this parameter estimate appears in Forecasting Appendix 7 in Chapter 6. 116 Table 5.1-2 Projected Growth (percent) of the Number of Actively Licensed Pharmacists to 1990 Indexed to 1978 (Based on Projections 1 - 4 ) Year Projection Projection Projection Projection # 1 # 2 #3 #4 1978 100 100 100 100 1979 105 104 105 104 1980 108 106 108 106 1981 112 109 112 109 1982 116 112 115 111 1983 119 114 118 113 1984 122 116 121 115 1985 126 119 123 116 1986 129 121 126 118 1987 132 123 128 120 1988 125 125 131 121 1989 128 127 133 123 1990 140 129 136 124 Findings As was outlined in Forecasting Appendix 7, the average annual number of out-of-province registrants was 34.25 between March 1, 1971 and February 28, 1978. Projections #1 and #2 have been made under the assumptions of 30 annual entrants and continuation of recent levels of student demand for pharmacy education. The difference between these two projections is a one percent variation in withdrawal from the profession. Table 5.1-1 shows the projected growth in absolute numbers and indicates a difference of 770 persons depending on this withdrawal rate. 117 The indexed growth rates displayed Table 5.1-2 project increases between 19 and 40 percent over the 1978 base year membership. Projection #1 forecasts the highest growth of any of the projections for the period, but this is considerably lower than the doubling indicated by the linear projection of "net growth" rates. St i l l Projection #1 is in the range of the highest growth projection for the general population of B.C. shown in Table 4.3-3. Between 1971 and 1976 total population growth did not come within the range of this high ferti l i ty and high migration projection. A continuation of high student demand in combination with 30 annual registrants, as well as the lower population growth trends would undoubtedly force the withdrawal rate of Projection #2. This assumes more migration of younger.- pharmacists to other provinces and other fields. Projections #3 and #4 reflect a 15 percent reduction in student demand for second year enrolment. The difference in absolute growth at the end of the forecasting period is fewer than 100 registrants. 5.2. Forecasts Based on Twenty Annual Out of Province Entrants The following series of projections is based on the assumption that the annual number of out-of-province registrants 2 with the College of Pharmacists will be twenty. Table 5.2-1 shows the projected number of actively licensed pharmacists to 1990, based on the two enrolment and two _ The Analysis which supports this parameter estimate appears in Forecasting Appendix 7 in Chapter 6. 118 withdrawal estimates summarized in Table 5.0-1. In Table 5.2-2 the projections are indexed to the February 28, 1978 base year total of 1903 pharmacists to show the percentage growth that would be sustained assuming an annual registration of 20 out-of-province graduates. Table 5.2-1 Projected Number of Actively Licensed Pharmacists to 1990 Assuming 20 Annual Out-of-Province Registrants Feb. 28 Year Projection #5 Projection #6 Projection #7 Projection #8 1978 1902 1092 1903 1903 1979 1981 1962 1981 1962 1980 2045 2007 2045 2007 1981 2104 2047 2104 2047 1982 2161 2085 2161 2085 1983 2218 2124 220 6 2112 1984 2273 2161 2250 2138 1985 2327 2197 2292 2162 1986 2379 2231 2333 2186 1987 2430 2263 2373 2209 1988 2479 2294 2412 2230 1989 2527 2324 2450 2251 1990 2573 2353 2487 2271 119 Table 5.2-2 Projected Growth (per cent) of the Number of Actively Licensed Pharmacists to 1990 Indexed to 1978. (Based on Projections 5 - 8 ) Projection Projection Projection Projection # 5 #6 #7 #8 1978 100 100 100 100 1979 104 103 103 ; 103 1980 107 105 107 105 1981 111 108 111 108 1982 114 n o 114 n o 1983 117 112 116 111 1984 119 114 118 112 1985 122 115 120 114 1986 125 117 123 115 1987 128 119 125 116 1988 130 121 127 117 1989 133 122 129 118 1990 135 124 131 119 Findings Recent levels of out-of-province registrations have fallen below the 1971-1978 average of 34.25 annual registrations. Projections #5 and #6 reflect the assumption of continuation of this trend in combination with the recent experience of student demand for pharmacy education. Projection #5 assumes a lower rate of withdrawal from the profession and indicates growth of 670 active pharmacists over the forecasting period. Persistance of a higher rate of membership withdrawal leads to the projected total of 2353 members, an increase of 450 persons. When Projections #5 and #6 are indexed to the 1978 base year total the projected percentage increases are 35 and 24 percent 120 respectively (Table 5.2-2). On a comparative basis with the indexed growth projected in the general population it is Projection #6 which is in the range of current population growth in B.C. Projections #5 and #8 in this series again compare the effects on growth of a 15 percent reduction in student demand for enrolment at the second year level. 5.3. Forecasts Based on Zero Out-of-Province Entrants This series of "hypothetical projections" (Statistics Canada, 1974, p. 79) is based on the assumption that no out-of-province graduates will migrate to B.C. between 1978 and 1990. The assumption is of course unlikely, but the calculation serves as a test of the capacity for growth of the active register provided by the local training programme alone. Table 5.3-1 shows the projected number of actively licensed pharmacists to 1990 based on the two enrolment and two withdrawal estimates summarized in Table 5.0-1. In Table 5.3-2, the projections are indexed to the February 28, 1978 base year total of 1903 pharmacists to show the percentage growth that would be sustained under the assumption of zero out-of-province entrants. 121 Table 5.3-1 Projected Number of Actively Licensed Pharmacists to 1990 Assuming Zero Out-of-Province Entrants. Year Projection Projection Projection Projection #9 #10 #11 #12 1978 1903 1903 1903 1903 1979 1961 1942 1961 1942 1980 2025 1987 2025 1987 1981 2064 2008 2064 2008 1982 2102 2028 2102 2028 1983 2141 2049 2129 2037 1984 2179 2069 2155 2046 1985 2216 2088 2180 2054 1986 2252 2107 2205 2062 1987 2286 2124 2229 2069 1988 2319 2141 2252 2076 1989 2351 2157 2274 2083 1990 2383 2173 2296 2090 Table 5.3.-2 Projected Growth (Percent) of the Number of Actively Licensed Pharmacists to 1990 Indexed to 1978. (Based on Projections 9 - 12). Year Projection Projection Projection Projection #9 #10 #11 #12 19,78 100 100 100 100 1979 103 102 103 102 1980 106 104 106 '. 104 1981 108 105 108 105 1982 110 106 110 106 1983 112 108 112 107 1984 114 109 113 108 1985 116 no 115 108 1986 118 111 116 108 1987 120 112 117 109 1988 121 113 118 109 1989 123 113 119 109 1990 125 114 121 110 122 Findings Table 5.3-1 shows the projections for growth as absolute numbers. It indicates that even under conditions of reduced student demand and high level of withdrawal from the profession (Projection #12) some growth in the register might be supported by the U.B.C. training programme alone. The magnitude of this growth depending on a 15 percent variation of student demand and a one percent difference in withdrawal from the register is between 187 and 480 persons over the 12 year period. From Table 5.3-2, which indexes this growth to the base year 1978 i t can be seen that the percentage range for projected growth is between 10 and 25 percent of the current register. 123 CHAPTER 6: APPENDICES ON FORECASTING SUPPLY As noted in this chapter there are a number of essential factors which shape and determine the annual number of pharmacists who maintain current licensed status in B.C. In the following appendices we will describe the parameters in the supply model and supply the estimates that were used in each year of the forecasting period. The factors to be discussed are: The Current Supply: The "Active Register" of the College of Pharmacists of B.C. The Faculty of Pharmaceutical Sciences, U.B.C. Enrolment Second Year Attrition: Second to Third Year Attrition: Third to Fourth Year Attrition: Fourth Year to Graduation The College of Pharmacists of B.C. New Registration of U.B.C. Graduates New Registration of Out-of-Province Graduates Attrition from the Profession: Withdrawal from Active Status Attrition from the Profession: Deaths of Active Members Reactivation of Active License 6.1. Appendix 1. The "Active Register" of Pharmacists The Pharmacy Act (1974) requires that all persons practising pharmacy in British Columbia be registered with the College of Pharmacists of British Columbia and hold a valid license to practice which is subject to annual renewal. There are several 124 types of membership in the College of Pharmacists for which separate registers are kept, and these are outlined as follows: Pharmacist: A member of the College registered under the Pharmacy Act, holding a valid license entitling him to "practice as a pharmacist in the province".1 Student: A person enrolled as a student in a Faculty of Pharmacy at a University in Canada affiliated with the Association of Faculties of Pharmacy in Canada. Provisional Registrant: A person who is a member of the Faculty of Pharmaceutical Sciences at U . B . C , and who has pharmacy qualifications approved by the. College Council or its executive. Retired Register: Members of the College who have retired from Practice and maintain no annual license. No fee is paid for this registration. Non-Practising Membership: This category is similar to the Retired Register in that members are not entitled to practise. An annual fee entitles the member to informational mailings from the College. Honorary Membership: This register is composed of selected persons who have rendered distinguished service to the profession of pharmacy or who have maintained 50 years of continuous registration with the College. Only persons actually qualified under the Pharmacy Act may vote or practice. Pharmacy Act, 1974 125 Table 6.1-1 shows the annual membership totals for the College of Pharmacists of B.C. for the period 1971 to 1977. The PHARMFILE registration totals by sex for 1974 - 1977 are shown in Table 6.1-2, and an estimate of PHARMFILE mid-year registration is shown in Table 6.1-3 for the same period. Table 6.1-1 Registration Statistics of the College of Pharmacists of B.C. 1971 - 1978 (February 28 year end) 1971 1972 1973 1974 1975 1976 1977 1978 Practising 1302 1338 1356 1394 1461 1672 1663. . 1731. Honorary 56 53 59 49 58 62 65 68 Provisional — — — - — 5 5 9 Total from Previous Year 1358 1391 1415 1443 1519 1634 1733 1808 U.B.C. New 30 34 51 71 87 90 90 79 Out of Prov. New 46 41 26 30 38 50 27 16 Total Practising 1434 1466 1492 1544 1644 1779 1850 1903 Non-Practising 99 113 124 139 148 124 112 113 Total Members 1533 1579 1616 1683 1792 1903 1962 2016 Source: College of Pharmacists of B.C. , Registrar's Statistical Report..' 126 Table 6.1-2 PHARMFILE Practising Pharmacist Totals September 1974 - 1977; Showing Number of Male and Female Pharmacists Male Fema1e Total 1974 1188 401 1589 1975 1283 448 1731 1976 1329 499 1828 1977 1344 535 1879 Source: PHARMFILE Table 6.1-3 PHARMFILE : Estimates of Midyear Register Totals 1974 - 1977 Male Female Total 1974 - 1975 1236 425 1660 1975 - 1976 1306 474 1780 1976 - 1977 1337 517 1854 Source: PHARMFILE Findings The "active membership" of the College of Pharmacists are those pharmacists holding current pharmacist licenses and includes qualified honorary members and provisional members. Parameter Estimation The Registrar's audited "total practising" membership of 1903 as of February 28, 1978 will be used as the base for the forecasting period 1978 to 1990. 127 The PHARMFILE totals and mid-year approximations will be used in estimating the parameters such as deaths, retirements, and return to practise which cannot be broken out of the College audited totals. 6.2. Appendix 2: U.B.C. Enrolment: Second Year While some students choose to enter the first year of Pharmaceutical Sciences, about one-half of the entrants come into the faculty with more advanced standing and are admitted as second year students. It is the policy of the faculty to accept all qualified B.C. students on the basis of academic standing, and to reserve ten percent of places for non- B.C. residents. Table 6.2-1, shows the second year enrolment for the period 1970-1978. Table 6.2-1 Number of Students Enrolled in Second Year, Faculty of Pharmaceutical Sciences, 1970-1978 Year # Students 1970 69 1971 94 1972 90 1973 101 1974 102 1975 125 1976 119 1977 115 1978 115* Source: Dean B.E. Riedel, Annual Reports of the Faculty of Pharmaceutical Sciences to the College of Pharmacists of B.C. *Dr. F.A. Morrison, Assoc. Dean 128 Findings Between 1970 and 1974 the Faculty of Pharmaceutical Sciences was "breaking-in" its revitalized undergraduate curriculum, and expanding its student enrolment. During these years new students were admitted to the f irst , second or third year of the programme depending on the extent and content of their previous university education. In 1975 direct admission to third year was discontinued because of time table conflicts and budget restrictions. There are s t i l l two admission year choices for pharmacy students, but all students must spend at least three undergraduate years in the faculty. This type of admission policy makes it somewhat difficult to gauge an exact "plant capacity" for second year, but i t appears to be in the range of 125 students. This capacity was reached in 1975, when there were more qualified applicants than places. The main source of excess student demand has been from Ontario students. Since 1976 when 119 students were registered in second year all qualified B.C. applicants have obtained places. As of October 2, 1978 the number of students enrolled was 115. This total does not tally with the 123 reported for October by the U.B.C. Registrar. Predictions of future enrolment were prepared in February 1978 by the University forecasting office from official registration data for a three year period. These 129 predictions were for 123 second year students in 1978 and 125 in the two years to 1980. No detailed projections of enrolment have been made beyond 1980. Parameter Estimation For the purposes of estimating the second year enrolment for each year of the forecasting period two enrolment levels have been used. 1. High Demand =118 This is the average of enrolment reported by the Faculty of Pharmaceutical Sciences for 1975 - 1978, and represents student demand at or near "plant capacity". The estimate has been set slightly below capacity because not all students who are accepted in the faculty will actually register. 2. Low Demand = 100 The number of persons age 19 to 24 in the population in Canada and B.C. is expected to peak and then decline slightly in the early 1980's. A reduction in the numbers of school aged children, the result of a falling birth rate has already had an impact on the public school system in B.C. The decline in demand for university education will not be dramatic, nor will i t occur evenly across all schools. Enrolment 130 would be expected to continue to be at "plant capacity" in medicine and dentistry. These small prestige programmes have reliably attracted student applications far in excess of the number of places available. Though the capacity of the Faculty of Medicine at U.B.C. has recently been enlarged some level of excess demand will continue. Both medicine and dentistry have attracted students and-graduates from Pharmaceutical Sciences, and there are transfers to these schools in most years. The increase in enrolment in medicine will not affect the number of young students who enter pharmacy: these persons would not be eligible to apply to medicine (or dentistry) in any case. However, the expansion of the medical class at the university could reduce the demand among more advanced students/for whom pharmacy is a second choice. The precedent for decreased levels of demand for pharmacy education exists at U . B . C ; moreover this occurred during a period of increasing enrolment across the entire institution, and appeared to affect mainly the male student demand. No precise estimate can be made of a level of enrolment which would represent a reduced student demand. An estimate of 100 has been chosen arbitrarily. This figure is 15 percent below the recent high demand average, and is close to the enrolment level experienced in 1973 and 1974 immediately prior to the peak demand year of 1975. 131 6.3 Appendix 3: Attrition: Second to Third Year Since 1975 there has been no direct admission of new students to third year. Thus the third year population is entirely composed of survivors from second year plus those few students who repeat third year. Table 6.3-1 shows second year enrolments since 1974 and the number of students who subsequently enrolled in third year. The data includes repeating students in the class totals. Table 6.3-1 Number of Students Enrolled in Third Year, Faculty of Pharmaceutical Sciences, 1974-1978; Showing Number and Percentage Attrition from Second Year. Year of admission Attrition second year # 2nd year # 3rd year # % 1974 102 83 19 18.6 1975 125 106 19 15.2 1976 119 87 32 26.9 1977 115 87* 18 24.3 Source: Dean B.E. Riedel, Annual Reports of the Faculty of Pharmaceutical Sciences to the College of Pharmacists of B.C. * Dr. F.A. Morrison, Assoc. Dean Findings Between 1975 and 1978 the percentage of students who did not return for third year ranged between 15.2 and 26.9 percent. It is important to note the break in the data involving the two student cohorts admitted in 1976 and 1977. Prior to this the average rate of non-return for second year students was 16.9 percent, but since 1976 this 132 rate has averaged 25.6 percent. Non-return has two components: the first is voluntary withdrawal of students who have reconsidered their choice of career training. The second component is forced withdrawal due to students being unable to meet performance standards set by the school. Increases in failure are a likely consequence of admission of lesser qualified students or of rising performance standards. Since 1976 the Faculty of Pharmaceutical Sciences has imposed new regulations pertaining to student advancement, so it is likely that the increased attrition between second and third year is not a reflection on the quality of the students recruited, but the effect of more stringent standards of advancement. Parameter Estimation For the purposes of estimating the number of students who will not return for third year an attrition rate of 25 percent will be applied to the estimates of second year enrolment for each year of the fore-casting period. It is recognized that the use of an average based on just two years of experience is not without risk for forecasting. However, the range has been small and the policy involved appears to be one that is ongoing. 133 6.4 Forecasting Appendix 4: Attrition: Third to Fourth Year In a professional school the main losses would be expected at the beginning of the training period, with only minimum attrition expected in the final years. By the third year of Pharmaceutical Sciences a student has a large investment in education and is undoubtedly quite looking forward to the final year with its clinical component. For their part, the faculty too has an investment in students at this stage, and would be likely to encourage a student to successful completion. Table 6.4-1 shows third year enrolments since 1971 and the number of students who subsequently enrolled in fourth year. The data includes repeating students in the class totals. Table 6.4-1 Number of Students Enrolled in Fourth Year, Faculty of Pharmaceutical Sciences 1971-1978 showing number and percentage attrition from third year. Year # Third Year # Fourth Year Attrition 1971 55 48 7 10.4 1972 78 75 3 3.8 1973 94 92 2 2.1 1974 94 94 0 0.0 1975 99 95 4 3.0 1976 83 80 3 3.6 1977 106 98 8 7.5 1978 87 87* 0 0.0 Source: Dean B.E. Riedel, Annual Reports of the Faculty of Pharmaceutical Sciences to the College of Pharmacists of B.C. * Dr. F.A. Morrison, Assoc. Dean 134 Findings Between 1971 and 1978 the attrition rate from third to fourth year ranged from zero to 10.4 percent with no apparent trend. Of a total of 696 third year students enrolled in this period 27 did not return for fourth year for an average attrition rate of 3.9 percent. Among students who returned in 1977 and 1978 under the new failure policy there is no evidence of any pattern. Eight students did not return in 1977, but in 1978 no students failed to return. The average'based on these two years alone is 4.1 percent. Parameter Estimation For the purposes of estimating the number of students who will not return for fourth year a 4.0 percent loss will be applied to the number of students enrolled in third year for each year of the forecasting period. This has been derived from combining the average for the entire period with that experienced in 1977-78. 6.5 Forecasting Appendix 5: Attrition: Fourth Year to Graduation Since 1971 the fourth year of the Pharmaceutical Sciences curriculum has consisted of a compressed academic load combined with designated blocks of clinical practice. The students are rotated through this orientation to practice and all gain experience in several types of pharmacy settings. 135 Table 6.5-1 Number of Bachelor of Science (Pharm.) Degrees Conferred at U .B .C. , 1972 - 1978; Showing Number and Percentage Attrition from Fourth Year Year # Fourth Year Graduated Attrition # % 1972 48 47 1 2.1 1973 75 71 4 5.3 1974 92 88 4 4.3 1975 94 93 1 1.1 1976 95 92 3 3.2 1977 80 80 0 0.0 1978 98 97* 1 1.0 Source: U.B.C. Calendar * Dr. F.A. Morrison, Assoc. Dean (This total is to June 1978) Findings Of a total of 568 students enrolled in fourth year between 1972 and 1978, there has been a loss of 14 students or 2.5 per cent. This loss has varied between zero to a high of 5.3 per cent, with the highest rates of loss occurring in 1973 and 1974. In the four year period since 1975 there have been just five fourth year students who did not receive degrees. This rate of attrition is 1.4 per cent. Parameter Estimation For the purposes of estimating the number of students who will receive degrees a 2.0 per cent rate of loss will be applied to the fourth year enrolment for each year of the forecasting period. This is an average of the 2.5 per cent attrition which occurred during 1972 to 1978, and the more recent loss rate of 1.4 per cent experienced since 1975. 136 6.6 Forecasting Appendix 6: New Registration: U.B.C. Graduates A period of internship is no longer demanded of new U.B.C. graduates, but all are required to be examined by a panel of practising pharmacists before first licensing. Since 1974 i t has been College policy to deny licensed status i f the Panel Examinations have been failed on five occasions, i f more than one year has elapsed since graduation, or i f English language proficiency cannot be demonstrated. Table shows the number of U.B.C. graduates for the years 1973 - 1977. They are recorded as licensed in the period 1974-1978 because the College year end is the last day of1 February. Table 6.6-1 Annual Number of U.B.C graduates Newly Licensed by the College of Pharmacists of B.C. , 1974-1978; Showing number and Percentage Attrition from Number Graduated. Year # Graduates* # New U.B.C. + Loss previous year 1 icensed # %_ 1974 71 71 0 0 1975 88 87 1 1.1 1976 93 90 3 3.2 1977 92 90 2 2.2 1978 88 79 1 1.1 Source: * U . B . C , Calendar + College of Pharmacists of B.C. , Registrar's Statistical Reports Findings Between 1973 and 1977 there were 424 U.B.C.graduates from the 137 Faculty of Pharmaceutical Sciences. Of these just 7 or 1.65 percent did not go on to obtain licensed status with the College of Pharmacists of B.C. While the number of unlicensed graduates has varied from none in 1974 to 3 in 1976 there is no evidence of trend. Parameter Estimation For the purposes of estimating the number of U.B.C. graduates who will obtain licensed status with the College of Pharmacists an attrition rate of 1.65 per cent of graduates will be assumed for each year of the forecasting period. 