HANSARD

NOVA SCOTIA HOUSE OF ASSEMBLY

STANDING COMMITTEE

ON

HEALTH

Tuesday, August 8, 2023

COMMITTEE ROOM

Expanded Scope of Pharmacists

Printed and Published by Nova Scotia Hansard Reporting Services

HEALTH COMMITTEE

Trevor Boudreau (Chair)

Kent Smith (Vice Chair)

Chris Palmer

John White

Danielle Barkhouse

Hon. Brendan Maguire

Rafah DiCostanzo

Gary Burrill

Susan Leblanc

In Attendance:

Judy Kavanagh

Legislative Committee Clerk

Philip Grassie

Legislative Counsel

WITNESSES

Pharmacy Association of Nova Scotia

Allison Bodnar

CEO

Nova Scotia College of Pharmacists

Beverley Zwicker

CEO and Registrar

HALIFAX, TUESDAY, AUGUST 8, 2023

STANDING COMMITTEE ON HEALTH

1:00 P.M.

CHAIR

Trevor Boudreau

VICE CHAIR

Kent Smith

THE CHAIR: Order. We will call this meeting to order. This is the Standing Committee on Health. I am Trevor Boudreau, the MLA for Richmond and Chair of the committee.

Today we are hearing from the Pharmacy Association of Nova Scotia and the Nova Scotia College of Pharmacists regarding the Expanded Scope of Pharmacists.

I’d ask all members - and anybody else in the room - to make sure your phone is on silent. I’m going to check mine too. In case of an emergency, please use the Granville Street exit.

What we’ll do first is have committee members introduce themselves with their name and constituency. We’ll start to my left here with MLA Smith.

[The committee members introduced themselves.]

THE CHAIR: Thank you, members. For the purpose of Hansard, I’ll also recognize the presence of Legislative Counsel Philip Grassie, who’s back with us for a second round after the last meeting, and Legislative Committee Clerk Judy Kavanagh.

As I mentioned before, the topic at hand is the Expanded Scope of Pharmacists. I’d like to welcome the witnesses. As they both know, I’m going to give a shout-out to my wife, who’s a pharmacist, and I think there will be a few other members who will give a shout-out to family members or friends who are also pharmacists in Nova Scotia. I just wanted to put that on the record, just in case my wife is watching at home.

Basically, at this point we’ll ask witnesses to introduce themselves. Once you do your introductions, we’ll have some time for you to do opening remarks. I’ll start with Ms. Bodnar.

[The witnesses introduced themselves.]

THE CHAIR: At this point, we’re open for opening remarks. I’m not sure which of you would like to go first. Ms. Bodnar.

ALLISON BODNAR: While the scope of pharmacy practice for pharmacy professionals in the last three years has expanded somewhat, the reality is that Nova Scotia has had one of the broadest scopes of pharmacy practice for over a decade. What has really changed in the last three years is the recognition and acceptance of the role our pharmacy professionals can play in our system, and the willingness to look at innovative health care delivery models to support the evolving needs of patients.

Pharmacists are the medication experts in our system. Pharmacy technicians are the experts in all the technical aspects of pharmacy, including dispensing, point-of-care testing, device demonstrations, and play a key role in the administration of injections. If utilized effectively, our pharmacy teams could support fundamental changes to how care is delivered in Nova Scotia.

What do I mean by this? Most prescription renewals - and I mean millions of them a year - should be done by pharmacists, at the pharmacy, by a professional familiar with the patient. We should not be wasting valuable ER, urgent care, mobile care, virtual care, NP, or physician time on most of these prescriptions.

Envision a medical neighbourhood model where physicians, NPs, and pharmacy teams work to co-manage chronic-disease patients, with the physician and NP focusing on a diagnosis and then sending the patients to the pharmacy with their information to prescribe and manage those medications with shared documentation and collaboration throughout the patient journey. Imagine having immunizations and injections fully managed at pharmacy. Pharmacy professionals have the expertise - after a few million COVID and flu shots - and exceptional cold chain management, and can instantly record those immunizations in CANImmunize, creating or updating the patient record instantaneously, providing patients and other providers with the information they need when they need it.

Why do we waste such scarce resources treating minor ailments at ERs or urgent care? Pharmacists have had this scope since 2011. With over 300 pharmacies across the province with extended hours of operation, patients could seek care where and when they need it, avoiding delays in treatment, advancing conditions, and unnecessary absenteeism from employment.

What would this mean for our system? Patients would have more options for timely access to care and would need to see their GP or NP fewer times per year, opening up the opportunity for larger rosters and reducing the need to continually increase the number of providers in Nova Scotia. As a province with one of the highest physician-to-population ratios, we need the system to work more efficiently and more effectively to support all providers to full scope.

What’s in our way? We don’t have the system support or infrastructure to change the way health care providers practice. To move ahead with a primary care system that has multiple access points - just think of the last few years. Virtual care, mobile care, urgent care, nurse practitioners, GPs, pharmacists - all with isolated and independent records. For primary care, all providers must be able to see and document into a patient record. We must absolutely prioritize OPOR - One Person One Record - for our community providers. Acute care is absolutely important, and I know that’s been the focus, but more care is done in community, and now that we have more access points to that care, we absolutely need to prioritize OPOR. We can no longer delay creating this infrastructure.

As for support and recognition for the pharmacy workforce, the government has focused a lot of attention on supporting physicians and nurses through COVID, and now with their HR challenges. Little has been done to support the pharmacy workforce, which, like nurses and physicians, has been dramatically impacted by COVID, as well as a long history of financial cuts to the industry. The pharmacy workforce is not just about pharmacists - we need technicians and qualified assistants so that pharmacists can be freed up to work to their full scope. Classes for pharmacy technicians have dramatically declined. Classes for our Pharm D program are only at 70 per cent capacity. The reasons for this are very complicated but we need to work collaboratively to improve this situation for all to benefit.

Many people like to blame the corporate business model or the fact that pharmacy professionals are not the employees of government for the issues in pharmacy. I would point out the physicians are not employees of government either - they’re also independent contractors - but it’s not that simple. Our provincial contract terms, the services paid for, and how they are paid impact professionals, directly or indirectly, and affect all pharmacy professionals, whether employed at a small independent pharmacy or a national corporation. We need to work collaboratively to understand the value our professionals bring to the system, the issues affecting them, and how we can work to fully utilize them for the benefit of patients and taxpayers.

As an association that represents pharmacy professionals, we are working tirelessly to support new workflow models that support patients and our teams. Our community pharmacy primary care clinic is an innovative model that provides timely access to primary care. We have provided over 41,000 services in the first six months, including 10,000 strep assessments - people who would have all needed to seek care elsewhere. It has also changed the professional life for the pharmacists who are working there. We hear things like, “I am so grateful” and “I have waited 20 years to practice this way, and now I’m finally here.”

These clinics are a win for patients, pharmacy professionals, and the system, and I truly hope you will support the expansion of these clinics across the province. Health care is complicated and change is hard, but no health care provider should be waiting on the sidelines while patients are waiting for care. I am encouraged by the efforts being made to improve access to care for all Nova Scotians and hopeful that we can continue to work collaboratively to truly incorporate pharmacy professionals into our primary care system in Nova Scotia.

THE CHAIR: Thank you, Ms. Bodnar.

Ms. Zwicker.

BEVERLEY ZWICKER: I’ve certainly been looking forward to our meeting today. As the pharmacy regulator, we are government’s partner in health care. We share a single focus on working to what’s in the best interest of the public, and the advances that have been made in repositioning pharmacy in primary health care - particularly over the last couple of years - are providing better care, not band-aid care. They are moving us in the right direction toward individuals being able to receive the right care from the right person at the right time. The full impact of improved access to care and improved quality of care that will come through pharmacy being optimally repositioned in primary care is still ahead

-   we’re not there yet. There are still significant gains that can be made, and that’s good news, because we still need to make some significant gains.