6.7 Appendix 7: New Registration: Out-of- Province Graduates In addition to the new entrants to the profession provided by the province's training school, there are a number of pharmacists who relocate in this province.. Table 6.7-1, shows the annual number who have entered B.C. from elsewhere during the period February 28, 1971 to February 28, 1978. Table 6.7-2 breaks down similar data from 1960 to show whether 2 these pharmacists came from other provinces or from outside Canada. Slightly different totals are presented but the overall pattern is not likely disrupted. 138 Table 6.7-1 Annual Number of Out-of-Province new Registrants with the College of Pharmacists of B.C. 1971-1978. Year # New Registrants 1971 46 1972 41 1973 26 1974 30 1975 38 1976 50 1977 27 1978 16 Source: College of Pharmacists of B.C. Registrar's Statistical Report. Table 7.6-2 Annual Number of Out-of-Province New Registrants with the College of Pharmacists of B.C. , 1960-1977; showing place of training of pharmacist Year Canada Outside Canada Total # % # % 1960 15 93.8 1 6.2 16 1961 15 100.0 0 0 15 1962 12 100.0 0 0 12 1963 13 86.7 2 13.3 15 1964 15 93.8 1 6.2 16 1965 16 100.0 0 0 16 1966' 22 91.7 2 8.3 24 1967 15 88.2 2 11.8 17 1968 33 89.2 4 10.8 37 1969 30 66.7 15 33.3 45 1970 35 76.1 11 23.9 46 1971 38 82.6 8 17.4 46 1972 20 76.9 6 23.1 26 1973 25 83.3 5 16.7 30 1974 34 91.9 3 8.1 37 1975 27 81.8 6 18.2 33 1976 42 76.4 13 23.6 55 1977 14 56.0 11 44.0 25 Source: College of Pharmacists of B.C. , Annual Reports  1976-1977 p, 69. 139 Findings The audited registration totals of the College (Table 6.7-1) are undoubtedly the more correct source of .the total numbers of outside graduates who have entered B.C. in recent years. Between 1971 and 1978 the average annual number of entrants was 34.25 with l i t t l e evidence of trend. However, two sharp breaks in the data are important to note. These are the reduced numbers entering for the years ended in February 1973 (26 registrations) and 1977 (27 registrations). It is considered that these reductions were a result of the business recession of 1970-71, and the more current one which began to be felt in the last half of 1975. A further reduction of entrants to just 16 is reported for the year ended February 28, 1978. This decrease likely reflects recent efforts of the Registrar of the College to caution prospective entrants to be assured of employment before they entered the province. The increase to 50 persons for the year end of February 1976 is most probably attributable to provincial government policies developed during 1973 and 1974. These policies of expansion of health care service resulted in an increase in the number of hospital pharmacies and the introduction of the Pharmacare programme. Table 6.7-2 shows the source of new entrants to the province since 1960 and indicates that graduates from outside Canada have 140 formed a larger proportion of entrants to B.C. since 1969 than they did in the previous decade. Between 1960 and 1968 just 12 or 7.14 percent of the 168 new entrants were from outside Canada. Between 1969 and 1977 theere were 78 or 22.7 percent non-Canadian trained pharmacists among the 343 new entrants. This increase in foreign trained entrants may have been a result of the adoption of the P.E.B.C. examination as the main criterion for acceptance of graduates. While the provincial credential 1ing process may be simpler for non-Canadian pharmacists, federal immigration law and policies have undergone recent changes which make the immigration of all foreigners more difficult. This will likely reduce the number of pharmacists entering Canada. Parameter Estimation For the purposes of estimating the number of pharmacists who will relocate in B.C. for each year of the forecasting period the effect of zero entrants, 20 entrants and 30 entrants will be used. 1. Zero Out-of-Province Entrants It is unrealistic to expect that no out-of-province registration will occur during the forecasting period, and a prohibition of such registration would violate the expectation of a professional that his/her skills are portable within the country. However, the assumption of zero entrants will be used to test the growth.that might be provided by the in-province training programme alone. 141 2. Twenty Out-of-Province Entrants During 1977 and 1978 there were sharp reductions in the numbers of entrants from the overall average of 34.25 between 1971 and 1978. The average for these last two years was 21.5 persons. A level in the range of 20 annual entrants has not been experienced in B.C. since the mid-19601s. However, at that time there were fewer local graduates to compete for entry positions. Obviously, those out-of-province pharmacists who can claim specialized training, a high level of experience or investment capital will continue to compete successfully for some positions in the province. Twenty out-of-province entrants has been chosen to reflect increased and successful competition for positions by U.B.C. graduates, and to reflect a likely decrease in the number of pharmacists who will enter Canada. 3. Thirty Out-of-Province Entrants While changes in immigration law will likely reduce the total number of pharmacists who enter B.C. , the magnitude of this change cannot be estimated with any degree of precision. In arriving at an estimate of 30 entrants the average of 34.25 for the period 1971-78 was reduced by approximately 10 percent to allow for immigration losses. This level of entrants assumes the willingness of out-of-province pharmacists to compete with the local graduates for entry 142 positions. 6.8 Appendix 8: Attrition from the Profession: Withdrawal from Active Status  The Pharmacy Act (1974) requires that a member, upon ceasing to practice place his/her name on the retired l i s t . There is however, no definition of "practice" in the act, and this requirement is not enforced. Withdrawals from active licensing normally take place voluntarily because of permanent retirement due to age, temporary withdrawal from practice, or relicensing in another jurisdiction (though dual licensing likely does occur). The Registrar's statistical report to the College each year shows just one total: the number of renewed licenses. No separation is made to indicate retirements, deaths or reactivation of licensing. This is illustrated in Table 6.8-1 for the period 1971-1978. Table 6.8-2 fromthe PHARMFILE system shows the number of withdrawals for the period of September 1974 to 1977 among male and female pharmacists. These are broken down further to show age distributions in Table 6.8-3, 6.8-4 and 6.8-5. 143 Table 6.8-1 Number arid Percentage of Non-renewals for All Causes Among Active Pharmacists February 1971 - 1978 * Year Total Practising # non Renewals % non Renewal 1971 1434 1972 1466 1973 1492 1974 1544 1975 1644 1976 1779 1977 1850 1978 1903 43 3.00 51 3.48 49 3.28 25 1.62 10 0.61 46 2.59 42 2.27 Source: College of Pharmacists of B.C. , Registrar's Statistical Reports Table 6.8-2 Number and Percentage of Withdrawals Among Active Pharmacists Sept. 1974 - 1977, Showing Sex of Pharmacists. Year # Ret Male #Reg °k t Female # Ret. # Reg. % # Ret Total # Reg % 74-75 23 1236 1. 86 14 425 3. 29 37 1660 2.73 75-76 41 1306 3. 14 13 474 2. 95 54 1780 2.03 76-77 38 1337 2. 84 26 517 5. 03 64 1854 3.45 Total 102 53 155 Mean 34 1286 2. 64 17.7 471 3. 76 51.7 1757 2.94 Source: PHARMFILE Table 6.8-3 Number of Withdrawals Among Male Pharmacists Sept. 1974 - 1977 Showing Age of Pharmacists. Year ?34 35-44 45-54 55-65 65+ Unkn Total 74- 75 1 2 2 6 IT. 1 23 75- 76 6 2 3 8 19 3 41 76- 77 11 5 2 2 11 7 38 Source: PHARMFILE * This total does not reflect true attrition from the profession because it contains reactivations 144 Table 6.8-4 Number of Withdrawals Among Female Pharmacists September- 1974 - 1977 Showing Age of Pharmacists Year -34 35-44 45-54 55-64 65+ Unkn Total 74-75 7 3 2 1 1 0 . 14 75-76 9 1 1 0 1 1 13 76-77 19 4 0 2 1 0 -26 11] Source: PHARMFILE Table 6.8-5 Number of Withdrawals Among Pharmacists in Two Age Categories, Sept. 1974-1977; Showing Percentage of Mid-year Register Retirement to age 34 Retirement 35+ Total Year # % % # % 74-75 8 0.48 29 1.75 37 2.23 75-76 15 0.84 39 2.19 54 3.03 76-77 30 1.62 34 1.83 64 3.45 Source: PHARMFILE Findings The number arid percentage of non-renewals as shown in the Registrar's statistical reports is a measure of "crude attrition" and shows no stability during the period 1971 - 1978. It must be noted that these figures include re-entry into the profession and cannot be used as a true measure of withdrawal. A more accurate estimation lies in the PHARMFILE data. Table 6.8-2, shows that the total number of withdrawals from practice increased substantially between 1974 and 1977. As well as the increase in the number of withdrawals there was growth in the overall percentage withdrawals from 2.23 percent to 3.45 percent. 145 In Table 6.8-3 and 6.8-4 the PHARMFILE data is further broken down to show the age of male and female pharmacists who have withdrawn from practice since September 1974. Table 6.8-3 shows that there was an increase in retirements of men age 55 and over between 1975 and 1976. While some of these may have been delayed from the period surrounding passage of the Pharmacy Act, an increase in the annual licensing fees as of March 1975 was a likely factor in influencing those persons who were at normal retirement age to withdraw from active status. More importantly the trend to withdrawal by pharmacists who are under age 35 should be noted. Some withdrawal of persons in this age group would be expected due to migration to other provinces, actual career change, and pressure of family responsibilities on women. However between 1976 and 1977 the number of withdrawals in this age group (and for both sexes) essentially doubled from 15 to 30 as is shown in Table 6.8-3 and 6.8-4. Table 6.8-5 shows that it is these withdrawals that have been the main factor in the increasing retirement rate for the period 1974-77. Parameter Estimation For the purposes of estimating the number of persons who will withdraw from active status in each year of the forecasting period two estimates of loss will be used. These rates are based on the highs and lows of withdrawal experienced between 1974-1977. Both contain what are admittedly intuitive type assumptions of withdrawal of young 146 pharmacists, and could likely be improved by more rigorous treatment of the data on an age and sex specific basis. 1. Low Withdrawal =2.5 percent This rate of withdrawal is a close reflection of the experience of 1974 - 1976 and assumes few losses of young pharmacists. 2. High Withdrawal ='3.5 percent This rate of withdrawal reflects that experienced in 1976-1977 and assumes considerable loss among young pharmacists. This type of loss would be likely under conditions of high rates of growth in the profession and restricted employment opportunity which would encourage migration to other areas or actual career change. 6.9 Forecasting Appendix 9: Attrition From the Profession: Deaths of Active Members  Each year the names of deceased College members are announced by the Registrar at the Annual General Meeting, and are recorded in the Minutes. The l i s t is prepared on an "ever registered" basis and does not differentiate between currently licensed and non-practising members. It has been possible to obtain the number of deaths among active members from the PHARMFILE tapes. The annual number for the period 1974 to 1977 is shown in Table 6.9-1 . 147 Table 6.9-1 Annual Number of Deaths of Actively Licensed Pharmacists, September 1974 - 1977; Showing Percentage of Mid Year Register. Year Mid-year Register # Deaths %_ 74- 75 1660 5 0.30 75- 76 1780 10 0.56 76- 77 1854 13 0.70 Findings The Annual General Meeting l i s t of pharmacist deaths is not suitable for forecasting, though i t could be modified quite readily to separate active from retired member deaths. Table 6.9-1 indicates that there has been both an increase in number and percentage of deaths among active members between 1974 and 1977. The numbers are however, small; and i t is unlikely that they represent any reliable trend, because it is known that the age structure of the profession has lowered during the same period. For the purposes of estimating deaths among active members an average rate was deemed most suitable. This then yielded the following estimate: R . _ Mean Deaths _ 9.33 x 100 = 0.53 percent of active register K a t e Mean Register 1757 This was rounded to 0.5 percent for the actual estimates. 6.10 Forecasting Appendix 10: Reactivation of Licence, The Pharmacy Act (1974) provides an incentive for pharmacists 148 to maintain active licensing status, or at least to resume active status before two years have elapsed, in order to avoid re-examination and/or retraining processes. Table 6.10-1 shows the annual number of reactivations during the period September 1974 to 1977, though the total for 1974 is likely understated. Twelve of the new registrations for that year showed evidence of previous College membership, and while they were classed as "new" to the PHARMFILE system they were likely "old" in terms of previous registration with the College before computerization of the register. A larger number of reactivations would be expected in 1974-75 because of the introduction and passage of the new Pharmacy Act. The numbers of persons less clearly identified as reactivations are shown in brackets in Table 6.10-1. Table 6.10-1 Annual Number of Reactivations of Licensed Status, September 1974 - 1977; Showing Sex of Pharmacist. Year Male Female Total 74- 75 18 (10) 7 (2) 25 (12) 75- 76 14 9 23 76- 77 11 11 22 Source: PHARMFILE 149 Table 6.TO-2 Total Number of Relicensed Pharmacists, September 1974 - 1977; Showing Age and Sex of Pharmacist Male Female Total To age 39 8 22 24 Age 40+ 32 5 43 Unkn 3 0 3_ 43 27 70 Source: PHARMFILE Table 6.10-3 Number arid.Percentage of Relicensed Pharmacists Reporting Pharmacy Employment, September 1974-75; Showing Sex of Pharmacist. Male Female Total Reactive 43 27 70 Employed 22 22 44 % Employed 51.2 81.5 62.9 Source: PHARMFILE Findings Table 6.10-2 which breaks down the total annual reactivations to show the age and sex of pharmacists indicates that there were two different demands for reactivation between 1974 and 1977. Among men 32 of 43 pharmacists or 74.4 percent were known to be age 40 or over. For women this pattern was the reverse: 22 of 27 female reactivations or 81.5 percent were age 39 or under. Table 6.10-3 shows the number of pharmacists reporting "pharmacy employed" status for the year of reactivation, and indicates that a higher percentage of women returned to the labour force. 150 The number of reactivations among male pharmacists has decreased between 1975 and 1977 indicating that reactivation prompted by the new Pharmacy Act is now complete. Parameter Estimation There are large numbers of young women entering the profession many of whom will face the extra pressures of childbirth and family formation which will cause them to withdraw from the profession on a temporary basis. For the purpose of estimating the number of pharmacists who will reactivate their qualifications it is considered that the female demand will likely continue at a similar rate. It is more difficult to estimate the future demand among males, but i t is considered that .the number will decrease because of the incentives built into the new legislation. For this reason it is thought that the current level will likely remain, and an estimate of 20 reactivations will be used for each year of the forecasting period. 151 PART III: THE PHARMACIST SURVEY INTRODUCTION The preceding two sections have involved first,an overview of the background to the recent high rates of growth in the profession as well as a description of the pharmacist register in B.C. Secondly, a component analysis method has been developed to aid in projecting future growth of the pharmacist supply. Considerable data on manpower supply had been accumulated by the Faculty of Pharmaceutical Sciences and the College of Pharmacists, over a period of years which made i t valuable forrestimating trend. There has however, been very limited information collected concerning the system of pharmacy practice in B.C. and its capacity to absorb the labour stock. Certainly the number of licensed pharmacy outlets has been regularly logged by the College, and in recent years the hours and weeks worked by pharmacists in these settings has been collected. However, there has not been any systematic way of recording how many prescriptions, or what auxiliary services have been provided by those pharmacies, nor has there been any information concerning what productivity or service target measures have been applied to pharmacists. The questions which have arisen fall into two main groups: 1. The current manpower and employment concerns 152 2. The system of pharmacy practice (a) Community practice (b) Institutional practice This section will deal primarily with the response to a survey of in-province resident pharmacists, which was designed to provide quite basic descriptive about pharmacy practice and pharmacist employment in 1977 and 1978. The survey mailing which included all 1717 B.C. resident pharmacists, went into the field on April 18, 1978, and drew 1343 useable returns for a response rate of 78.2 per cent. (Appendix A) Clearly there'is almost nothing in the way of trend information in this material; thus there can be no quantitative projections for future practice based on the survey data. Where practical there will be a discussion following each section on the likely implications of the findings. 153 CHAPTER 7: THE CURRENT MANPOWER CONCERNS 7.1. Unemployment and Underemployment During 1976 and 1977 considerable pressure had been put on the B.C. Pharmacists' Society placement service by young graduates looking for full time employment. However, there was l i t t l e information to indicate how many people were affected, or whether they were conducting job searches from employed or non-employed status. An effort was made in the survey to obtain data concerning the number of persons who had experienced unemployment in 1977 and also the number who were unemployed or marginally employed .at the time of the survey in 1978. The survey period (April 18 to May 30, 1978) was considered to be relatively neutral, though perhaps slightly biased to a low current unemployment rate. The membership l i s t had just been updated to reflect the withdrawals and retirements of the past fiscal period, and the 1977 graduates had had more than six months in the profession since first registration to search for positions. It was thought that there would be l i t t l e extra demand during the survey period for pharmacists to f i l l :holiday relief positions. In the following sections employment/unemployment data were examined for the total survey response to provide a general overview, and to establish a reasonable estimate of an unemployment rate. Secondly, the data of 1977 unemployment were disaggregated to determine which groups of pharmacists had experienced employment problems. 154 Because there were specific concerns for the employment difficulties of recent U.B.C. graduates, separate tables have been provided within the following sections to provide more details of their absorption into the system. A short statement of findings follows. 7.11 Employment/Unemployment: 1978 From Table 7.1 - 1 it canibe seen 1195 persons or 89.0 percent of the 1343 survey respondents were currently employed in some type of pharmacy practice. Table 7 . 1 - 1 Employment Status Reported by Respondents to B.C.Ph.S. Survey, 1978 Employed in pharmacy 1195 89.0 Employed outside of pharmacy 26 1.9 Not employed 63 4.7 Retired 39 2.9 Semi-retired 15 1.1 Not stated 5 0.4 1343 100.0 While there were 63 pharmacists or 4.7 percent of respondents who indicated that they were "not employed", this response should not be considered as "active unemployment", which according to a strict Canada Employment and Immigraiton Commission (CEIC) definition would require a persion to actually seek employment. 155 Active unemployment for 1978 is detailed more specifically in Table 7.1-2. Of the 127 persons who indicated that they were not in current practice, 34 or 2.5 per cent of the total number of respondents stated that they had made efforts to seek pharmacy employment within the past three months. Of this group of 34 persons, there were 12 or 35.3 per cent who had sought employment "in areas which would involve relocation." Table 7.1-2 Number of Not Employed Pharmacists Reporting Efforts "Within Last Three Months" to Return to Pharmacy Employment, 1978 Return not considered 64 Considered, no efforts 29 Efforts in own area 22 Efforts to relocate 12 127 A less stringent definition of unemployment would include at least some of the 29 persons who had considered returning to practice but had not sought employment. Together with the core group of 34 actual "seekers" this would indicate a maximum unemployment level of 4.7 per cent. 156 7.12 Part Time Employment Choices: 1978 Those pharmacists in active practice were asked to report their level of employment, with the 35 hour work week and 48 week year defining full time participation. Table 7.1-3 shows that just over one quarter of all pharmacists classed their situations as part time. Table 7.1-3 Level of Employment Reported by Respondents in Active Pharmacy (and related) practice, 1978 # % Full time 899 74.2 Part time 313 25.8 1212 100.0 157 The majority of persons reporting part time work indicated that they had a regular but short work week as is shown in Table 7.1 - 4 Table 7.1-4 Pattern of Part Time Employment Reported by B.C. Pharmacists, 1978 # % Short work week 283 86.3 Few weeks per year 45 13.7 328 100.0 Of the respondents who were in part time situations just over three quarters indicated that they had freely chosen this type of work pattern. However Table 7.1-5 shows that for 79 persons or 5.9 percent of the total of 1343 respondents, part time work was a "no choice" situation, and of this group 44 or 55.7 percent expressed willingness to consider relocation for full time employment. Table 7.1-5 Number of Pharmacists Reporting Choice/ No Choice in part time employment # % Part time chosen 252 76.1 No choice 79_ 23.9 331 100.0 7.13 Unemployment!:. 1977 There were 167 pharmacists or 12.4 percent of respondents who reported that they had spent one or more weeks during 1977 "out of work and seeking pharmacy employment". The total number of 158 unemployment weeks reported was 2725 and on the basis of a 48 week employment year this represents a loss of 57 full time pharmacist equivalents. The average number of unemployed weeks was 16.3 per person: though the range was between 1 and 52 weeks. From Table 7.1-6 i t can be seen that 69 persons or 5.1 percent of all respondents were out of the labour force for 14 or more weeks, a period which would have clearly involved them with the CEIC unemployment insurance programme, depending, of course, on their e l igibi l i ty . Table 7.1-6 Number of Pharmacists Reporting Weeks of Unemployment in 1977; Showing Duration of Unemployment Unemployment Weeks # % 1 - 6 54 32.3 7 - 13 44 26.3 14 - 26 41 24.6 27 - 52 28 16.8 167 100.0 It is of l i t t l e comfort to the unemployed pharmacist to inform him that the "average" duration of unemployment in 1977 was 16.3 weeks. Nor does this statistic provide much help to labour force planners. In this section more detail will be provided of the characteristics of the 167 pharmacists who stated that they had spent actively unemployed weeks in 1977. 159 Table 7 . 1 - 7 Number and Percentage of Pharmacists Reporting Weeks of Unemployment in 1977; Showing Sex of Pharmacist Total Unemployed Sex Response # % Male 941 101 10.7 Female 400 66 16.5 N/S 2 -- — TOTAL 1343 167 12.4 Table 7 . 1 - 7 and 7 . 1 - 8 provide information of the sex and age of persons who reported time out of employment. While Table 7.1-7 indicates that a higher percentage of women than men reported weeks out of the labour force, any conclusions that these women faced discrimination, must be tempered with the realization that the age distribution of female pharmacists is much younger than that of the male 1icenseholders. Table 7.1-8 Number and Percentage of Pharmacists Reporting Weeks of Unemployment in 1977, Showing Age of Pharmacist Age Total Unemployed Response # % _ 24 65 26 40.0 25 - 29 281 67 23.8 30 - 34 157 12 7.6 35 - 44 256 13 5.1 45 - 54 244 18 7.4 55 - 64 206 17 8.3 65+ 130 11 10.8 N/S 4 — — 1343 167 12.4 160 From Table 7.1-8 it can be seen that the reporting of un-employment'Was highest among pharmacists who were under age 30 years. Of 65 persons who were age 24 or less, 26 or 40 per cent had some unemployment in 1977, and among those who were age 25 to 29 there were 65 of of 281 or 23.8 percent had spent some weeks unemployed and seeking pharmacy employment. The first major response to employment problems came in 1976 with the establishment of the B.C.Ph.S. Retail Opportunities Committee. Though the name of the committee was ultimately generalized to embrace broader manpower concerns; there was considerable unease about the employment situation in community pharmacy, especially in the Vancouver area. Table 7.1 - 9 Number and Percentage of Pharmacists Reporting Weeks of Unemployment in 1977; Showing Field of Practice Total Unemployed Response 2 0 Community 1071 140 13. 1 Hospital, Government 190 22 11. ,6 Other, N/S, retired 82 5 6. .1 1343 167 12. ,4 From Table 7.1-9 it would appear that there was l i t t l e difference in the percentage of persons reporting unemployment in the community and institutional fields of practice. Unfortunately, an awkward wording of the question dealing 161 with geographic distribution asked for "area of practice" rather than "area of practice or residence", with the result that some regional information is missing from Table 7.1-10. As well, some pharmacists, in an effort to protect their privacy, were unwilling to state their location in the province. S t i l l , the percentage of persons reporting unemployment was higher in Greater Vancouver, Lower Mainland and South Central Regions of B.C. Table 7.1-10 Number and Percentage of Pharmacists Reporting Weeks of Unemployment in 1977; Showing Geographic Region of Practice. Total Unemployed Area Response _# %_ 1. Capital 142 7 4.9 2. N. Island 98 8 8.2 * • Lower Mainland 114 15 13.2 4. Okanagan 148 20 13.5 5. Kootenays 55 1 1.8 6. Cariboo & Noth 90 8 8.9 * G.V.R.D. 635 94 22.9 N/S 61 14 22.9 1343 167 12.4 These areas include College Districts and B.C.Ph.S. Chapters 3, 7, 8, 9 7.14 Return to Employment In Table 7.1-11 the employment status as of the 1978 survey period is shown for the 167 persons who reported unemployment in 1977, and indicates that more than three quarters had found pharmacy employment. However, Table 7.1-12 indicates that 51 or 40.2 percent of the 127 who returned to the workforce had no choice but to accept 162 part time work. Table 7.1 - 11 Employment Status 1978.Reported by Respondents with Weeks of Unemployment in 1977 Status # % Employed in Pharmacy 127 76.0 Outside Pharmacy 2 1.2 Not employed 32 19.2 Retired 2 1.2 Semi-retired 3 1.8 Unknown 1 0.6 167 100.0 Table 7.1 - 12 Number of Pharmacists Reporting Choice/No Choice Part Time Employment 1978, Showing Number Reporting Weeks of Unemployment in 1977. Unemployed 1977 Not Unemployed Total Part time chosen 19 233 252 No Choice 51 28 79 70 261 331 7.15 The Recent U.B.C. Graduates: 1978 Status Because of the specific concerns for the employment of recent U.B.C. graduates, the responses of 243 persons who indicated that they had graduated from the 1974 - 1977 classes have been treated separately. The employment status of this group is shown in Table 7.1 - 13. As might be expected, because of their youth, there was a higher percentage of recent graduates in employment (94.2 percent), and also fewer (20.2 percent) in part time situations. 163 Table 7.1 - 13 Employment Status Reported by 1974-1977 UBC Graduate Respondents, 1978; Showing Year of Graduation 1974 1975 1976 1977 Total Employed Pharmacy 49 57 67 56 229 Outside pharmacy 1 1 1 3 Not Employed 2_ 2 2_ 5_ 11 52 .60 69 62 243 Except for the five persons from the 1977 class who reported "not employed" status l i t t l e evidence of any employment problem emerges from this data. However, when data concerning choice/no choice of part time employment are compared a disproportionately high number of recent graduates were in "no choice" part time employment. This is broken out more completely in Table 7.1 - 14, and indicates that recent graduates who comprised 18.1 percent of the survey response were in 32 of 79, or 40.5 percent of these marginal positions. The 1977 graduates were obviously facing the most difficulties, with all 16 persons who were in part time employment indicating that this was a-. Table 7.1 - 14 Number'and Percentage of Pharmacists Reporting Choice/No Choice Part Time Employment, 1978; Showing 1974 - 1977 UBC Graduates 1974-1977 Other Total # % # % # % Choice 17 34.7 235 83. 3 252 76.1 No choice 32 65.3 47 16. 7 79 23.9 49 100.0 282 100. 0 331 100.0 164 "no choice" situation. The complete employment status of the 1977 graduates is shown in Table 7.1 - 16. It indicates that after more than six months since first licensing 35.5 percent of the 1977 graduates had not been satisfactorily absorbed into the labour force. In fact the employment difficulties of this group may have been more severe than the data would indicate. Several of those reporting full pharmacy employment were in temporary hospital residency positions which were due to terminate at the end of the survey period. Table 7.1 - 15 Number of 1974 - 177 UBC Graduates Reporting Choice-No Choice of Part Time Employment; Showing Year of Graduation 1974 1975 1976 1977 Total Choice 7 5 5 0 17 No Choice 1 7 8 16 32 8 12 13 16 49 Table 7.1 - 16 Employment Status Reported by 1977 UBC Graduate Respondents, 1978. # % Employed pharmacy 40 64.5 Part time, no choice 16 25.8 Outside Pharmacy 1 1.6 Not employed 5_ 8.1 62 100.0 165 7.16 The Recent UBC Graduates: Unemployment 1977 Undoubtedly there:is more job mobility among young persons in the labour force, and the cost of job search may include a period of unemployment. Some problems for the 1977 graduates were not unanticipated by the B.C. Ph.S. placement information service or by the large employers. The last of the 1976 registrants were thought to be just settled into employment situations as the 1977 class was 1icensed. Table 7.1 - 17: Number and Percentage of UBC Graduate Respondents Reporting Weeks of Unemployment in 1977; Showing Year of Graduation Year of Graduation Total Response Unemployed # % 1949 - 58 252 13 5.2 1959 - 68 185 10 5.4 1969 - 73 151 16 10.6 1974 52 7 13.5 1975 60 14 23.3 1976 69 22 31.9 1977 62 37 59.7 831 119 14.3 Table 7.1 - 17 indicates that 37 or 59.7 percent of the 1977 graduate respondents spent one or more weeks unemployed and seeking employment in the months after graduation. However, i t is also important to note that the security of the 1975 and 1976 graduates was also questionable. This group of 129 pharmacists formed 9.6 percent of the survey response, but 36 or 27.9 percent reported unemployed weeks in 1977. 166 SUMMARY OF FINDINGS 1. As of April - May 1978 the rate of "active unemployment" among respondents was 2.5 percent 2. A less stringent definition of unemployment would include persons who had considered returning to the labour force, but had made no recent efforts to seek employment. This more inclusive measure of unemployment was 4.7 percent 3. In addition to those persons who were not employed there were 5.9 percent of respondents who had had no choice but to accept part time work. 4. Recent UBC graduates (1974 - 1977) comprised less than twenty percent of the response, yet they were bearing forty percent of the marginal "no choice" employment reported in the profession in 1978. 5. Over one-third of the 1977 UBC graduate respondents were not in full employment in their profession six months following 1icensing. 6. In 1977 there were 167 or 12.4 percent of respondents to the B.C.P.S. (1978) survey who spent, on average, 16.3 weeks out of the labour force seeking employment. 7. If the total of 2725 unemployed weeks is generalized from the survey response rate of 78.2 percent to the total .register, a calculation of 2725 - .782 = 3485 weeks can be made. Using a 48 to 52 week employment year, an estimate of unemployed pharmacist equivalents indicates a non-demanded surplus of 167 67 - 73 full time pharmacists in the province for 1977. 8. Two-thirds of those persons reporting unemployment were out of the labour force for periods longer than six weeks. 9. Among young pharmacists (under age 30) 37.8 percent reported weeks unemployed and seeking employment in 1977. Just 7.4 percent of older pharmacists reported unemployment during the year. 10. Forty percent of the 1977 UBC graduates were absorbed into employment with no apparent problem, but 59.7 percent indicated difficulties which cost them time (and money) after licensing. 168 7.2 Recent Demand for Pharmacists in B.C. In order to obtain a picture of recent demand for pharmacists, pharmacy managers were asked to indicate whether they had hired a pharmacist "during the past year". Some understatement of pharmacist hiring is obvious because there was no practical way to include the more diverse practice fields. Table 7.2-1: Number and Percentage of Pharmacy Managers Reporting Hiring a Pharmacist "During the Past Year," Showing Practice Field. Community Institution Total # % #. .% # % Yes 155 36.3 30 42.3 185 37.1 No 247 57.8 38 53.5 285 57.2 N/S 25 5.9 3 4.2 28 5.6 427 100.0 71 100.0 498 100.0 From Table 7.2-1 i t can be seen that 185 or 37.1 percent of managers reported hiring a pharmacist. In the 71 institutions there were 30 or 42.3 percent who reported hiring. While this is a slightly higher percentage than in community pharmacy, i t is likely that some of these managers included their hospital residents. This is actually a recurring a employment pattern for those institutions in B.C. which employ and train a total of 12 residents on a one year basis. The numbers of management and staff pharmacists hired as a result of business expansion, staff turnover and temporary needs are shown in Table 7.2-2 for community pharmacies and in Table 7.2-3 for institutional pharmacies. These data provide an indication of the 169 Table 7.2-2 Number of Pharmacists Hired "During the Past Year," Reported by Community Pharmacy Managers, 1978 Managers Staff Total % of total # employed (1026) Expansion 18 49 67 6.5 Replacement 36 85 121 11.8 Temporary 96 96 9.4 percentage of pharmacists who were in their positions for one year or less. While the incidence of temporary and replacement hiring was similar in both of the major fields, a comparison of the percentage of new positions, as shown in Table 7.2-4 indicates that despite provincial government policies to slow the growth of public subsidized employment there were 5 new management and 20 staff positions in insti-tutions. The percentage of expansion positions in institutional Table 7.2-3 Number of Pharmacists Hired "During the Past Year;" Reported by Institutional Pharmacy Managers, 1978 Managers Staff Total % of total # employed (191) Expansion 5 20 25 13.1 Replacement Temporary 9 16 25 13.1 18 18 9.4 pharmacies was 13.1 percent or double the 6.5 percent increase in positions which resulted from business expansion in community based outlets. Among managers it is likely that most of the positions were 170 full time; however no data were collected to indicate whether the new staff pharmacist positions were full time or part time. Table 7.2-4 Managers Staff Number of Pharmacists Hired for Business Expansion Positions "During the Past Year1 as Percentage of Total Employed, 1978; Shwoing Field of Practice. Community Total Employed Expansion 427 599 # 18 49 % 4.2 8.2 Institutions Total Employed Expansion # # % 71 120 5 20 7.0 16.7 Total 1026 67 6.5 191 25 13.1 171 SUMMARY OF FINDINGS 1. During 1977-78 more than one-third of community and institutional pharmacy managers reported that they had hired a pharmacist. 2. While there is no evidence of trend, the rate of expansion hiring in institutional pharmacies was twice that in community pharmacies in 1977-78 172 7.3 Staff Recruiting Problems While few full time positions for pharmacists have been advertised in the Lower Mainland area since 1976, there has been speculation that community pharmacies in more remote areas have experienced problems in recruiting staff. Pharmacy managers were asked i f they had had "any difficulty in finding a pharmacist" to f i l l a vacant position in the last year Table 7.3-1 Number and Percentage of Pharmacy Managers Reporting "Any Difficulty in Finding a Pharmacist" to Fi l l a Vacant Position in Last Year, Showing Practice Field Community Institutional Total # % # % # Difficult 24 19.7 3 12.5 27 18.5 Not difficult 98 80.3 21 87.5 119 81.5 122 100.0 . 24 100.0 146 100.0 There were 27 managers who reported problems in recruiting, and of these just three were institutional managers, all of whom were located in the south west quadrant of the province. Close to twenty percent of community pharmacy managers who responded to this question reported that they had had difficulty finding a pharmacist. Table 7.3-2 and 7.3-3 show this response by geographic location and by type of pharmacy organization. From Table 7.3-2 i t can be seen that of 49 managers who responded concerning the difficulty of hiring a pharmacist, only two in the Greater Vancouver Region had 173 Table 7.3-2 Number of Community Pharmacy Managers Reporting "any difficulty in Finding a Pharmacist" to Fi l l a Vacant Position in the Last Year, Showing Geographic Location 1978 Area Difficulty N/Difficult Total 1. Capital 3 10 13 2. N. Island & Coast 5 7 12 * Lower Mainland 2 8 10 4. South Central 2 16 18 5. Kootenay 2 3 5 6. Cariboo - North 7 4 11 * G.V.R.D. 2 47 49 Not stated 1 3 4 24 98 122 includes College Districts and BCPS Chapters 3,7,8,9 experienced problems. However, 12 of 23 managers or 52.2 percent of respondents from the North Island-Central Coast and Cariboo-North indicated that there had been some problems in recruiting. These areas correspond to College Districts and B.C.P.S. Chapters 2 and 6. Table 7.3-3 Number of Community Pharmacy Managers Reporting "Any Difficulty in Finding a Pharmacist" to f i l l a vacant position in the last year; showing type of pharmacy organization, 1978. Pharmacy Type Difficult N/Difficult Total Owner operated 20 54 74 Chain 3 29 32 Prescription Spec. 0 8 8 Department Store 1 7 8 24 98 122 It is also important to note that 20 of the 24 community pharmacy managers who had difficulty in hiring a pharmacist were owner-operators as is shown in Table 7.3-3. These people would be 174 more likely than chain managers to be hiring their own temporary relief staff and, as was shown in Table 7.2-2, of the 230 staff pharmacist hi rings 96 or 41.7 percent involved temporary staff. 175 SUMMARY OF FINDINGS 1 . More than half of the 23 Northern B.C. community pharmacy managers who reported on recent hiring indicated that they had had some difficulty in finding a pharmacist. 2. The majority of managers who reported difficulty in finding a pharmacist were owner operators. It is likely that this group and their prospective employees would benefit from an enlargement of the B.C.P.S. employment relations function. 176 7.4 Participation of Male and Female Pharmacists There have been concerns in all professions in which there are large or increasing proportions of female registrants .that there are higher rates of withdrawal from professional activity by women which could eventually lead to manpower shortages. Some reduced participation by women during their family formation years is to be expected, but there has been speculation that for many women this withdrawal has been permanent. Both the number and percentage of women in pharmacy in B.C. have increased substantially in the 1970's and as of September, 1977 and 535 female registrants comprised 28.5 percent of the total active register. Because the training programme enrols almost equal proportions of male and female students the<;percentage of women will increase as older pharmacists, who are mainly male, retire. In the following sections male and female career patterns have been compared for retrospective, prospective and current differences. This involved an examination of the Register of Pharmacists to determine what losses occurred in the past among persons who had graduated from UBC. Secondly, because there is speculation that past trends in female withdrawal may not be valid for future predictions, individual pharmacists were asked to make their own judgements concerning their likely career duration. Finally, a comparison, was made of the 1977 full time equivalence (FTE) worked by practising pharmacists. 177 7.41 Retention of Active Status by UBC Graduates Maintenance of active licensed status by a practitioner cannot be used as an accurate measure of actual participation, but it is at least an indicator of retention of interest in the profession. Since 1974 the Pharmacy Act has provided a more positive incentive for pharmacists to retain current licensed status. In an effort to compare losses among male and female registrants in B.C. , the original Register of Pharmacists was checked to determine the number of "ever-licensed" men and women who were UBC graduates. Registrants from other jurisdictions were not included, because in the absence of age data, i t could not be assumed that these persons had entered the province at the beginning of their pharmacy careers. The losses of men and women were compared in five year groups from time of first registration to February 1977. Then this "retained" group was followed through one licensing period and compared for losses as of September 1977. Table 7.4-1 shows the number of UBC graduates since 1949 and the number who retained active status as of February 1977. While the overall retention rate for men and women is very nearly identical at about 75 percent, this type of comparison is misleading because i t does not take age into consideration. The largest numbers of 178 Table 7.4-1 Number and Percentage of Male and Female UBC Graduates Pharmacists Retaining Active Status in February 1977, in 5 Year Groups by Year of First Registration MALE FEMALE Registered^ Retained 2 Registered^ Retained 2 Year # # % # # % 1949-51 151 112 74.2 24 15 62.5 1952-56 155 125 80.6 40 21 52.5 1957-61 130 104 80.0 40 26 65.0 1962-66 113 93 82.3 47 33 70.2 1967-71 99 95 95.9 65 57 87.7 1972-76 213 199 93.4 175 176 100.0 Unknown 1 -- 5 Total 861 729 84.7 391 333 85.2 Source: 1. College of Pharmacists of B.C . , Registration #1451-3354 2. PHARMFILE, Health Manpower Working Unit, UBC female registrations have occurred since 1970, and a high rate of retention of qualifications would be expected because of the relative youth of these women. The largest proportion of losses has occurred among women registered between 1952 and 1956. Just 21 of 40 or 52.5 percent s t i l l held licensed status in February 1977. This compared to an eighty percent retention rate among male pharmacists who registered during the same period. It was not possible to obtain information to indicate when the withdrawals by male and female pharmacists had actually occurred, so no judgement of career length was possible. However, ten or more years after registration the losses among women averaged 37.1 percent, and among men they had averaged 20.9 percent. 179 The number of status changes among UBC graduates was compared for the relicensing period between February and September 1977. No major fluctuations were anticipated during this time which was well after the incentives of the Pharmacy Act (1974) had been put into effect, and also ahead of the administration of the competency self-evaluation paper mailed in November 1977. Table 7.4-2 shows a net loss among men of 9 persons or 1.2 percent of licenseholders; and among women, 11 losses or 3.3 percent. While this rate of loss among women is clearly higher i t may also be important to note that most losses (for both sexes) occurred among relatively recent graduates. Among post 1966, UBC graduates Table 7.4-2 Number of Active/Non Active Status Changes Among Male and Female U.B.C. Graduate Pharmacists Between February and September 1977, in five year groups by year of first registration. February 1977 September 1977 Change M F M F M F 1949-51 112 15 109 15 -3 0 1952-56 125 21 127 21 +2 0 1957-61 104 26 102 25 -2 r l 1962-66 93 33 93 34 0 +1 1967-71 95 57 93 55 -2 -2 1972-76 199 176 194 167 -5 -9-Unknown 1 5 0 7 -1 +2 Total 729 333 718 324 -11 -9 Source: PHARMFILE, Health Manpower Working Unit, U.B. C. the crude attrition rate for females was 4.7 percent and for males, 2.4 percent. It is not known whether these losses were to other 180 licensing bodies or whether they were to other career choices. St i l l these high rates of withdrawal among young and expensively trained persons will require monitoring for evidence of trend. 7.42 Expected Duration of Career Because i t was felt that past patterns of withdrawal might not be valid for the future, pharmacists were asked to indicate the - J. "total number of years you expect to practice in pharmacy". It was realized that several factors besides sex would influence these estimates, and one of the most important would likely be age. Younger persons in all occupations tend to estimate an earlier retirement than do older workers who are facing the reality of inflation on reduced income. Certainly in pharmacy it has been traditional for many older persons to fade out of the full time workforce into relief or part time work, rather than to retire from practice abruptly. As well, changes in societal attitudes toward women in the work force have encouraged many women to plan longer and more serious careers. The mean estimate of career duration for the 802 male respondents was 33.8 years and for 360 females, 28.0 years, a difference of 5.8 years. However, when young pharmacists under age 35 years was considered separately the expected duration was 28.7 for males and 26.1 for females, a difference which had narrowed to 2.6 years. In Tables 7.4-3 and 7.4-4 the ranges of career l i fe expectation for both age groups and sexes is shown. Among those persons under age 181 35 years 36.3 percent of female respondents estimated a career duration of that was 20 years or less. This compares with 26.2 percent of males who made estimates in this range. Comparisons in the older age group should be made cautiously because there are few women in the profession who are over age 55. Table 7.4.-3 Expected Duration of Practice, Pharmacists Under Age 35 Years,: by Sex Male Female Year • # % # % 1 - 10 25 11.5 34 14.7 11 - 20 32 14.7 50 21.6 21 - 30 79 36.4 51 39.4 31 - 40 67 30.9 47 20.3 41 - 14 6.5 9 3.9 217 100.0 231 100.0 Table 7.4-4 Expected Dura tion of Practice, Pharmacists Age 35 and Over by Sex Year Male Female # % # % 1 - 10 21 3.6 8 4.7 11 - 20 35 6.0 26 15.4 21 - 30 122 20.9 69 40.8 31 - 40 264 45.1 43 25.4 41 - 143 24.4 23 13.6 585 100.0 169 100.0 7.43 Full Time Equivalence of Male and Female Pharmacists From 1977 PHARMFILE data the percentage of male and female pharmacists who reported "employed" status differed by just 2.7 percent, (Table 7.4-5) with 90.4 percent of men and 87.7 percent of women indicating that they were in some form of pharmacy employment. 182 Table 7.4-5 Employment Status and Full Time Equivalence(FTE) of B.C. Pharmacists September 1977, Showing Sex of Pharmacist. Male Female Total # Licensed 1344 535 1879 # Employed 1215 469 1684 %Employed 90.4 87.7 89.6 # FTE 1098 309 1407 FTE/Licensed .82 .58 .75 FTE/Employed .90 .66 .84 Source: PHARMFILE, Health Manpower Working Unit, U.B.C. Again, this simple "count the bodies" approach provided l i t t l e evidence of any differences in male/female participation. However, when the level of employment or full time equivalence (FTE) of these pharmacists was compared the differences became more apparent. The 1215 employed male pharmacists were participating the labor force as 1098 FTE for a ratio of 0.90 equivalence per employed pharmacist. For the 469 employed female pharmacists who were participating as 309 FTE this ratio was 0.66 equivalence. Table 7.4-5 also shows the labour force participation per licensed pharmacist, regardless of sex or practice field, is 0.75 FTE or "three-quarter time". Among males this ratio is 0.82, and drops for females to 0.58. Thus licensed female pharmacists participated at (0.58 * 82) x 100 = 70.5 percent of the male rate in 1977. From the 1978 survey data Table 7.4-6 shows that 87.7 percent of male and 92.0 percent of female respondents were in 183 pharmacy employment, and again this was not significantly different from the 1977 PHARMFILE data. Table 7.4-6 Employment Status Reported by Respondents to B.C.P.S. (1978) Survey, Showing Sex of Pharmacists. Male Female # % # % Employed pharmacy 825 87.7 368 92.0 Outside pharmacy 21 2.2 5 1.3 Not employed 40 4.3 23 5.8 Retired 38 4.0 1 0.3 Semi-retired 13 1.4 2 0.5 N/S 4 0.4 1 0.3 941 100.0 400 100.0 However, when the response of employed pharmacists was compared for part time work there were 164 men or 19.9 pecent of those in employment who reported part time involvement. Among the 368 pharmacy employed women 166 or 45.1 percent stated that they were part time workers. While women were more than twice as likely to be in part time employment and a higher percentage were thus in "no choice" part time work, this last difference is more likely related to the employment problems among young pharmacists rather than to discrimination against women. Table 7.4-7 Number of Pharmacists Reporting Choice/No Choice in Part Time Employment Showing Sex of Pharmacist Male Female Part time Choice 123 128 No Choice 41 38 164 166 # Employed 825 368 % part time 19.9 45.1 184 SUMMARY OF FINDINGS 1. The average loss of U.B.C. graduates who had been registered between 10 and 25 years was 20.9 per cent among men and 37.1 per cent among women. 2. The 1977 relicensing period was notable for withdrawal of young U.B.C. graduates who had registered between 1972 and 1976. A total of 14 pharmacists or 3.6 percent of this group did not renew their qualifications. 3. The crude attrition rate among 1972 - 1976 female U.B.C. graduate registrants was 5.1 percent, double the rate of loss among the recent male graduates. 4. The expectation of women survey respondents who were under age 35 in 1978 was for a career l i fe span mean of 25.1 years. Their male counterparts estimated that they would spend an average of 28.7 years in their pharmacy career. 5. Over one-third of employed female survey respondents indicated that they chose to work part time in their careers. This type of choice was made by 15 per cent of men. 6. On average the full time equivalence of male 1icenseholders was 0.82 FTE in 1977, with females participating at 0.58 FTE. 185 7.5 Career Attitudes of B.C. Pharmacists 7.51 Pharmacy as a Career Choice 1968, 1978 In 1968 and 1978 B.C. pharmacists were asked i f they would again choose pharmacy and their present field of practice i f they were "starting all over to choose a career". From Table 7.5-1 it can be seen that there was a reduction from 41.2 per cent to 30.9 per cent of pharmacists who would not choose,pharmacy again between the 1968 and Table 7.5-1 Number and Percentage of Pharmacists Indicating Their Choice of Pharmacy/not Pharmacy as a Career, 1968 and 1978. 1968 1978 # % # % Pharmacy same 336 35.7 524 40.7 Pharmacy different 79 8.4 125 9.7 Not pharmacy 387 41.2 397 30.9 Do not know 138 14.7 240 18.7 940 100.0 1286 100.0 x 2 = 25.95 x 2 g 5 (3) = 7.81 1978 respondents. While there was an increase in the percentage of persons who indicated that they would choose their present f ield, i t should be noted that there was also an increase in the percentage of uncertain responses in 1978. In 1968 there were 371 of 962 pharmacists or 38.6 percent who indicated some alternate choice of career. While a similar number (370) gave a preferred choice in 1978, they accounted for just 27.6 percent of the total survey response. These alternate choices are shown in Table 7.5-2. The coding procedures for the two 186 surveys may have been different in that where several career alternates were given in 1978, the first was selected. It is thought that a coin flip system was used to select from multiple responses in 1968. Table 7.5-2 Number of B.C. Pharmacists Indicating Alternate Career Choice 1968, 1978. 1968 1978 Medicine 102 98 Dentistry 56 30 Law 30 34 Business/Acct. 31 48 Education 23 15 Engineering/Phys.Sci 29 35 Other 100 n o 371 370 x 2 = 14.57,x 2 g 5 (6) = 12.59 Table 7.5-2 shows that medicine was s t i l l the preferred alternate career among disenchanted pharmacists in 1978, with the main differences in choices being an increase in the number who would choose a business oriented career, and a decrease in dentistry as a preference. 7.52 Satisfaction with Current Field of Practice Space limitations did not allow for an extensive probe of pharmacists' attitudes to practice and participation in pharmacy related activities. However, in 1978 pharmacists were asked whether they were satisfied with their current field of practice, and whether they had actually attempted? to change fields. Table 7.5-3, shows that of 1264 187 persons who responded to the question 886 or 70.1 percent were satisfied and "would not wish to change fields." Of the 378 persons who did not find their field satisfying, there were 81 or just over one in five who had made an attempt to change fields. Because of the forced choice nature of the satisfaction question which allowed no "moderately satisfying" or "don't know" responses, a large number of persons in 1978 were led to the following open question which asked for a reason for their dissatisfaction. In those cases where more than one reason was given, the first was coded. From Table 7.5-4 the most frequently named irritation was a lack of challenge, and many pharma-cists commented that their skills were not being well utilized. The Table 7.5-3 Satisfaction/non Satisfaction with Present Field of practice; number and percentage of pharmacists 1978 # # Satisfied, would not wish change 886 70.1 Not satisfied, no attempt to change 297 23.5 Not satisfied change attempted 8J_ 6.4 1264 100.0 Table 7.5-4 Reason for Dissatisfaction with Present Field of Pharmacy, Number and Percentage of Pharmacists, 1978. 1. Lack of challenge # 85 % 27.1 2. Lack of status 35 11.1 3. Lack of health focus 49 15.6 4. Outside regulation, control 37 11.8 5. Low wages, profits 38 8.9 6. Hours, workloads 25 8.0 7. Lack of job security 26 8.3 8. Other 29 314 9.2 100.0 188 second most common reason given for dissatisfaction concerned the lack of a health focus in the profession as a whole. These reasons, plus outside regulation by government, corporations and pharmacy organizations and a general lack of status formed a group of four dissatisfactions which were classed as job-intrinsic factors. Together they comprised 65.6 per cent of the expressed dissatisfaction. A further group of reasons for dissatisfaction were classed as job-extrinsic. They were not part of actual pharmacy practice, but related more to the contractual arrangements between employees and employers. These are shown in Table 7.5-4 as dissatisfactions concerning wages (or profits), hours, workloads and lack of job security. Together job extrinsic factors accounted for 25.2 percent of the stated reasons for dissatisfaction withthe present field of pharmacy practice. A comparison of the reasons for dissatisfaction across the two major employment fields of community and institutional pharmacy is shown in Table 7.5-5. Among those pharmacists who were employed in hospitals and by government the primary reasons for dissatisfaction were those related to challenge, health focus and status. Just one pharmacist (3.1%) in this group indicated that employment arrangements were the main problem, but 29 of the 32 respondents or 90.6 percent reported job-intrinsic dissatisfactions. Among community pharmacists job-intrinsic dissatisfactions were noted by 172 or 63.0 percent of these respondents, however wages profits, job security, hours and workloads were mentioned by 76 or 27.8 189 Table 7.5-5 Reason for Dissatisfaction with Present Field of Pharmacy, Number and Percentage of Pharmacists, 1978; Showing Field of Practice. 1. Lack of challenge 2. Lack of Status 3. Lack of health focus 4. Outside regulation 5. Low wages, profits 6. Hours, workloads 7. Lack of security 8. Other Community 74 28 35 35 27 25 24 25 273 Institutional 10 7 11 1 1 32 percent. It should be noted that most institutional practitioners in B.C. are covered by collective agreements with their employers, but union or formal written employment.contracts are s t i l l the exception among community pharmacists. 190 SUMMARY OF FINDINGS 1. Survey respondents in 1978 were slightly more positive about pharmacy and their present field of practice as a career choice than were those who were surveyed in 1968. 2. The most frequently mentioned reason for dissatisfaction with the present field of practice among B.C. pharmacists in 1978 was the lack of challenge they faced considering their education. 3. A direct quotation from one of the surveys (1978) illustrates vividly the "druggist's dilemma", and is a likely indicator of the reason why medicine was most frequently named as a preferred career: " I would choose a profession in which I could to a great part control my destiny. I would involve myself with service only - not product and service." 4. Institutional pharmacists indicated l i t t l e in the way of dissatisfaction with their contractual arrangements with their employers. 5. Employment related concerns were more commong among community pharmacists where organizations are small and terms of employment are often individually negotiated. 191 Chapter 8 Community Pharmacy Practice in B.C. In this chapter the responses of pharmacists in community based practice have been treated in several different ways. First data provided by dispensing pharmacists and pharmacy managers were used to develop various estimates of total retail prescription demand in B.C. A subsequent section examined the 1977 prescription statistics of approximately 350 pharmacy outlets for relationships to the type of pharmacy organization, and also for regional differences which might be attributed to the age distribution of the population. A further section in this chapter documents pharmacist staffing levels and personnel mix in response to prescription demand in 1978. Finally the responses of dispensing pharmacists concerning their usual prescription workloads have been analyzed for relationships to their estimates of how they spend their working time, and to their use of computer records and pharmacy assistants. 192 8.1 Estimates of Total Retail Prescription Demand Several different approaches to estimating prescription demand were built into the pharmacists survey of 1978. The individual estimates were based on reporting of individual pharmacist workloads, on weekly store volume reported by managers, and also on 1977 total volumes. 8;11 Estimates from Individual Pharmacist Workloads, 1978 The mean workload reported by B.C. community pharmacists who reported four or more hours of employment "last week" was 254 pres-criptions. The number of pharmacists who reported "last week" and "usual week" dispensing loads is shown in Table 8.1-1. Several pharmacists commented that they had some difficulty in coming to grips with a "typical" or "usual" week, because they were employed on a casual or relief basis. This would account for some of the difference in the numbers of responses. Table 8.1 - 1 Mean Weekly Prescription Load Reported by B.C. , Community Pharmacists, 1978 #Rx/week # pharmacists Last week 253.5 894 Usual week 253.8 782 The survey response rate of 78.2 per cent was used to 3 calculate the estimate of total prescriptions dispensed by pharmacists on the basis of a 48 week year. 193 Estimate 1: Based on "last week" 894 x 254 x 48 = 13.95 million prescriptions .782 Estimate 2: Based on "usual week" 872 x 254 x 48 = 13.60 million prescriptions .782 8.12 Estimates from Pharmacy Weekly Volumes. 1978 The overall response of community pharmacy managers to the questions dealing with pharmacy open hours and staffing patterns was 427 of 533 licensed pharmacies, or 80.1 per cent. However when managers were asked to estimate the number of prescriptions f i l led "last week" or for a "typical week", fewer were willing to divulge this information. This response is shown in Table 8.1-2. Table 8.1-2 Mean Weekly Prescription Volume Reported by B.C. Community Pharmacy Managers, 1978 # Rx/week # Pharmacies Last week 460 391 Usual week 469 373 The following series of estimates is based on last week and usual week volume generalized across 533 outlets for 52 weeks. Estimate 3: Based on "last week" 460 x 533 x 52 =12.75 million prescriptions 194 Estimate 4: Based on "usual week" 469 x 533 x 52 = 13.00 million prescriptions 8.13 Estimates Based on 1977 Annual Volumes Of the 427 managers who responded to sections dealing with staffing patterns, just 332 provided information of prescription volumes for 1977. From a mid year estimate of 525 pharmacies for 1977, the response rate is 62.3 per cent. The mean prescription volume across this response was 24,698 prescriptions per pharmacy. Estimate 5: Based on 1977 total prescription volume 24,698 x 525 = 12.97 million prescriptions (1977) 8.14 Estimates Based on Pharmcare Billing Statistics For several years the B.C. Pharmacists' Society has estimated that 40 per cent of all prescriptions f i l led at the retail level have been billed to the Pharmcare programmes which provide benefits to the elderly (Plan A) and Human.Resources assistance clients (Plan C). The 1978 survey indicated a range of between four and 85 per cent across 364 outlets, with a mean of 39.87 per cent. Table 8.1-3 shows the actual dollar volumes paid out by Pharmacare since 1976. The average prescription price was used to estimate the number of prescriptions billed to the agency in each year. 195 Table 8.1-3 Total billing to Pharmacare Plans A and C, 1976 to 1978(estimated); showing average price per prescription and estimated number of prescriptions 1976-77 1977-78 1978-79(est) Plan A ($ x 106) Plan C Total 20.4 4.7 25.1 23.3 5.5 28.8 24.6 5.6 30.2 Average Rx Price ($) 5.90 6.50 6.70 Estimated # Rx (millions) 4.25 4.43 4.51 Source: P. Tidball, Director of Pharmacare (Sept. 6, 1978). The following estimates of 1977 and 1978 volume for the province were made using the number of Pharmacare prescriptions divided by the mean percentage billing reported by pharmacy managers. Estimate 6: Based on Pharmacare billing 1977-78 4.43 - 11.11 million prescriptions 0.3987 Estimate 7: Based on Pharmacare 1978-79 , 4.51 = 11.31 million prescriptions -0.3987 196 Summary of Findings Several estimates of total prescription volume have been made for B.C. using in-province data sources, rather than borrowed statistics. The estimates are shown for 1977 and 1978 in Table 8.1-4, and are numbered for easy reference to the calculations shown in the previous sections. Table 8.1-4 Estimates of Total Retail Prescription Volume for B.C., 1977 and 1978. Year Reference # Total Estimated (xlO :) 1977 5 12.97 6 11.11 1978 1 13.94 2 13.60 3 12.75 4 13.00 7 11.31 Though none of the above estimates depend on borrowed statistics, estimates #6 and #7 were derived from Pharmacare data. A more direct estimate of total volume for 1977 is #5 or 12.97 prescriptions. This corresponds closely to the "usual" weekly volume estimates for 1978 provided by dispensing pharmacists (#2) and pharmacy managers (#4) which are in the range of 13.00 and 13.60 prescriptions per year. The use.of the Pharmacare data, or even that obtained more directly, to project trend should be done with caution. In early 1979 the policy of a single fee per pharmacy was adopted, and by April 1, 1979 Pharmacare will pay pharmacies on a per diem basis for service to patients in community care facil it ies. The per diem fee is expected 197 to encourage pharmacists to review medication records in an effort to supply less medication. The single fee concept will simplify the price signals for consumers, and may encourage comparison shopping for different levels of service. 8.2. Community Pharmacy Outlets in B.C. There were 533 community pharmacies licensed by the College of Pharmacists of B.C. in April 1978. A total of 427 responses to the survey were received from the four main types of outlets as shown in Table 8.2-1, for a response rate of 80.1 per cent. Table 8.2-1 Number of Community Pharmacy Responses, 1978; Showing Type of Pharmacy Organization # % Owner Operated 253 59.3 Chain (4 or more) 99 23.2 Rx specialty 44 10.3 Department store 26 6.1 N/S 5 1.2 427 100.0 While most managers provided data of pharmacy staffing patterns, not as many divulged information concerning their prescription volumes. The number of responses to the latter types of questions ranged between 332 and 372 which lowered this response rate to between 62 and 70 per cent. For this reason the actual number of responses will be shown where it differs significantly from the total of 427 shown in Table 8.2-1. 198 8.21 Prescription Statistics: 1977 The mean total number of prescriptions f i l led (332 responses) in B.C. Pharmacies during 1977 was 24,698, although this ranged from 750 to 300,000. In several cases where volume was extremely low, the manager commented that the business had been recently established. The range of the responses is shwon in Table 8.2-2 which indicates that 63.6 per cent of pharmacies had an annual volume between 10 and 30 thousand prescriptions in 1977. Table 8.2-2 Annual Prescription Volume Reported by B.C. Community Pharmacies, 1977 # Rx(lOOO's) # % -10 43 13.0 10-20 137 41.3 20-30 74 22.3 30-50 60 18.1 50-100 14 4.2 100+ 4 1.2 332 100.0 Just 5.4 per cent of outlets had volumes in excess of 50,000 prescriptions. The average percentage of prescription sales to total sales (347 reporting) 1977 was 36.0 per cent, though the range was one through ninety-five per cent. Not surprisingly, chain pharmacies reported lower ratios of prescriptions to total sales than did owner operated pharmacies. (Table 8.2-3) Among prescription speciality outlets 35 of 39 reported prescription sales in excess of 70 per cent of total volume. 199 Table 8.2-3 Prescription Sales as a Percentage of Total Sales Reported by B.C. Community Pharmacies, 1977; Showing Type of Pharmacy Organization. Owner Chain Rx spec. Dept Total op. Store %Rx 1-10 5 20 0 2 27 11-20 41 44 0 7 92 21-30 75 8 1 0 84 31-50 60 6 0 1 67 51-70 19 5 3 0 27 71 + 6 3 35 4 48 206 86 39 14 345 The wide dispersion of the department store ratios is likely a result of confusion concerning the choice of a sales figure from among pharmacy sales, drug department or entire store totals. In 1977 the mean percentage of prescriptions billed to Pharmacare was 39.9 per cent, with a range across 364 reporting outlets between four and eighty-five per cent. The mean compares closely to the 40 per cent which has been estimated in previous years by the B.C. Pharmacists Society. The range of the percentage of prescriptions billed to Pharmacare by type of pharmacy is shown in Table 8.2-4. it indicates that 46.7 per cent of owner operated and 52.5 per cent of prescription specialty pharmacies billed more than 40 per cent of their prescriptions to Pharmacare. Just one department store and 28 or 30.7 per cent of chain pharmacies reported this level of bill ing. 200 Table 8.2-4 Percentage of Prescriptions Billed to Pharmacare in 1977, Reported by B.C. Community Pharmacies; Showing Type of Pharmacy Organization % Pharmacare Owner Op. Chain Rx spec. Dept. Store Total -20 23 27 2 6 58 21-40 91 36 17 8 152 41- 100 28 21 1 150 214 91 40 15 360 In their work for the Ontario Economic Council, Evans and Williamson (1978) speculated that chain pharmacies and department stores with low ratios of prescription sales to total sales would be unlikely to f i l l large numbers of Pharmacare prescriptions. They reasoned that persons who were fully price subsidized would be more sensitive to neighbourhood convenience, and would tend to patronize a pharmacy in thier own community rather than to search one out which might offer price incentives. Table 8.2-5 shows that where the rates of prescriptions to total sales was high the percentage billed to Pharmacare also tended to be high. 8.2-5 Percentage of Prescriptions Billed to Pharmacare in 1977, Reported by B.C. Community Pharmacies; Showing Prescriptions as a Percentage of Total Sales. Rx as % total sales 1-10 11-20 21-50 51- Total Pharmacare -20 11 27 11 5 54 21-40 12 41 68 24 145 41- 4 24 72 46 146 27 92 151 75 346 201 It should be noted that there was no control in the above tables for the likely demand for Pharmacare prescriptions; and Table 8.2-6 is presented as a reminder of effects which can be attributed to population differences throughout the province. The sharp contrast between the Greater Vancouver Regional District (GVRD) and the Cariboo and Northern regions should be noted. While both areas had 19 pharmacies which reported Pharmacare billings which were one-fifth (or less) of total prescriptions in 1977, the 19 outlets represented 61.3 per cent of northern pharmacies, but just 12.3 per cent of those in the Vancouver area. None of the northern stores reported Pharmacare billings in excess of 40 per cent; yet 19 outlets or 54.3 per cent of those responding from the Capital Regional District where the population of elderly is high, reported a high rates of Pharmacare prescriptions. Table 8.2-6 Percentage of Prescriptions Billed to Pharmacare in 1977, Reported by B.C. Community Pharmacies; Showing Geographic Location Region -20 21-40 41- Total 1. Capital 3 13 19 35 2. N. Island & Coast 6 17 9 32 * Lower Mainland 3 18 15 36 4. South Central 7 19 22 48 5. Kootenay 0 10 9 19 6. Cariboo & North 19 12 0 31 7. GVRD 19 62 74 155 57 151 148 356 * Includes College Districts and BCPS Chapters 3,7,8,9. 202 8.22 Prescription Volume and Pharmacist Staffing, 1978 In response to the 1978 survey the "average" B.C. pharmacy reported 63.8 weekly open hours and the employment of 2.46 pharmacists for a total of 82.0 hours per week. The range across 418 outlets the range was from one to nine pharmacists who were employed for between 18 to 400 weekly hours. Pharmacy assistant hours were reported by 201 managers, with a range of one through nine assistants per outlet. A summary of the means of open hours, pharmacist hours and prescription data is shown in Table 8.2-7. Table 8.2-7 Summary Statistics of Weekly Open Hours, Pharmacist Employment and Weekly Prescriptions, Reported by B.C. Community Pharmacies, 1978 Mean # Reporting Weekly open hours 63.8 417 Pharmacists/store 2.46 418 Pharmacy assistants/store 1.46 201 Weekly pharmacist hours 82.0 418 Weekly prescriptions 469 373 Rx/open hour 7.48 369 Rx/pharmacist hour 5.69 370 Because it was thought that there was likely considerable seasonal variation in prescription demand, managers were asked for their judgement of whether the volume of prescriptions f i l led "last week" was within the usual range. Fifty-nine mangers or 14.6 per cent of the 404 respondents to this question indicated that last week was not typical, and where volume statistics were provided a computer selection was made to reflect their judgements of a usual weekly volume. 203 The mean of this weekly volume as shown in Table 8.2-7 was 469 prescriptions, though the range varied between 40 and 2300 per week. Table 8.-2-8 shows the range of this volume as reported by 368 managers in the main types of pharmacy outlets. Table 8.2-8 Weekly Prescription Volume Reported by B.C. Community Pharmacies, 1978; Showing Type of Pharmacy Organization Owner Chain Rx. Dept. Total Op. Spec. Store -200 37 5 1 3 46 201-300 53 17 6 2 78 301-400 47 13 6 6 72 401-600 45 24 14 5 88 601-800 25 14 5 3 47 801- 14 17 4 2 37 221 90 36 21 368 From these data i t can be seen that 196 or 53.3 per cent of the pharmacies indicated weekly volume of 400 or fewer prescriptions, a level of demand which given "ideal" conditions (CPS, 1971) could be handled by one full time dispensing pharmacist. Just 37 or 10.1 per cent of pharmacies reported volumes that were in excess of 800 prescriptions per week. It would appear that chain pharmacies have been more successful in attracting these higher volumes; and of 90 pharmacies there were 17 or 18.7 per cent in this high volume range. While prescription volume statistics were withheld by some managers, there were more who provided data concerning their staff patterns. A total of 1026 pharmacists were reported as staff members 204 in 418 outlets. Generalized across 533 licensed pharmacies (April, 1978) this would indicate that about 1300 pharmacists were employed in community pharmacies in B.C. in 1978. This may be slightly high, because some pharmacists are employed in more than one outlet. The number of pharmacists per store is shown in Table 8.2-9. Table 8.2-9 Number of Pharmacists on Staff (including manager), Reported by B.C. Community Pharmacies, 1978 # Per pharmacy Pharmacies # % 1 72 17.2 2 163 39.0 3 129 30.9 4 41 9.8 5 8 1.9 6-9 5 1.2 418 100.0 Actual "solo practice" or staffing by one pharmacist was reported by 72 managers or 17.2 per cent, but the most common pattern involved staffing by two or three pharmacists, as reported by 292 or 69.9 per cent of managers. Clearly most community pharmacies in B.C. are very small.organizations, with just 3.1 per cent indicating a staffing range of between five and nine pharmacists. The range of pharmacist hours per week is shown in Table 8.2-10 and indicates that 40.2 per cent of outlets employ pharmacists for more than 80 hours per week. This would indicate that many pharmacies "overlap" their professional staff beyond their 205 weekly open hours, a practice contrary large volume chain policy. Table 8.2-10 Weekly Pharmacist Hours Reported by B.C. Community Pharmacies 1978 # Hours Pharmacies # % -40 13 3.1 41-60 108 25.8 61-80 128 30.6 81-100 97 23.2 101-150 59 14.1 151-200 8 1.9 201- 5 1.2 418 TOO.O 206 8.23 The Use of Pharmacy Assistants One of the issues in the profession in B.C. has centred on the employment of large numbers of pharmacy assistants per outlet. The first area of concern is that there may be a danger to the quality of the dispensing process, especially i f a pharmacist is called upon to supervise several assistants. The second is a concern over loss of employment for pharmacists where assistants are employed to perform the traditional pharmacist functions of drug supply. The College of Pharmacists of B.C. has moved to regulate the content^ of the pharmacy assistants' work, and the B.C. Pharmacists' Society has endeavoured to limit their numbers, so that they "do not exceed by more than one the number of pharmacists on duty at any one time". In actual practice this recommendation for limitation of numbers, i f enforced, has the potential to create problems for both the large and small pharmacy operator. In a small pharmacy, a single pharmacist is often called upon to exercise supervisory control over merchandise and staff beyond the pharmacy area; and he might conceivably be pushed beyond the limits of his span of control by the two "allowable" pharmacy assistants. In a larger operation, more specialized task division among pharmacists is possible, and it seems likely that a team of three pharmacists could effectively supervise more than the four "allowable" pharmacy assistants. 1 Pharmacy Act of B.C. , 1974, Rule C-52 2 "Employment Code, 1978-79", B.C. Pharmacists' Society, p.14 207 In their discussion of the use of auxiliary personnel in pharmacy and dental practice Evans and Williamson (1978, pp. 209 -212) stated that there was l i t t l e extensive use of assistants in community pharmacies. From survey responses of 427 B.C. pharmacy managers, there were 201 or 47.1 percent who indicated that they did employ a pharmacy assistant. Data of numbers employed and weekly hours were provided by 199 managers. The mean staff ratio across these 199 pharmacies was 2.1 pharmacists for each assistant, though a range of 2.25 assistants to one pharmacist through one assistant for 9 pharmacists was observed. Table 8.2-11 shows the range of these staff ratios and indicates that the most common pattern, as reported by 79 pharmacies, was for the number of assistants to be more than one-half or just equal to the number of pharmacists employed. Table 8.2-11 Pharmacy Assistants Per Pharmacist, 1978 Reported by B.C. Community Pharmacy Managers. Pharmacies with Total Pharmacies # Assist/# Pharmacists Assistants # % # % 1 +:• 51 25.6 11.9 1/2 - 1 79 39.7 18.5 1/3 - 1/2 52 26.1 12.2 1/4 - 1/3 13 6.5 3.0 - 1/4 4_ 2.0 0.9 199 100.0 No assistant, N/S 288 53.4 Total 427 100.0 The number of assistants exceeded the number of pharmacists in 51 or 25.6 per cent of outlets reporting auxiliary use through this.represented 208 just 11.9 percent of the total response. When the hours of employment were compared,the mean ratio was 3.1 pharmacist hours for every assistant hour. A range of 1.8 assistant hour per pharmacist hour through to one assistant hour for 45.5 pharmacist hours was observed. This range is shown in Table 8.2-12. The most common pattern of auxiliary use reported by 77 outlets was for pharmacy assistant hours to be just over one-half or equal to pharmacist hours. Just 16 or 8.0 per cent of outlets reporting auxiliary use indicated that pharmacy assistant hours exceeded pharmacist hours. When all 427 pharmacies were considered, there was either no use of auxiliary personnel, or use which amounted to one-third or less of the reported pharmacist hours in 67.7 per cent of outlets. Table 8.2-12 Pharmacy Assistant HOurs per Pharmacist Hour, 1978, Reported by B.C. Community Pharmacy Managers. Pharmacies with Assistants Total Pharmacies Assistant hrs/ # ' % # % pharm.hrs. 1+ 16 8.0 3.7 1/2 - 1 77 38.7 18.0 1/3 - 1/2 45 22.6 10.5 1/4 - 1/3 31 15.6 7.3 - 1/4 30 15.1 7.0 199 100.0 No assistant,N/s 228 53.4 Total 427 100.0 209 Summary of Findings 1. The total number of prescriptions f i l led during a "usual" week during 1978 was 174,982 as reported by the managers of 373 community pharmacies. If this response is generalized to the 533 pharmacies licensed in April 1978, the weekly volume for the province was in the range of (174982 x 533 ) - 373 = 250,000 prescriptions. 2. If the "ideal" productivity standard of 80 to 120 prescriptions per day as recommended by the Commission on Pharmaceutical Services (1971) is applied to the above estimate of volume a need for full time dispensing pharmacist equivalents (FTE) would be: 250,000 r (80 x 5) = 625 FTE/week or 250,000 - (120 x 5) = 416 FTE/week 3. If the 35 hour week is used to measure "full time"; the use of this productivity standard would generate a need for between 14,560 and 21,875 dispensing pharmacist hours per week. 4. The number of weekly pharmacist hours reported by 418 pharmacy managers in 1978 totaled 34,275. Generalized across 533 outlets this would indicate an actual demand for (34275 x 533) v 418=43,682 community pharmacist hours per week in B.C. 210 All of the 533 established community pharmacies in B.C. in 1978 were operating under the legal constraints on staffing imposed by the Pharmacy Act (1974). This Act requires that "no pharmacy shall be open for business unless a pharmacist is in the pharmacy". On the basis of 63.8 mean weekly open hours, the legal requirement for pharmacist staffing, given the reality of 533 outlets was: 63.8 x 533 = 34,005 pharmacist hours. If the lower productivity recommendation of the-Commission on Pharmaceutical Services (1971), ie. 80 prescriptions per day, is used to provide a cushion which recognizes the need for access to pharmacy service in small communities; the 21,875 hours are s t i l l approximately 12,000 fewer hours than the legal requirement generated by the established outlets given their current open hours. This need for 21,875 hours is almost exactly one half of the level of hours actually demanded in the system. This level of demand for pharmacist hours in B.C. indicates that about one-half of community pharmacist time is spent in supplying the convenience/ambience aspects of a decentralized prescription service, as well as the entrepreneurial functions associated with small retail business. 8.3 211 Staffing Patterns in Relation to Prescription Demand In this section the responses of 370 community pharmacy managers who provided data of prescription volume and pharmacist staffing hours were treated in several different ways. First the inputs of pharmacist hours at three levels of demand were compared, and then different personnel mixes were examined for differences of input of pharmacist hours. Table 8.3-1 shows the number of stores at each of the levels of demand and the range of reported pharmacist hours. Clearly at all three levels of prescription demand there was considerable variation in the number of pharmacist hours, though 221 or 59.7 per cent reported 80 or fewer hours. Among the 128 outlets with weekly Table 8.3-1 Weekly Pharmacist Hours Reported by B.C. Community Pharmacies, 1978; Showing Weekly Prescription Volume. Rx/week Pharmacist hours -300 300 - 600 601 - Total 60 66 42 1 109 61 - 80 43 56 13 112 81 -100 12 41 28 81 101 -150 7 18 30 50 128 159 83 370 volume of 300 or fewer prescriptions just 19 or 14.8 percent reported more than 80 pharmacist hours. Where volume was between 301 and 600 prescriptions as reported by 159 pharmacies, there were 61 or 38.4 per cent above 80 pharmacist hours, and at volumes exceeding 600 212 prescriptions, 69 of 83 pharmacies or 83.1 percent reported pharmacist inputs in excess of 80 hours per week. Three categories of pharmacist/pharmacy assistant "mix" were developed to compare the effect of use of assistants on pharmacist hours. The categories were based on ratios of reported weekly hours, and were defined as follows: No PA: Zero pharmacy assistant hours were reported LE .1/2: Pharmacy assistant hours were less or equal to one-half the reported pharmacist hours. GT 1/2: Pharmacy assistant hours were greater than one-half the reported pharmacist hours. In Table 8.3-2 the numbers of pharmacies with each "mix" of personnel is shown for the three levels of demand previously defined. In this group of 370 pharmacies 180 or 48.6 per cent reported some Table 8.3-2 Pharmacist/Pharmacy Assistant Staffing Mix in B.C. Community Pharmaices, 1978; Showing Weekly Prescription Volume. # Rx/Week Staff Mix -300 300 - 600 601 - Total No PA 97 84 9 190 LE 1/2 17 39 36 92 GT 1/2 14 36 38 88 128 159 83 370 x 2 = 84.46 x 2 g 5 (4) = 9.49 pharmacy assistant hours. However, therrelationship to weekly volumes should be noted. At the high range of prescription volume 213 just 9 of 83 or 10.8 pendent reported no use of auxiliary personnel, with 38 or 45.8 per cent employing assistants for more than half of pharmacist hours. Where weekly prescription volumes were low, 97 of 128 managers or 75.6 per cent reported no auxiliary hours. In these pharmacies the managers had apparently chosen to follow the old maxim quoted by Evans and Williamson (1978): don't gamble with the rent money unless the hiring of auxiliaries will assist in generating new revenues. In the following three tables, 8.3-3, 8.3-4 and 8.3-5, the three staffing mixes of pharmacist only, some auxiliary use, and more intensive auxiliary use, were compared for their effect on the number of pharmacist hours at three levels of demand. From Table 8.3-3 at a volume of 300 or fewer prescriptions per week,there were 108 of 128 stores or 84.4 per cent reporting inputs of 80 or less pharmacist hours. However, among the 14 pharmacies with a more intensive level of auxiliary personnel use, 12 or 85.7 per cent reported that:the level of pharmacist input was 60 hours or less, and non indicated more than 80 pharmacist hours. Where no pharmacy assistant or limited use was reported there were 19 of 114 stores or 16.7 percent reporting pharmacist inputs of 81 or more hours. Table 8.3-4 shows the staff mix and pharmacist hours for 159 pharmacies reporting weekly volumes in the range of 301 to 600 prescriptions. The majority of these outlets, 139 or 87.4 percent 214 reported pharmacist inputs of up to 100 hours. Among those reporting the more intensive employment of pharmacy assistants 34 of 36 pharmacies or 94.4 percent had pharmacist inputs of 80 or fewer hours. Table 8.3-3 Weekly Pharmacist Hours Reported by B.C. Community Pharmacies With Weekly Volumes of 300 or Fewer Prescriptions, 1978; Showing Pharmacy Assistant Use. Pharmacist hours No PA LE/1/2 GT 1/2 Total - 60 48 6 12 66 61 - 80 35 6 2 43 81 - 100 8 4 0 12 101 - 150 6 1 0 7 151 - 0 0 0 0 97 17 14 128 Table 8.3-4 Weekly Pharmacist Hours Reported by B.C. Community Pharmacies With Weekly Volumes Between 301 and 600 Prescriptions, 1978 Showing Pharmacy Assistant Use. Pharmacist hours No PA LE 1/2 GT 1/2 Total - 60 16 4 22 42 61 - 80 32 12 12 56 81 - 100 24 17 0 41 101 - 150 1:0 6 2 18 151 - 2 0 0 2 84 39 36 159 Table 8.3-5 Weekly Pharmacist Hours Reported by B.C. Community Pharmacies With Weekly Volumes of More Than 600 Prescriptions, 1978; Showing Pharmacy Assistant Use. Pharmacist hours No PA LE 1/2 GT 1/2 Total. - 60 0 0 1 1 61 - 80 1 5 7 13 81 - 100 4 15 9 28 101 - 150 1 12 17 30 151 3 4 4 11 9 36 38 83 215 Where no use, or less intensive use of an assistant was reported 64 of 123 or 52.0 per cent reported pharmacist hours in this range. From Table 8.3-3 which shows staff mix and pharmacist inputs in pharmacies reporting more than 600 prescriptions per week, there were 42 of 83 or 50.6 per-.cent reporting pharmacist inputs of up to 100 hours. While i t is clear that few outlets at this volume did not employ a pharmcy assistant, no relationship could be shown between increasing auxiliary use and pharmacist hours. It should be noted that this group of pharmacies included the entire range of prescription demand through to 2300 prescriptions per week. However a more rigorous segmenting of the demand levels resulted in too few cases for reliable interpretation. 216 Summary of Findings 1. Three measures of pharmacy personnel mix were defined based on ratios of pharmacist and pharmacy assistant employed hours. These were defined as no use of assistant hours, assistant hours which were half or less of pharmacist hours, and assistant hours that were greater than one-half the reported pharmacist hours. 2. Where data was controlled for level of prescription demand, savings of pharmacist hours were demonstrated with increased use of pharmacy assistant time. 3. Two third of pharmacy managers indicated that they either made no use of auxiliary personnel,or use which amounted to one third or less of pharmacist employed hours. Only 3.7 per cent of outlets employed pharmacy assistants for more hours than pharmacist hours. 4. No information was collected concerning the content of pharmacy assistants' work; but the quantity of their participation indicated that intensive use of auxiliary personnel was not a common pattern in community pharmacies in B.C. 217 8.4 Community Pharmacists in B.C. The Commission on Pharmaceutical Services (1971, p.153) inferred individual dispensing workloads from store volumes and numbers of pharmacists employed. In this study there was no differentiation of part time and full-time employees, nor was there any separation of pharmacists not actually involved in dispensing. S t i l l , a wide variation in 1967 workloads was reported by the Commission, and the "owner or manager in the smaller, mixed line pharmacy" was identified as a "major source of under utilization" of pharmacy manpower. The B.C.P.S. (1978) survey obtained data of pharmacist workloads directly from those community pharmacists who stated that they were involved in dispensing prescription medication. Table 8.4-1 shows the number of community pharmacists respondents who were involved in dispensing in their practice. Table 8.4-1 Number and Percentage of BC Community Pharmacist Respondents Involved in Dispensing, 1978 # % Dispensing 969 90.5 No dispensing 30 2.9 Not stated, or not in employment 72 6.7 1071 100.0 For one reason or another, not all of these pharmacists disclosed their hours or workloads, and indeed some pharmacists indicated that their work pattern was so irregular they could make 218 no accurate estimates. In the process of analysing dispensing loads only those pharmacists who reported employment equivalent to "four or more hours last week" were selected. Of the 1071 total response, 174 or 16.4 per cent of pharmacists indicated that their hours worked "last week" were not typical of their regular pattern. As well, 125 persons or 11.7 per cent stated that their prescription load for "last week" was not typical. In these cases, the individual judgements of the more usual workloads and hours of work were ;accepted. In the following sections, the "usual" prescription workloads are presented in two ways. First, the traditional method of reporting the number of prescriptions f i l led per week was examined for relationships to the pharmacist's position in the workforce and to part-time and full-time employment. For the next sections, prescription productivity was calculated on an hourly basis, and comparisons were made to activity patterns, use of aids to productivity, type of employing organization as well as position in the workforce. A short summary of findings follows this section. 8. 41 Weekly Prescription Loads The "usual" weekly prescription loads reported by 872 dispensing pharmacists are shown in Table 8.4-2. However, i t should be noted that these data provide relatively l i t t l e information of actual workflows, because a large number of pharmacists reported part time employment. St i l l i t is likely worthwhile to note that 219 422 or 48.3 per cent of dispensing pharmacists were involved in dispensing 200 or fewer prescriptions which would indicate an annual workload of under 10,000 prescriptions per year. Indeed one fifth of the workforce reported weekly workloads so low that they were in the range of what the Commission on Pharmaceutical Services (1971) considered to be an "ideal" daily workload. There were just 115 or 13.2 per cent of pharmacists with workloads within, or above this CPS (1971) standard of 80 to 120 prescriptions per day. Table 8.4-2 Weekly Prescription Workloads Reported By B.C. Community Pharmacists Employed Four or More Hours per Week, 1978; Showing Position of Pharmacist Staff Owner/Manager Total Weekly Rx -100 122 65 187 101-200 106 129 235 201-300 109 110 219 301-400 61 55 116 401-600 48 33 81 601-999 24 10 34_ 470 402 872 The number of dispensing pharmacists in part time employment, defined as fewer than thirty-five hours per week, is shown in Table 8.4-3. From these data i t is clear that relatively-few owner/ managers report a short work week, but for staff pharmacists this pattern was more common than was previously suspected. Among 470 staff pharmacists there were 218 or 46.4 per cent who were employed "four or more hours last week", and less than 35 hours in a "usual" week. 220 Table 8.4-3 Number arid Percentage of BC Dispensing Community Pharmacists-Reporting Part time/full time Weekly Hours, 1978; Showing Position of Pharmacist. Staff Owner/Manager Hours # % ••• % ; % -34 218 46.4 ?:. 23 • 5. 7 35 - 252 53.6 379 94. 3 470 100.0 402 100. 0 As a partial form of control for variation in hours of work the workloads of staff and owner/manager pharmacists who were employed 35 or more hours were separated out. This is presented as Table 8.4-4 which shows that 234 of 631, or 37.1 per cent of full time dispensing pharmacists reported workloads of 200 or fewer prescriptions per week, or less than 10,000 each year. This workload-was twice as likely to be reported by owner/managers (44.3 per cent) than by staff Table 8.4-4 Weekly Prescription Workloads Reported by BC Community Pharmacists Employed 35 or More Hours Per Week, 1978; Showing Position of Pharmacist Staff Owner/Manager Total Weekly Rx -100 13 56 69 101-200 43 122 165 201-300 81 106 187 301-400 50 54 104 401-600 44 32 76 601- 21 9_ 30_ 252 379 631 x2 = 45.36, x 2 (5) = 11.07 221 pharmacists (22.2 per cent). Workloads above 400 prescriptions, in the range of "ideal" described by the"Commission on Pharmaceutical Services (1971), and as expected by the large volume chains were reported by 106 or 16.8 of full time dispensing pharmacists. There were 25.0 per cent of staff pharmacists and 10.8 per cent of owner/ managers with this type of workload which would represent at least 19,200 prescriptions annually. It would be facile to conclude from this data that because of their tendency to report higher prescription workloads, staff pharmacists were "better" utilized than were owner/managers, without noting again that 46.4 per cent of staff pharmacists were in part time employment. This type of employment may be freely chosen by the pharmacist, and likely represents efficient utilization from the point of view of his/her employer. However, part time employment contains a component of non-utilization of trained manpower resources. 8.42 Hourly Prescription Workloads In the previous section which examined the weekly prescriptions workloads of staff and owner/manager dispensing pharmacists, higher weekly dispensing loads were noted for staff pharmacists. Many managers would argue hotly that they f i l l as many prescriptions in a week as do their staff pharmacists; and a comparison of means (Table 8.4-5) for those 839 pharmacists who supplied this data, and also gave estimates of how they distributed their time during a 222 "typical working week" shows that many were likely correct. However, the longer hours of work of owner/managers should again be noted. It was recognized that a more complete control for variations in hours of work was required; a control which did not simply remove from the analysis all those pharmacists who worked part time. For this reason prescription workloads were calculated on an hourly basis; and from Table 8.4-5 the mean hourly workload for staff pharmacists was 8.22 prescriptions. For owner/managers this was 5.86 prescriptions per hour. The range of these workloads was wide, and is shown more completely in Table 8.4-6. Table 8.4-5 Summary Statistics of Mean Usual Weekly Prescription Load, Weekly Hours and Prescriptions per Hour for B.C. Community Pharmacists, 1978; Showing Position of Pharmacist. Staff Owner/Manager Weekly Rx 259 252 Weekly hours 30.7 44.1 Rx/hours* 8.22 5.86 # pharmacists 445 394 * Computer calculation Table 8.4-6 Hourly Prescription Workloads of B.C. Community Pharmacists, 1978; Showing Position of Pharmacist. Rx/hour Staff Owner/Manager Total -2 13 39 52 2-4 58 92 150 4-6 95 109 204 6-8 109 81 190 8-10 70 31 101 10-12 24 15 39 12- 76 27 103 445 394 839 x 2 = 63.38 x 2 (6) = 12.59 223 In Ontario a productivity norm of 7.5 prescriptions per hour has been negotiated between community pharmacists and government third party payment agencies. Workloads within this range (6-8 prescriptions per hour), or which were even higher were calculated for 62.7 per cent of staff pharmacists and for 39.1 per cent of owner managers. St i l l there were 406 or 48.4 per cent of community dispensing pharmacists, for whom prescription workloads of 6 or fewer prescriptions were estimated; and productivity in this lower range is below the breakeven point for hiring a pharmacy assistant. No controls of variations in the level of prescription demand in the individual pharmacy setting were built into this section of the survey; and as in the Ross (1966, p. 106) study, the assumption was made that "the average retail pharmacist is capable of performing more professional services than he is , at present, required to accomplish." For the following sections the range of hourly dispensing workloads were compressed into three categories which were defined as: Six or fewer prescriptions per hour (n=406) A workload generally considered to be below the breakeven point for hiring auxiliary personnel. Above six, and up to ten prescriptions per hour (n=291) A mid-range which includes the 7.5 Rx/hour Ontario negotiated service target. 224 Above ten prescriptions per hour (n=142) A high productivity range which approximates that of the CPS (1971) "ideal", and that expected by the high volume chain pharmacies. In Table 8.4-7 the number of pharmacists in each category is shown for the four main types of pharmacy organizations. Though the department store and prescription specialty outlets accounted for just 141 or 16.8 per cent of the respondents, the contrasts of pharmacist productivity are interesting to note. In prescription specialty stores just 15 per cent of pharmacists dispensed six or fewer prescriptions per hour, while 64 per cent of those in department stores reported this type of load. This is likely a reflection of Table 8.4-7 Hourly Prescription Workloads of B.C. Community Pharmacists, 1978; Showing Type of Pharmacy Organization Rx/hour Owner Op. Chain Rx spec. Dept. Store N/s. Total -6 242 110 12 38 4 406 6 -10 143 83 45 17 3 291 10 - 51 61 25 4 1 142 436 254 82 59 8 839 the very different merchandise policies and patterns of pharmacist utilization in these outlets. Major department stores in B.C. have traditionally hired pharmacists to manage staff and merchandising activities in what is often an enormous front shop department beyond 225 the pharmacy area. In chain pharmacies 21 per cent of pharmacists had prescription loads of over ten prescriptions per hour. In the largest of these outlets, the policy has been to hire a non-pharmacist general merchandise manager to free the pharmacist for a "prescription specialty" type of practice. This higher productivity range was reported by just 12 per cent of pharmacists in owner operated organizations. 8. 43 Aids to Productivity a) Use of a Pharmacy Assistant From American studies which analyzed the content of dispensing pharmacists' duties, i t was estimated that "a pharmacist could delegate tasks which now consume up to 46 per cent of his time." (Division of Manpower Intelligence, 1974, p. 6.11) From the inverse of time which could not be delegated (0.54) the maximum productivity gain from task delegation was calculated to be 1.85 the current productivity. A sophisticated task breakdown was beyond the scope of this study, but pharmacists were asked to report i f they worked "with a pharmacy assistant in the dispensing area". The extent of pharmacy assistant use was expressed as use "during peak hours only" or "during almost all hours." ) 226 From Table 8.4-8, 418 or 49.8 per cent of the dispensing pharmacists reported use of as assistant, though in the highest range of productivity this increased to 81.7 per cent. The level of use of an assistant also increased with workload and pharmacists with workloads over ten prescriptions per hour were twice as likely to indicate that they used an assistant at almost all hours than were those in the lowest productivity range. Table 8.4-8 Use/nonuse of Pharmacy Assistant Reported by B.C. Community Pharmacists, 1978 : Rx hour PA No PA NS Total - 6 125 278 3 406 6-10 177 112 2 291 10- 116 24 2 142 418 414 7 839 Table 8.4-9 Hours of Use of Pharmacy Assistant Reported by B.C. Community Pharmacists, 1978 PA used at Almost all Total peak hours hours Rx/hour - 6 83 42 125 6-10 92 85 177 10- 38 78 116 213 206 418 x 2 = 27.36 x2Q, (2) = 5.99 227 b. Computer Record Systems On-line computerized record systems were available in the lower mainland regions,and throughout the southern portions of Vancouver Island at the time of the survey. In addition, a few free-standing units were being used in more distant areas. No attempt was made to separate out the responses from areas without on-line service. Table 8.4-10 Use/non Use of Computer Records Reported by B.C. Community Pharmacists, 1978 Yes No N/s Total Rx - 6 51 292 61 406 6-10 92 178 23 291 10- 58 81 3 142 201 551 87 839 Table 8.4-10 -shows that 201 or 24 per cent of the dispensing pharmacists used computerized records. Where workloads were in the range of six or fewer prescriptions per hour just 12.6 per cent reported computer use. Where productivity was over six prescriptions, computer use increased considerably; and 40.8 per cent of pharmacists who fi l led more than ten prescriptions per hour used this kind of tool. 8.44 , Patient Records and Patient Counselling Many studies of pharmacy practice have predicted a clinically, oriented "new role" for the pharmacist, one based less 228 on the technical functions of drug supply, and more on the knowledge system of pharmacy. (Study Commission on Pharmacy, 1975) (CPS 1971) The major Canadian study conducted in 1968 and 1969 indicated "that most pharmacists already spend as much as an hour a day consulting with patrons" (CPS 1971, p. 174). Since these studies there have been several types of record plans marketed to facilitate the counselling process, and in some jurisdictions patient records have become mandatory. St i l l there have been no changes to the large systems of disincentives (Evans and Williamson, 1978) (Study Commission in Pharmacy, 1975) which work against involvement of the pharmacist in record keeping and/or counselling, though this has been a matter of recent negotiation between Pharmacare and the B.C. Pharmacists' Society. As part of the 1978 survey (Appendix A) community pharmacists were asked to: "estimate what percentage of yjur time is spent reviewing patient medication records and counselling patients about their use of prescription and non-prescription medication" This question was separated from the time budget because of the difficulties experienced by several pharmacists who completed the pilot survey which had more categories in the time budget section. Pharmacists were also asked i f the pharmacy in which they practised had a patient record plan. 229 From Table 8.4-11 there were 345 or 41.1 per cent of the 839 dispensing pharmacists who used some type of records. In those cases where the pharmacist had noted that records were kept only for nursing home patients (mandatory under the Pharmacare agreement), this was coded as No record plan. Little difference was observed in the percentage who used records at workloads of ten or fewer prescription per hour. However where workloads were over ten prescriptions the incidence of records dropped to 31.7 per cent. Table 8.4-11 Use/non Use of Patient Records Plan Reported by B.C. Community Pharmacists, 1978 Yes No N/s Total Rx/hour - 6 177 217 12 406 6-10 123 154 14 291 10- 45 90 7 142 345 461 33 839 When the responses of the 427 pharmacy managers were considered separately the data indicated an almost even split of numbers of outlets with and without record plans. A higher rate of use was noted among owner operated and prescription specialty pharmacies. Just two of 26 department stores reported use of records. It may be important to note that since the survey period a major chain has implemented record plans in its pharmacies. On a regional basis the use of record plans...was well above average in the Qkanagan - South Central region arid the Kooteney area. A wide range of estimates of time spent in patient counselling and record review was observed. Among managers the maximum was 80 per 230 cent of time,and for staff this was .95 per cent. There were 76 pharmacists for whom an estimate of zero counselling time was coded, but this may also contain some non-response to the question. Table 8.4-13 Estimated Percentage Time Spent in Review of Patient Records and Medication Counselling Reported by B.C. Community Pharmacists, 1978; Showing Position in Practice Staff Owner/Manager Total Counsel 0 34 42 76 1 - 10 195 19] 386 11 - 15 44 35 79 16 -20 64 45 • 109 21 - 30 61 41 102 31 - 50 33 34 67 51 - 14 6 20 445 394 839 x 2 = 9.25 x 2 g 5 (6) = 12.59 shows that the modal category was an estimate of between one and ten per cent of time spent in patient counselling and record review. Fully 46.0 per cent of pharmacists indicated this range of counselling in their practice, which on the basis of a five day, thirty-five hour week would indicate a maximum of about 45 minutes per day. No significant differences were observed between the estimates of staff and owner/manager dispensing pharmacists. 231 Summary of Findings 1. Almost half of the dispensing community pharmacist reported "usual" dispensing workloads of .200 or fewer prescriptions per week, which on an annual basis would be under 10,000 prescriptions. 2. Workloads above 400 prescriptions per week, as expected by the large volume chains, and defined by the Commission on Pharmaceutical Services (1971) as "ideal", were reported by 106 or 16.8 per cent of the 631 dispensing community pharmacists in full time positions. 3. Lower hourly prescription workloads were associated with ownership or management status. 4. In terms of trained manpower, a large source of what might be described as non-utilization of resources was evident in that 218 or 46.4 per cent of staff pharmacists were in part-time employment. Many pharmacists freely choose this type of employment pattern, but as has been discussed in other sections, there are some for whom part-time employment is a "no choice" situation. The B.C. Pharmacists' Society has moved to strengthen its employment relations services with the goal of assisting employee pharmacists-in their bargaining with employers. A system of ensuring representation of part-time employees on Society committees may also assist in advancing the perspective of this group. 232 5. Approximately one half of dispensing pharmacists reported that they worked with a pharmacy assistant, and one quarter used a computer system. Where productivity was over ten prescriptions per hour these inputs were twice as likely to be used as when productivity was six or fewer prescriptions per hour. 6. Over thirty-five per cent of staff dispensing pharmacists reported hourly workloads of six or fewer prescriptions per hour which is below the breakeven point for hiring auxiliary personnel. This level of productivity effectively requires them to perform most of the clerical and technical tasks associated with the dispensing process. 7. Almost half of the community dispensing pharmacists estimated that they spent between one and ten per cent of their time in the review of patient records and medication counselling.. In a seven hour day this represents a maximum of 45 minutes devoted to the "new role". 233 8.45 , Activity Patterns of Community Pharmacists Earlier Canadian studies (Morrison, 1962) (Ross, 1968) (CPS, 1971) found that community pharmacists distributed their time over a wide range of activities. The Commission on Pharmaceutical Services (1971, p. 154) concluded that "over one-third of community pharmacists s t i l l spend less than one-half their working time on dispensing and related duties." This "substantial amount of under-utilization" was attributed to low prescription demand due to excessive decentralization of services into smaller, marginal units where non-prescription sales subsidized the pharmacy operation. The thrust of more recent studies of pharmacist activities has been to identify the functions of the pharmacist so that better judgements of personnel needs and allocations can be made (Rodowskas and Gagnon, 1972); and/or to provide more accurate estimations of the costs of providing prescription service. (Siecker, 1977). In order to obtain information about the activities of dispensing pharmacists, a modification of the Siecker (1976, pp.254-263) time allocation study was used. Pharmacists were asked to describe their "typical working week" by estimating the percentage of time they spent in the following categories: 1. Prescription Department Management Functions (PPM) Time spent in ordering stock from wholesalers and detail men, recording in what books, decisions on drugs to be stocked. 234 Scheduling, training and supervising dispensary staff, including pharmacy assistants. 2. Prescription Department Duties (PDD) Time spent dispensing prescription medication, including packaging, labelling and recording prescription transactions. Searching for, and communicating information about prescription, non-prescription and pharmacy area medication. 3. Duties and Management of Front Store (DFS) Time spent in management duties of the areas outside the dispensary. Includes opening and closing, daily bookkeeping, banking, cash management. Supervising, hiring front store staff, and salary administration. General selling, ordering OTC, cosmetic and sundry merchandise. 4. Other Duties Major duties which are unique to your practice. Except for the inclusion of the residual fourth category, the time allocation titles were the same as those which had been used in a 1977 trial by the B.C. Pharmacists' Society. The short explanation of each category;'.represented an addition, and it should be noted that the communication functions associated with non-prescription and pharmacy area medication were allocated to the prescription department. It was recognized that this was not consistent with the 235 Siecker methodology which had as its objective a very clear separation of activities for cost assignments. However, this inclusion of all medication counselling functions in the category of prescription department duties (PDD) was consistent with the intent of provisions of the Pharmacy Act (1974) which regulate non-prescription medication removed from public access (NPM) and pharmacy area self-selection medication. More rigorous separation of activities would have required more categories; and considering the comments of pharmacists who participated in the survey pre-test, different study methods. No analysis was made to determine the content of the residual "Other Duties" category; and again i t should be noted that no on-site observations were conducted to validate the time allocation estimates. The responses of 839 community pharmacists are detailed below. As was outlined in a previous section all of these persons provided information of their weekly hours and dispensing loads; and as well completed the question which adked them to estimate how they divided their time during a "typical working week". Because of the historic concerns that owner/manager pharmacists spend large amounts of time in front shop activities the time allocation estimates were first separated by position. In Table 8.4-14 the means of the percentage estimates (rounded to the nearest whole number) were summed to display an average "Time Budget" for each group. The range across each category was wide, but on 236 average staff pharmacists estimated that they spent 76 per cent of their "typical Working Week" in prescription and other medication;: related activities (PDD), with a further 10 per cent of time spent in prescription department management ,(PDM). The mean estimate for time spent in front store activities (DFS) was 9 per cent, with a further 5 per cent spent in "Other" activities. Table 8.1-14 Mean "time budget" of B.C. Community Pharmacists, 1978; Showing Position in Practice Staff Owner/manager Category (%) PDM 10 14 PDD 76 51 DFS 9 27 Other 5_ 8 Total % time 100 100 # reporting (445) (394) Mean weekly hours 30.7 44.1 Among the 394 managers the average of the estimates of time spent in prescription and other medication related studies was 51 per cent, with prescriptions management accounting for a further 14 per cent. The mean of the estimates of front store time (DFS) was 27 per cent, or three times that estimated by staff pharmacists. 237 The thrust of the Siecker (1977) study was to develop a method of apportioning pharmacist time costs across the entire pharmacy operation. The small sample was not intended to provide comparative data, but it did indicate that "a charge-off of all pharmacist salary to the prescription department would be an overstatement of the department's cost of operation". (Siecker 1977, p. 163) From Table 8.4-14 the general prescription department duties (PDD) and prescription management (PDM) estimates were considered appropriate charge-offs by staff and owner/managers, though in individual situations the content of the residual category might warrant its inclusion. The cost of pharmacist time per prescription was calculated as: PDD + PDM x $10.00 100 = $Cost Pharmacist time per prescription Rx/Hour For the sake of simplicity the cost of dispensing pharmacist time (PDD) and management time (PDM) were both set at ten dollars per hour, and the 86 per cent charge-off for staff pharmacists can readily be seen to be $8.60. For owner managers this was $6.50 per hour when time apportioned to front store (DFS) and other duties were removed. Table 8.4-15. indicates a time cost difference of just six cents per prescription or 5.7 per cent, a margin which could have been attributed to error. Again the ten dollar charge might be modified for management (PDM) functions, but this basic rate was not considered to be out of line with staff dispensing pharmacist wages during 1978. 238 Table 8.4-15 Estimated Charge-off of Pharmacist Wage Cost per Prescription, Showing Position in Practice Staff Owner/manager PDD+PDM(%) 86 65 Mean Rx/hour 8.22 5.86 Cost/Rx ($) 1.05 1.11 # pharmacists (445) (394) Because there were large variations in the prescription workloads reported by community pharmacists, time budgets were calculated at several ranges of hourly prescription productivity. These are shown in Table 8.4-16. Table 8.4-16 Mean "time budgets" of B.C. Community Pharmacists, 1978; Showing Hourly Prescription Workload Rx/hour Category(%) -4 4-6 6-8 8-10 10-PDM 13 11 12 11 12 PDD 46 64 71 75 76 DFS 33 19 13 9 8 Other 8 6 6 5 4 Total % time 100 100 100 100 100 # Pharmacists(202) (204) (190) (101) (142) Not unexpectedly the amount of time pharmacists estimated was spent in prescription duties (PDD) increased with increasing workloads, and time spent in front store activities decreased sharply from a mean of 33 per cent at workloads of four or fewer prescriptions to 8 per cent where workloads were over ten prescriptions per hour. 239 Table 8.4-17 Estimated Charge-off of Pharmacist Wage Cost per Prescription at Varying Hourly Prescription Workloads, Showing Percentage of Pharmacists Reporting Use of Pharmacy Assistant, Computer Records -4 4-6 6-8 8- 10 10-PDD+PDM 59% 75% 83%. 86% 88%: Mean Rx/hours 2.60 5.01 7.06 9. 24 14.64 Cost/Rx($) 2.27 1.50 1.18 0. 93 0.60 # Pharmacists (202) (204) (190) (1 01) (142) % Assistant Use 26.7 34.8 58.4 65. 3 81.7 % Computer Use 10.9 14.2 41.1 32. 7 40.8 In Table 8.4-17 the Charge-off of pharmacist time per prescription was calculated for each level of productivity, again using $10.00 as the hourly charge for both prescription department management (PDM) and general prescription department duties (PDD). In addition to showing the pharmacist time cost, data which indicate the percentage of pharmacists reporting use of a pharmacy assistant and computer records are again displayed. Clearly these other inputs do not come without cost, but their increased use at higher levels of prescription productivity should be recognized by the profession. Also from Table 8.4-17, the magnitude of the variation..in pharmacist time cost at different levels of productivity are important to note. This ranged from $0.60 at the mean of 14.64 prescriptions per hour to $2.27 for those 202 pharmacists with workloads of four of fewer prescriptions per hour (mean = 2.60). Even when the costs of other inputs are considered, the data suggest B.C. community dispensing pharmacists were in widely varying cost situations at a time when the range of dispensing fees reported by pharmacare was narrowing. 240 Summary of Findings 1. The "average" time spent by owner/managers in prescription and medication related duties (including prescription department management) was .65 per cent. 2. For staff dispensing pharmacists the "average" time spent in prescription., and medication related duties (including prescription department management) was 86 per cent. 3. While the estimates of pharmacist time cost were not explored completely, there were indications that this cost varied considerably across each range of productivity. 241 CHAPTER 9 Institutional Pharmacy in B.C. The Canadian Council on Hospital accreditation (CCHA) has developedidetailed standards for pharmacy service in various types of institutions; and as well, there have been two major recommendations made for actual levels of pharmacist staffing in hospital settings. The first of these was made by the Canadian Society of Hospital Pharmacists (CSHP) to the Royal Commission on Health Services in 1962. (Ross, 1966, p. 92) (CPS, 1971, p. 356). More recently, during a series of meetings held in 1975, the federally funded Working Party on Standards for Institutional Pharmacy Service brought together provincial hospital pharmacy consultants, practising pharmacists, and educators. This group was chaired by Dr. J.A. Bachynsky in his capacity as Pharmacy Consultant to the Department of National Health and Welfare. The group was asked to make recommendations concerning scope of pharmacy services, staffing, and physical facilities in various types of institutions. Their work was confined to providing an overview of good pharmacy service "based on what actually was being done, rather than on what theoretically could be done." (Bachynsky, 1976). The final report was aimed at policy makers at the federal, provincial and individual hospital levels, and drew broad guidelines concerning "the breadth of service they can reasonably expect in an institution; as well as the criteria to determine the orientation and level of services, and the resources required to achieve these." 242 In B.C. between 1961 and 1968 the level hospital pharmacy staffing was quite consistently the lowest of all Canadian provinces, and for the last mentioned year the number of pharmacy department paid hours per 100 patient days averaged 7.8 hours. (D.B.S. 1970, p.15) This compared to the average for Canada of 11.4 and the high in Quebec of 15.3 hours. In Saskatchewan, which had a legal requirement for pharmacist staffing in institutions over 75 beds, there were 13.5 paid hours per 100 patient days. The number of hospital pharmacists in B.C. increased rapidly between 1974 and 1976, as did the number of licensed hospital based pharmacies. This was mainly due to the introduction of pharmacy service into small institutions. However neither the CSHP nor the 1975 Working Party guidelines for staffing levels have been adopted officially by the province. In the following brief sections staffing patterns in institutions reporting beds will be compared to the standards of CSHP and the 1975 Working Party. 9.1 Staffing Patterns in B.C. Hospitals The following sections detail the responses of 60 hospital pharmacy managers to questions concerning pharmacy staffing patterns. It should be noted that there was no information gathered to differentiate between acute care rehabilitation, or long term care beds. 243 9.11 Ratios of Beds per Pharmacist To implement the staffing pattern recommended by the CSHP "would require at least one pharmacist for every 67 beds in acute care hospitals" (CPS, 1971, p. 356) Between 1961 and 1968 this study reported that the ratio of beds per pharmacists decreased from 169.7 to 119.4 in Canadian hospitals. The 1978 survey data was provided by 60 hospital pharmacy managers from institutions which ranged in size between 10 and 1631 beds. They indicated that they had staffs of from one to twenty pharmacists for an average ratio of 130.9 beds per pharmacist. Table 9.1-1 shows that 21 hospital pharmacies or 35.0 per cent were staffed at a ratio of 75 or fewer beds per pharmacist, and these would certainly be within the CSHP standard. A further 25 hospitals or 41.7 per cent reported pharmacist staffing levels between 76 and 150 beds. The remaining 14 institutions had levels above 150 beds. Table 9.1 - Bed/pharmacist ratios calculated for 60 B.C. Hospitals, 1978 Beds/pharm. # % 75 21 35.0 76-150 25 41.7 151-225 6 10.0 226- 8 13.3 60 100.0 244 9.12 Ratios of Pharmacist Hours The use of paid pharmacy hours per patient day as a measuring device takes into account'part time workers as well as the occupancy rate of the hospital. The recommendations of the 1975 Working party were for 0.15 to 0.20 hours per patient day in acute care and short term rehabilitation units. In institutions providing chronic care, a staffing level in the range of 0.04 to 0.08 was considered appropriate. Neither occupancy rates nor actual patient day statistics were available, so an approximation of patient days was made by multiplying the number of beds by seven. This calculation assumes 100 per cent occupancy and will thus understate staffing where occupancy is low. Despite the obvious overstatement of patient days in this rough calculation,Table 9.1-2 indicates .that few of the responding institutions were likely staffed in the range of 0.15 to 0.20 pharmacist hours/patient day recommended for acute care hospitals. Table 9.1-2 Weekly Pharmacist Hours/beds x 7 calculated for 54 B.C. hospitals, 1978 ph. hours/beds x 7 # % .01 - .04 19 35.2 .04 - .08 27 50.0 .08 - .15 5 9.3 .15 - .20 1 1.9 .20 - 2 3.7 54 100.0 245 9.13 Pharmacy Assistant Staffing The Division of Manpower Intelligence (1974) considered the position of the pharmacy assistant in hospitals to be "broadly accepted" and with l i t t l e potential for "expansion of task delegation beyond the level which is currently found." The Canadian Commission on Pharmaceutical Services (1971) concluded that "an equal number" of assistants were currently being employed in hospitals. Of 58 responses from inpatient institutional pharmacy managers, there were 31 or 53.4 per cent who reported pharmacy assistants on staff. The mean ratio of pharmacists to assistants was two to one. In addition there were responses from 11 institutional or government pharmacies with no inpatient beds. These pharmacies employed a total of 13 pharmacists and 6 assistants.. 9.2 Drug Distribution Systems in B.C. Institutions An automatic ward stock replacement system or unit dose were recommended for acute care and short term rehabilitation facilities by the 1975 Working Party. For all chronic care institutions a monitored dose system was the first choice. Table 9.2-1 shows the drug delivery systems reported as "mainly" used in 68 B.C. institutions. This response is likely biased to the top part of the l i s t , because where multiple responses were given the first was coded. St i l l i t indicates that some type of ward stock system was used in close to 80 per cent of these pharmacies. 246 Table 9.2-1 Drug Delivery Systems "Mainly Used" in 68 B.C. Institutions, 1978 Individual Rx 7 Ward stock 21 Combination of above 33 Unit dose 2 Monitored dose 4 Other 1 68 From these same 68 responses, there were 33 managers who stated that another system whould be best in the institution in which they practised. These preferences were mainly for unit dose (15), combination ward stock (10) and monitored dose (4). 9.3 Activity Patterns of Institutional Pharmacists Three recommendations for use of pharmacists' time were made by the 1975 Working Party. These concerned: 1. Mechanics of medication systems: not more than 25 per cent of pharmacists' time. 2. Material management: not more than 10 per cent of pharmacists' time. 3. Regular review of patients' therapy: not less than 25 per cent of pharmacists' time. The design and testing of a separate time budget question to reflect all of these functions was considered to be beyond the scope of the study. The 154 hospital pharmacists who attempted the time distribution adopted from Siecker (1976) indicated that they were highly involved in unique practice activities. Some of these included special medication programmes such as I.V. additives, 247 Hyperalimentation, and also teaching activities. Table 9.3-1 presents the responses of these pharmacists to the question which asked them to estimate the percentage of time they spent "in the regular review of drug therapy of individual patients, and total use of drugs in the institution." The largest number of responses were in the range of one through ten per cent. It should be noted that no observation studies were conducted to validate the estimates, but this range is clearly lower than the recommendation that 25 per cent of pharmacists' time be spent in this function. Table 9.3-1 Estimates of Percentage Time Spent in Drug Use Review, BC Institutional Pharmacists, 1978 % time # % 1-10 50 32.5 11-20 16 10.4 21-30 20 13.0 31-50 29 18.8 51-70 7 4.5 71- 11 7.1 N/S 21 13.6 154 100.0 On the other hand there were 47 pharmacists who estimated that therapy review activities consumed more than 30 per cent of their time. 9.4 Dispensing Workloads of Institutional Pharmacists From the responses of 179 institutional pharmacists, there were 143 or 79.9 per cent who indicated that they were involved in 248 dispensing in their practice. However there were fewer than 100 who could quantify their workloads in terms of "number of prescriptions filled". This would be expected, because over,80 per cent were employed in institutions which used drug distribution systems based, at least partially, on ward stocks. No tables have been presented to detail these workloads because the range was very wide over relatively few cases. 249 Summary of Findings 1. Almost half (48.5%) of the managers of institutional pharmacies had a recommendation for change concerning the type of drug distribution system currently in use in that institution. 2. The average bed per pharmacist ratio was 130.9 among 60 responding institutions in 1978. 3. While the comparisons of staffing levels with those recommended by the 1975 Working Party undoubtedly contain distortions, i t would appear that few BC institutions are staffed to meet these standards. 4. In 1978 just over one-half of institutional pharmacy managers reported that their staffs included a pharmacy assistant 250 CONCLUSIONS AND RECOMMENDATIONS Three main organizations are involved in planning the policies of education, regulation and advocacy within the profession of pharmacy in British Columbia. The first of these is the College of Pharmacists of B.C. which is the licensing body responsible for the administration of the Pharmacy Act. Secondly, there is a voluntary agency, the B.C. Pharmacists' Society, which is the economic self-interest group of the profession. Finally the Faculty of Pharmaceutical Sciences at the University of British Columbia prepares students to meet the academic requirements for entry to the profession. These three organizations interact, and as well, are influenced by the policies of the Education, Human Resources and Health Ministries of the provincial government. While each of the above groups has its own specific role, many interdependences, cooperative endeavours, and inevitably, conflicts among them have been long established. Because of the historic overlaps, the conclusions and recommendations which follow have not been arranged to speak to any one organization individually, but rather to the many concerns which have been aired throughout this thesis. All professions at this time are facing the dilemma of access. If too few are recruited, the traditional accusation arises that existing members are seeking to maintain a monopoly position, and to drive up price. If too many are admitted, the accusation 251 becomes that of inefficiency in allocation of resources, which again results in a high price. There is mounting evidence, as reported in this study that efficient allocation of resources is a problem, especially in community pharmacy practice. The prescription workloads of many pharmacists were below norms accepted in other parts of Canada, and part time employment was a common pattern. In addition, some recent graduates reported that they had had difficulty in finding employment in the profession. This study has focused mainly on the professional activities of pharmacists. Wide ranges were observed both in dispensing workloads and in the way pharmacists estimated they distributed their time. Further research will be required to identify the complex range of market pressures on the profession in B.C. It will be important for planners to examine these, as well as income levels, for they will be as important as the selected data presented here. The main factor in the growth of the College of Pharmacists of B.C. since 1974 has been an increase in the annual number or registrations of graduates from the local training programme. Beginning in 1971 the Faculty of Pharmaceutical Sciences at U.B.C. developed an innovative system of training which sparked the interest of both Canadian and American pharmacy educators. As well, the school expanded its enrolment in response to demand from prospective employers, and also to demands from young people for professional 252 education. Between 1974 and 1977 the percentage of persons under age thirty-five increased from 29.9 percent to 35.4 per cent of the total College of Pharmacists active register. In this study a method of projecting future growth of the College has been developed. The actual projections which have been made to 1990 indicate that while there is s t i l l a great potential for growth, it will not likely be at the rates experienced during 1974 to 1977. S t i l l , considerable potential growth is there, but i f the profession wishes to remain outside of government regulation of migration and enrolment, i t will have to monitor its own growth carefully. Government is rapidly becoming aware that high rates of growth, at least in the medical profession, contribute to increased health care costs. Recent policy decisions by Pharmacare indicate that there is a similar awareness concerning the profession of pharmacy. The results of the pharmacist survey conducted as part of this study indicate that the employment security of some of the recent U.B.C. graduates is questionable. A higher than expected number reported weeks out of employment in 1977, and as well there was a higher incidence of "no choice" part time employment among 1974-1977 graduates at the time of the survey. Of the 62 respondents who had graduated in 1977, there were 16 in "no-choice" part time work, 5 who were not employed, and one in non-pharmacy employment. Stated another way, 22 of these respondents or 35.5 per cent were not fully absorbed into the system after more than six months since graduation. 253 The comparisons of community pharmacist workloads with those described as "ideal" by the Commission on Pharmaceutical Services during its 1968 study, indicate that there is a "drug dispensing" overcapacity in the system. This could likely be overcome in some areas by the large scale consolidation of existing service to small communities into central "drug dispensing" units under government control. However, as has been stated before, i t has not been the policy of the federal or provincial governments in Canada to interfere with the traditional modes of organization of health care, but rather to endeavour to build into its various payment structures incentives to improve patient outcomes, and where possible to effect economies in the processes of care. The largest, and thus most influential third party payment agency for prescriptions, is the provincially financed Pharmacare programme. Since its inception in 1974 it has worked with the profession and within the existing organization of outlets toward a broad definition of community pharmacy service. The objective has been to balance the incentives which encourage the provision of accessible services both in terms of convenience and price, a range of sound professional services, and rational drug therapy. Pharmacare has been willing to recognize regional cost differences in its payment mechanisms, but it has moved to increase price competition within the profession. Since 1977 the rate of escalation of dispensing fees charged to Pharmacare has slowed, and the range across fees has narrowed. Little work was done in this 254 study to explore the cost structures of community pharmacies, however wide variations in pharmacist workloads indicated that as many as one-quarter of dispensing pharmacists were not generating enough revenue from prescriptions to cover their costs. Some pharmacy managers may be willing (and quite able) to subsidize dispensing activity through sales of other merchandise, but on-going efforts will be needed to assist pharmacists to become more aware of their costs. Work is proceeding at several levels within the profession to improve pharmacists' communication and counsel 1ing ski l ls . In addition, incentives to promote pharmacist participation in drug therapy review are at the point of revision. Survey data indicated that one-quarter of community pharmacists estimated that they were already spending between 15 and 30 per cent of their time in these activities in 1978. However, there were 46.0 per cent who, by their own estimation, spent just one to ten per cent of their time in communication about medication and in patient record review. For the field of hospital pharmacy comparisons of pharmacist staffing levels were made to standards established by the Canadian Society of Hospital Pharmacists. Conformity would require, on average, staffing by one pharmacist for every 67 beds. Of the 60 responses from institutional pharmacy managers there were 21 or 35.0 per cent of hospital pharmacies staffed at ratios of 75 or fewer beds per pharmacist. A further 25 or 41.7 per cent 255 indicated ratios between 76 and 150 beds. The mean ratio across the 60 institutions was 130.9 beds per pharmacist. Less successful comparisons were made with the recommendations of the 1975 Working Party on Standards for Institutional Pharmacy Service because patient day statistics were not known. S t i l l , i t would appear that few B.C. hospitals meet these more recent standards of staffing. As has already been noted, considerable planning has gone on in the profession with the assistance of government, to improve access to pharmacy service, and to improve the quality of that service. However governments at all levels are making demands for more controls on the costs, standards and efficiency of health services. Several advisory groups have been established, and while coordination is not yet complete, there has been large scale involvement by government in nursing and medical manpower planning in British Columbia. The cooperative efforts of all pharmacy organizations will be required to effect changes which must balance the interests of the profession and of society as a whole. Government has only recently recognized the potential of pharmacy to make a very significant contribution to the health of the public. This was explicitly noted by the Honourable R.H. McClelland, Minister of Health for B.C. , at the Canadian Pharmaceutical Association meetings held in Victoria in 1978. He reminded pharmacists that they were definitely in a situation parallel to that of the last person admitted to an already overcrowded lifeboat, and that their contribution to health care would be carefully scrutinized. 256 The following is a l i s t of specific recommendations which arise from the study: 1) That the College of Pharmacists of B.C. annual Registrar's statis-tical report be compiled from the PHARMFILE data base. 2) That the College of Pharmacists of B.C. annual Registrar's statistical report be expanded to provide information of the numbers of deaths and withdrawals among currently licensed pharmacists, and also the number of reactivations. 3) That hospital residency certification be recorded on PHARMFILE 4) That because of the uncertaincies surrounding the factors of growth of the profession; ie. enrolment levels, withdrawal from active licensing status, and migration; the College of Pharmacists of B.C. review each element of the forecasting model on an annual basis. 5) That after annual review of the elements of the forecasting model, revised projections based on explicitly defined changes in the assumptions be made i f necessary. 6) That the current and projected student enrolment levels be reviewed by the Faculty of Pharmaceutical Sciences in cooperation with the Health Manpower Research Unit for the likely effects on future growth, and the age and sex distribution of the profession. 7) , That the success of recent graduates in securing employment be monitored as an on-going project conducted by the College of Pharma-cists of B.C. and the B.C. Pharmacists' Society. This can be 257 accomplished as part of the pharmacist biography update process immediately following the licensing up-date of PHARMFILE. 258 B I B L I O G R A P H Y ANDREOPOULOS, Spyros, ed., National Heath Insurance: Can We Learn  from Canada? New York: John Wiley & Sons, 1975. BACHYNSKY, J.D. "Working Party on Standards for Institutional Pharmacy Service." The Canadian Journal of Hospital Pharmacy, (Nov. - Dec., 1976) pp. 179-182 BAKER, Timothy D., "Health Manpower Planning," in Health Planning:  Qualitative Aspects and Quantitative Techniques, edited by Reinke W.A. and Williams, K.N., Baltimore: The Johns Hopkins University School of Hygiene and Public Health, 1972. BOWEN, Howard R., "The Manpower vs_ the Free-Choice Principle." in Manpower Planning for Canadians: An Anthology, edited by Moore, L . F . , Institute of Industrial Relations. Vancouver, B.C.: University of British Columbia, 1975. BRITISH COLUMBIA, Pharmacy Act (1974) S.B.C., Ch. 62 CANADA, Statistics Canada. Population Projections for Canada and  the Provinces 1972 - 2001. Catalogue 91-514, June 1974. CANADA, Dominion Bureau of Statistics, Health Manpower in Hospitals: Pharmacists, 1961-68, Ottawa: Queens Printer, December, 1970. CARPENTER, Eugenia S., "Women in Male Dominated Health Professions." International Journal of Health Sciences, Vol. 7:2 (1977) pp. 191-207. Commission on Pharmaceutical Services, Pharmacy in a New Age. Toronto, Ont.: The Canadian Pharmaceutical Association, 1971. CURTISS, F.R., Hammel, R.J. Johnson, C.A., "Psychological Strain and Job Dissatisfaction in Pharmacy Practice: Institutional versus Community Practitioners." American Journal of  Hospital Pharmacy, 35; 1516-1520 (Dec. 1978. DEE, Donald A. , "Understanding Pharmacy Manpower in Terms of Society's Needs." Journal of the American Pharmaceutical  Association, Vol. NS 16:7 (July 1976) pp. 393, 416. DES ROCHES, Bernard P., "A Study of Women in Pharmacy." Report submitted to the Ontario College of Pharmacy, June 1973. 259 DUNCAN, G.R., "An Analysis of Pharmacy Manpower in Ontario." Faculty of Pharmacy, University of Toronto, 1975." EVANS, R.G., and WILLIAMSON, M.F., Extending Canadian Health Insurance: Options for Pharmacare and Denticare. A Report for the Ontario Economic Council. Toronto: University of Toronto Press, 1978. FREIDSON, Eliot, Professional Dominance: The Social Structure of  Medical Care. New York: Atherton Press, 1970. Health Services Research and Development, Rollcall-75 Health Sciences Centre, University of British Columbia, 1975. Health Services Research and Development, Roll col 1-77. Health Sciences Centre, University of British Columbia, 1977. HEWITT, G.B., "A Study of Pharmacy Manpower in British Columbia." Paper submitted to the Faculty of Education, University of British Columbia, 1971. HORNOSTYi Roy W., "A Comparison of Sex Differences Among Pharmacy Students in Canada, 1962 and 1972." Report submitted to the Ontario College of Pharmacy, February 1974. LINSKY, Arnold S., "Stimulating Responses to Mailed Questionnaires: A Review," Public Opinion Quarterly, Vol. 39 (Spring 1975): pp.82 - 101 -McCORMACK, Thelma Herman, "The Druggists' Dilemma: Problems of a Marginal Occupation." The American Journal of Sociology, LX1 (January, 1956.) pp. 308-318. MORRISON, Finlay A. , "Recruitment, Education and Utilization of Pharmacists in Canada." 1962. (Typewritten.) R0D0WSKAS, C.A. and Gagnon, J . P . , "Personnel Activities in Prescription Departments of Community Pharmacies." Journal of the American Pharmaceutical Association, Vol. NS 17:4 (April 1972) pp. 208-212. ROSS, Thomas M., Pharmacist Manpower in Canada. Ottawa: Royal Commission on Health Services, 1966. SIECKER, B.R., A Multisite Implementation of the Uniform Cost  Accounting System for Pharmacy. Washington: American Pharmaceutical Association Foundation, 1976. SIECKER, B.R., "The Uniform Cost Accounting System for Pharmacy Pricing Decisions." Journal of the American Pharmaceutical  Association, Vol. NS 12:8 (Aug. 1977) pp.407-411. 260 SLAYTON, P. and Trebilcock, .M.J. , eds., The Professions and Pub.1 ic Pol icy. Toronto: University of Toronto Press, 1978. SORKIN, Alan L . , Health Manpower: An Economic Perspective. Lexington, Mass.: Lexington Books, 1977. TORRANCE, George M., "The Influence of the Drug Industry in Canada's Health System." Paper prepared for the Community Health Centre Project (Hastings Project) Ottawa: Canadian Public Health Association, 1972. U.S. Department of Health, Education, and Welfare. The Effects of  Task Delegation on the Requirements for Selected Health  Manpower.Categories in 1980, 1985, and 1990. (HRA) 75-57, WERTHEIMER, Albert I . , and Gorgan, James E . , "Should we Regulate the Location of Pharmacies? " Journal of the American  Pharmaceutical Association Vol. NS 16:3 (March 1976) pp. 121 - 123, 136. 261 APPENDIX A The Survey Methodology In order to obtain information concerning pharmacist employment status and practice activity a mailed questionnaire was developed. Data was requested on position and practice field, geographic area, time distribution, weekly hours, age, sex, and usual prescription workloads. The Population All 1717 British Columbia resident pharmacists who held active practice licences with the College of Pharmacists of B.C. were included in the survey which was mailed on April 18, 1979. The computer based College register had been updated for status changes and address changes following the annual licensing process only a few days before the survey mailing l i s t was generated in mid-April. 262 THE MAILINGS The College of Pharmacists required its annual update of pharmacist biographical and employment level information during the survey period. A decision was taken to combine the mailing to avoid duplication of staff effort in the busy preconvention period. The addition of the College material made the survey package and return procedures slightly more complicated; but gave the advantage of a further office control measure for the protection of individual privacy. It was considered too, that the official College aura might aid in stimulating the return of the questionnaire. It had been planned to send the survey package into the field under the letter head of the B.C. Pharmacists' Society as the funding agency. In a review of methods of stimulating survey response Linsky (1975) reported conflicting evidence of effects of use of letter heads on response; but reported a definite increase in response when letters bore signatures. Two covering letters were felt to be necessary. The f irst , with a simple typed letter head naming the College and the B.C.P.S., explained the uti l ity and joint nature of the project and requested membership response. It bore the signatures and titles of College President John E. Little and B.C.P.S. President Fred W. Wiley. The second letter, with a blind letter head, gave directions for completion and return of the questionnaire, and went on to outlined the several provisions built into the survey process to protect individual privacy of response. It went out over the names of 263 all those persons who were members of the B.C.P.S. Manpower Committee. The final survey package consisted of: 1. Outer mailing envelope (labelled) 2. Questionnaire 3. Ballot type envelope 4. Stamped return envelope (labelled) 5. Pharmacist biography 6. Covering letters Identification of the envelopes (1 and 4 )above and a single follow-up postcard reminder notice, was accomplished using three sets of computer generated address lebels. The return envelope bore a large size commemorative issue stamp. All surveys were mailed on Wednesday April 18, 1978, and the bulk of the returns arrived during the week of April 24th. The College biographies and identifying envelopes were separated from the unopened survey material before the surveys were released for tabulation. The covering envelopes were matched against the remaining set of address labels. These matched labels were removed and the labels which remained became the reminder notice l i s t . The reminder notice took the form of a post card, and was mailed on May 10th when returns had slowed considerably. This mid-week date was the last day of the Canadian Pharmaceutical Association Conference in Victoria, and was chosen to coincide with return of pharmacists and B.C.P.S. staff. 264 The Coding Procedures and Data Processing Most of the responses to the survey were precoded. The exceptions were the questions dealing with area of residence and the open-ended career attitude responses. Where the pharmacist indicated a city or town of residence or practice this was assigned a number corresponding to its Regional District within the province. No coding material for the open-ended career attitude questions was prepared prior to mailing. The preferred occupational choices of medicine, dentistry and law were fairly obvious. However the rest of the categories, and those which described the reasons for dissatisfaction with the present practice field, were developed using frequencies of response from the first 300 surveys returned from the field. Each survey generated one punched card, with a second being used where needed for pharmacy manager responses. Frequency and crosstabulation tables were drawn using the programme SPSS at the UBC Computing Centre. 265 The . Survey_;Responseu The first 66 responses to the April 18, 1978 mailing of 1717 surveys were received on April 20, 1978. By Monday (April 22) a response rate of 20 per cent was noted. The final number of useable responses was 1343 for a response rate of 78.2 per cent. This tally, including refusals and responses received after Junel, is shown in Table A - l . Table A-l Number of Responses to the B.C. Pharmacists' Society Survey, 1978 # % Useable responses 1343 78.2 Late responses 6 0.3 Refusals, blank surveys 8 0.5 Total response 1357 79.0 Total mailing 1717 100.0 266 The Survey Respondents Despite the excellent survey response rate, the fact remains that the respondents were a self-selected group. Many questions remain about the non-response of the remaining 21 per cent of the profession. Because of these concerns the survey response was compared across several known characteristics of the entire membership as a check of representativeness. The variables chosen for comparison were sex, age, place of education., area of practice (on. residence), principle field of employment. A table is also shown for the number of recent (1974-77) UBC graduates who were registered. These variables are presented as frequency and percentage distributions in Tables A-2 through A-6. The computer tape which was available for these comparisons listed 1734 pharmacists, and was dated May 17, 1978. This was approximately one month later than the f i le which generated the total of 1717 pharmacists to whom surveys were mailed. However, i t seems unlikely that the addition of 17 persons would produce any major distor-tions. Two items may be worth noting from these very close comparisons. The f irst , involving field of practice, indicates the survey drew few responses from among the 18 pharmacists in employment classed as wholesale or manufacturing. The second involves region of practice for which the area described as Region #789 drew a slightly lower than expected response. It is probable that this survey had l i t t l e appeal 267 to pharmacists in very specialized practice fields; and probable that these people would tend to be resident in the lower mainland area. Regions #3 and #789 included all of Greater Vancouver, the Fraser Valley and Sunshine Coast. Table A-2 Survey Respondents and Total in-province Registrants, May 1978; Showing Sex of Pharmacist Survey Register Sex # % # % Male 941 70.1 1231 71.0 Female 400 29.8 503 29.0 N/S 2 0.1 - -1343 100.0 1734 100.0 Table A-3 Survey Respondents and Total in-province Registrants, May 1978; Showing Age of Pharmacist Survey Register Age # % # % -24 65 4.8 94 5.4 25-29 281 20.9 343 19.8 30-34 157 11.7 190 11.0 35-39 146 10.9 183 10.6 40-44 110 8.2 145 8.4 45-54 244 18.2 317 18.3 55-64 206 15.3 271 15.6 65-74 101 7.5 112 6.5 75- 29 2.2 32 1.8 N/S 4 0.3 47 2.7 1343 100.0 1734 100.0 268 Table A-4 Survey Respondents and Total in-province Registrants, May 1978; Showing Place of Pharmacy Education Survey # Register Place of Education % % British Columbia 991 73.8 1278 73.7 Canada, not B.C. 274 20.4 352 20.3 Outside Canada 74 5.5 100 5.8 N/S 4 0.3 4 0.2 1343 100.0 1734 100.0 Table A-5 Survey Respondents and Total in-province Registrants, May 1978, Showing Region of REsidence and/or Practice Survey Register )ion # % # % 1 142 10.6 185 10.7 2 98 7.3 121 7.0 3 114 8.5 144 8.3 4 148 11.0 188 10.8 5 55 4.1 73 4.2 6 90 6.7 113 6.5 7,8,9 635 47.3 910 52.5 N/S 61 4.5 - -1343 100.0 1734 100.0 269 Table A-6 Survey Respondents and Total in-province Registrants, May 1978; Showing Principal Field of Employment Survey Register Field # % # % Retail, Commun. 1071 81.9 1284 81.7 Hospital 176 13.5 186 11.8 University, Research 14 1.1 19 1.2 Fed., Prov. Govt. 18 1.4 15 1.0 Mnf, Wholesale 6 0.5 18 1.1 Phcy. Assoc., Coll. 5 0.4 6 0.4 Armed Forces - - 3 0.2 Other, Unkn. 17 1.3 41 2.6 1307 100.0 1572 100.0 Table A-7 Survey Respondents and Total in-province Registrants, May 1978; UBC Graduates by Year of Graduation 1974 to 1977 Survey Register UBC Grad # % # % 1974 52 21.4 65 21.2 1975 60 24.7 85 27.7 1976 69 28.4 83 27.0 1977 62 25.5 74 24.1 243 100.0 307 100.0 7 Regional Hospital D i s t r ic t 1 t u t koatenay 2 Central Koateniy 2* Koateniy Boundary 3 Okanagan-Slmllkaaeen 4 Columbta-Shuswap 5 tlorth Okanagan 6 Central Okanagan 7 Thompson-Nicola S Cariboo 9 Squamlsh-Llllooet 10 Fraier-Cheaa 11 Central Fraser Valley 12 Ocwdney-Alouettt 13 Greater Vancouver 14 Sunshine Coast 15 Powell River 16 Mount Uaddington 16a Ocean Falls 17 Skeena-Queen Charlotte 18 mimat -S t lk lne 19 Bulkley-Nechako 20 Fraser-Fort George 21 Peace Rlver-Llard 22 Stlklne 23 Capital 24 CoHlchan Valley 25 Nanalmo 26 Albcrnl-Clayoquot 27 Comox-Strtthcont REGIONAL HOSPITAL OISTRICTS OF BRITISH COLUHBIA -273 B R I T I S H C O L U M B I A P H A R M A C I S T S ' S O C I E T Y PHARMACY MANPOWER STUDY: Y o u r p r o m p t response to this survey w i l l he lp a l l o f us w i t h i n the p r o f e s s i o n t o bet te r u n d e r s t a n d the cu r ren t ro le of the p h a r m a c i s t in his o r her d a i l y p r a c t i c e , a n d w i l l assist in p l a n n i n g fo r f u t u r e m a n p o w e r needs . The i n f o r m a t i o n y o u s u p p l y w i l l be he ld in c o n f i d e n c e , and the survey p r o c e d u r e s have b e e n c a r e f u l l y d e s i g n e d so that no rep ly c a n be t r a c e d b a c k to any i n d i v i d u a l respondent . Ins t ruct ions : P lease answer by c h e c k i n g the a p p r o p r i a t e box for e a c h q u e s t i o n , o r by p u t t i n g a n u m b e r in the spaces p r o v i d e d . Ignore the s m a l l n u m b e r s w h i c h are p r i n t e d o n the survey , these are part o f the c o m p u t e r t a b u l a t i o n p rocess . K PERSONAL AND EDUCATIONAL BACKGROUND: In this section we would like information which will help correlate the survey response with the College of Pharmacists of B.C. registration data. Please answer J3 1. Your age -2. Your sex Male Female • • Where did you receive your basic pharmacy education? British Columbia 1 CD Canada, other than B.C. Outside Canada 3 D In what year did you become fully licensed in British Columbia? j j If you have a degree in Pharmacy from U.B.C, that is a B.S.P. or B.Sc. (Pharm.), what was your year i— i — of graduation? I l_ B. PRACTICE ACTIVITY: We would now like to know if you are presently in active pharmacy practice, as well as your general location in the province. 6. Please indicate the name of the CITY or TOWN where you do most of your prac-tice; or if you prefer to further protect your privacy, give the name of the REGIONAL HOSPITAL 0ISTRICT where you are located. Regional District or Community Name 7. For the year of 1977, please indicate, if applicable, how many weeks you were of work and seeking pharmacy out employment. 8. Which of the following best describes your present status? Employed in pharmacy 1 CI Go to Question #10 Employed outside of pharmacy Not employed Retired 2 • 1 3 • \ OFFICE USE ONLY 6-7 9 10-11 12-13 14-15 RHO • PA 16 17-18 19 PHARMACISTS NOT IN ACTIVE PHARMACY PRACTICE: 9. Please indicate the statement which comes closest to describing your efforts to return to active pharmacy practice DURING THE LAST THREE MONTHS. I have not considered returning to active practice, and I have not sought pharmacy employment 1 I have considered returning to active practice, but I have not sought pharmacy employment 2 • I have made efforts to return to active practice, and I have sought pharmacy employment in the area where I reside 3 O t have made efforts to return to active practice, and I have sought pharmacy employment in my own area, and in areas which would involve relocation 4 • Please go lo Question »14 PHARMACISTS IN ACTIVE PHARMACY PRACTICE: Full time employment is defined as 35 or more hours per week for 48 or more weeks per year... 10. Are you employed Fulltime 1 D Go to Question #14 Part time 2 D Please continue... PHARMACISTS IN PART TIME PRACTICE: 11. Do you work part time: By choice 1 • Only part time available 2 • 12. Which best describes your pattern of employment as a part time worker? Short weekly hours 1 • Few weeks per year 2 • 13. Would you consider moving to another community if full time employment was available? Yes 1 • No 2 • 1-4 00 5 274 C. CAREER CHOICES: Would you please Indicate your field of pharmacy practice, and also some of your feelings toward your career as a pharmacist. 14. Which one of the following categories best describes your present or most recent pharmacy employment situation? Answer by placing in the box below the appropriate number from the i—r— i table of codes. I—I—I 31-32 PHARMACY RELATES EMPIOYMEMT ACTIVITY Community Pf* •imacy Hoe p4 lei Pharmacy Ptwrmocoutksai h dwafry Owngr — 11 Chief pharmacist — 21 Management — 31 Manager — 12 Sole-charge — 22 Sales — 32 $< aft-regular — 13 Statt-disoensing — 23 Promotion - 33 Staff -casual — 14 Staff-con Butting — 24 Packaging, Mnt. - 34 Administrator — 15 Further Education Other - 91 TwcMng — 71 Graduate Studies — 61 Please specify: Cottage o» Sod •ttf —51 Residency program— 02 Provincial — 41 15. Pick the statement which best describes the way you feel toward your present field of pharmacy: I find it very satisfying, and I would not want to change fields • I find it not very satisfying, but I have not attempted to change fields 2 D I find it not very satisfying, and I have attempted to change tields 3 • 16. If you answered "not very satisfying" could you indicate why? 17. Since we have little^fiformation of the career length of practising pharmacists in Canada, would you please indicate the total number ot years you expect to practice i—•-in pharmacy I L 18. If you were starling all over to choose a career, which of the following statements comes closest to indicating your choice? I would choose pharmacy and the particular field in which I now practise 1 • t would choose pharmacy, but in another field I would not choose pharmacy I don't know 2 • • • 19. If you checked "not pharmacy", what would you choose? (Pharmacists not in active practice go to Question #55) 25 26 27-28 29 30 D. WORK PATTERN AND WORK LOAD: .The following questions deal with your hours of employment in a typical week, and your usual dispensing load. 20. Did you work four (4) or more hours last week? Yes 1 No 21. How many hours did you work last week? 2 • 22. Was this the usual number of hours that you are employed in a week? Y e s , Q Go to Question #24 No 2 D Please continue 23. How many hours do you work in a typical week? 24. In your pharmacy practice are you involved in dispensing prescription medication? Yes 1 • Please continue... No 2 D Go to SECTION E 25. How many prescriptions did you dispense last week? 26. Was this the number of prescriptions you would dispense during a typical work week? Yes 1 • Go to Question #28 No 2 D Please continue ... 27. How many prescriptions do you dispense in a typical week! 28. Do you work with a pharmacy assistant in the dispensing area? No 1 • During peak hours only 2 ED During almost all hours 3 • 275 E WORK SETTING AND TIME BUDGET: In the following section pharmacists are asked to describe their activities during a typical working week. Please proceed through the next set of questions according to your present field of practice. HOSPITAL or INSTITUTIONAL • Go to Question #29 COMMUNITY or RETAjJ _CL-v Go to Question #33 OTHER PHARMACY FIELDS • Go to Time Budget (#36) PHARMACISTS IN HOSPITAL OR INSTITUTIONAL PRACTICE 29. What percentage of your time is spent in the regular review of drug therapy of individual patients, and total use of r drugs in the institution? L 30. What type of drug distribution system do you mainly work with in your practice? Individual prescription 1 • Ward stock 2 • Combination of above 3 • Unit dose 4 • Monitored dose 5 • 6 • Not involved in drug distribution - Q ?tn > e C o J e e sV i o n i ( # 3 6 ) 31. Do you feel that this is i drug distribution system for this institution? y e s j Go to Time Budget (#36) No 2 • Continue... 32. Which drug distribution system do you feel would be best in this hospital or institution? Indicate by above numbers • PHARMACISTS IN COMMUNITY RETAIL PRACTICE: 33. Please estimate what percentage of your time is spent reviewing patient medication records, and counselling patients about their use of prescription and non- i— i—i prescription medication I I 1 % 34. Does the pharmacy in which you do most of your practice have: Computer (Unidrug) Yes 1 • No 2 D Patient record plan Yes 1 D No 2 D 48-49 50 51 52 53-54 55 56 35. Which best describes your practice organization? Community pharmacy Owner operated 1 Community pharmacy Chain - 4 or more 2 Prescription specialty 3 Department Store 4 • • • • TIME BUDGET STUDY We would now like to determine how you per-sonally distribute your time as a pharmacist during a typical week. We recognize that there may be many seasonal variations, and that you cannot make a very precise judgment. Still, we would appreciate it if you could give us some idea of what percentage of your time is spent in the areas outlined below. Obviously some of these functions are performed simultaneously, and any separation of them is difficult, though pharmacists who participated in recent cost accounting studies will likely recognize the major categories tor assigning their time. For those of you who are new to this concept • Please bear with us and do the best you can. Instructions: Please describe your typical weekly activities as a pharmacist by placing in the blanks the percentage of your time spent in each activity. Please check to see that the total percentage of time equals 100% 36. What percentage of your time during a typical work week is spent in: - A. PRESCRIPTION DEPARTMENT MANAGEMENT -FUNCTIONS Time spent in ordering stock from whole-salers and detail men, recording in want books, decisions on drugs to be stocked. Scheduling, training and supervising dis-pensary staff, including pharmacy assistants m » -- B. PRESCRIPTION DEPARTMENT DUTIES Time spent dispensing prescription medica-tion, including packaging, labelling and re-cording prescription transactions. Searching for, and communicating information about prescription, non-prescription and pharmacy area medication. I—I—I % -I - C. DUTIES AND MANAGEMENT OF FRONT STORE Time spent in management duties of the areas outside the dispensary. Includes open-ing and closing, daily bookkeeping, banking, cash management. Supervising, hiring front store staff, and salary administration. Gen-eral selling, ordering OTC, cosmetic and sundry merchandise i — i — i - D. OTHER OUTIES Major duties which are unique to your prac-tice |—i—i > NOTE: This total should equal 100 % 276 F. PHARMACY MANAGERS and CHIEF PHARMACISTS This section should be completed by one pharmacist per licensed community retail, hospital or institutional pharmacy. 37. Have you held your present position as manager for More than one year 1 O Go to Question #39 Less than one year 2 Q Continue ... 38. If you replied "less than one year", was your position New, resulting from business expansion 1 D Existing, replacing a previous manager 2 D 39. In the last year have you had a vacant position for a pharmacist? Yes 1 • No 2 • 40 If you answered "Yes" above, did you have any difficulty finding a pharmacist to fill this position? yes No In the last year have you hired a pharmacist? Y e s No • • 1 • Continue. 2 • • Go to Question #43 42. Please indicate the number of pharmacists hired in your pharmacy in the following categories: Permanent Staff: New position resulting from business expansion [ | Permanent Staff: Replacement position [__] Temporary Staff: Replacement due to Illness, vacation of regular staff 43. How many pnarmacists (including yourself) are employed in the pharmacy i— i you manage? I—I 44. What is the total of PHARMACIST HOURS worked in a typical week in this pharmacy? Answer by adding together the total number of hours worked by all pharmacists, and record 45. How many pharmacy assistants are employed in your pharmacy? r r 46. What is the total of PHARMACY ASSISTANT HOURS worked in atypical week r-in this pharmacy? I— 47. How many hours each week is the pharmacy open? Please add together the hours for each day of the week, r-and record total L LT n r 1-4 5 10 11 12 13 14-15 16-18 19-20 21-23 24-26 48. Was the total number of prescriptions (Including repeats) filled in your pharmacy last week the number that you would expect to be filled during a typical week? Yes No 1 • 2 • 49. Please record the total number of prescriptions filled: TOTAL NUMBER of PRE- r SCRIPTIONS LAST WEEK L TOTAL NUMBER of PRE-SCRIPTIONS TYPICAL WEEK 27 28-31 32-35 HOSPITAL and INSTITUTIONAL MANAGERS Please record prescription volumes for AMBULATORY and OUT-PATIENTS and STAFF only. 50. What is the rated bed capacity of your institution? LT COMMUNITY PHARMACY MANAGERS: 51. How many nursing home beds do you now serve? r FOR THE ENTIRE YEAR OF 1977: 52. Please estimate the percentage of prescriptions billed to PHARMACARE? 53. How many prescriptions (total new and repeat) were filled in this r-pharmacy? L II 54. What percentage of total sales volume was derived from prescriptions in 1977? 36-39 40-43 44-45 46-51 52-53 ALL PHARMACISTS: 55. You have now completed the questionnaire, and we would like to thank you for your participation. If you have any questions or comments, please contact: B.C. Pharmacists' Society #1400 • 207 West Hastings Street Vancouver, B.C. V6B1K5 Phone: 688-6438 Elaine Polglase Phone: 224-0558 1. SEAL YOUR COMPLETED SOCIETY SURVEY IN THIS ENVELOPE. 2. ENCLOSE THIS ENVELOPE WITH YOUR COLLEGE BIOGRAPHY IN THE STAMPED RETURN ENVELOPE. 3. MAIL PROMPTLY. 

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