The largest barrier that the NSCP has encountered and continues to encounter, to that end, is entrenched thinking that is rooted in an outdated and historic paradigm where physicians and nurses are the only professions recognized as having the breadth of knowledge necessary to provide primary health care to the population, where the other professions are understood to play a supporting role, and are often referred to as allied health care professionals. In that historic paradigm, pharmacy was understood as the allied health care professional with a primary supporting role of drug dispenser. I would flag any time that the term allied health care professional is used - it’s an indication that there is a historic paradigm at play that you need to pause and rethink.

This entrenched thinking exists broadly across society. It impacts government and system planners - the decisions about which professions are at the senior tables for planning and implementing change to the health care system. It impacts the nature of government’s relationship with nursing and physicians versus the other health professionals that Allison mentioned.

It impacts what practitioners believe - physicians, pharmacists, nurses - about what their role is and what the roles of others are in the health care system. It impacts what the public believes access to health care should look like, and what a fix to our health care system looks like.

I’m going to provide you with some information that’s aimed at helping you to disrupt some entrenched beliefs that you may have about pharmacy. Pharmacy, the profession - not the drug store, the profession - and the professionals. In Nova Scotia, there are 1,450 pharmacists - university-educated health care providers with broad and deep education and competencies in health care. There are 250 licensed pharmacy technicians who have expert technical skills needed to accurately dispense and compound drugs, and also administer injections and perform tests. There are any number of pharmacy assistants. We don’t regulate pharmacy assistants, but they are also in the pharmacy working to help support the work in the dispensary.

There are 315 community pharmacies in which many of these professionals practice. They also practice in different locations, certainly in hospitals, but increasingly in some innovative community care clinics. There are some who are practicing in a community care clinic within a community pharmacy. There are some who are set up and practicing in a community that has been set up by a pharmacy, but there is no dispensary. Then there are some primary care clinics that have been set up by NSHA, and again, they’re more collaborative, they’re with health care teams, and there’s no pharmacy dispensary there. Again, there are those who work in hospital.

As the pharmacy regulator, we establish the scope of practice for these licensed health care professionals. Our approach is to begin with the core competencies of the pharmacist - which again, is broad and deep in health care related to medications - certainly more so than any other profession - but is not limited to medications. Pharmacists have completed a minimum of six years of university education. Currently they’re graduating with a Doctor of Pharmacy degree.

They begin by completing at least two years of specific prerequisites in biomedical sciences, including anatomy, physiology, biochemistry, and microbiology. They then build on this foundational education with the pharmacy program, another four years of intensive education - the pharmaceutical sciences of pharmacokinetics, pharmacogenomics, therapeutics, pharmacology. All of that is integrated in the medical sciences of pathophysiology, immunology, cardiology - the full scope of health systems that comprise the human body - the cardiovascular system, the nervous system.

The pharmacy program also trains pharmacists in patient assessment and physical assessment, ordering and interpreting labs, focused medical history-taking, health promotion and wellness, lifestyle, and other non-drug strategies. It prepares pharmacists to provide patient care in consideration of unique ethnic and cultural factors, and also unique factors for special populations - the elderly, pregnant, the gravely ill.

[1:15 p.m.]

Pharmacists are equipped to identify and address drug-related problems, and those solutions can include referral to another health care professional or can include a solution that is not a drug treatment. It’s true that pharmacists are often referred to as medication experts, and that is certainly true, but they are much more. They are health care professionals with a specialization in medications.

As I mentioned at the beginning, there are gains to be realized by optimally repositioning pharmacy - the profession - in health care. We have stood up truly innovative health care delivery models in Nova Scotia over the past couple of years - Virtual Care Nova Scotia, mobile primary care clinics and the pharmacy primary care clinics.

Now we need to take these new pieces and we need to not only try to retrofit them into an old system, but we need to intentionally build and incorporate them into a redesigned health care system with redesigned patient-care pathways, new technology communication platforms that will connect these new pieces with the information between health professions, and a redesigned system of governance and oversight. Pharmacy, the profession, needs to be involved in planning and making decisions around this redesign.

I look forward to our discussion today. Thank you so much.

THE CHAIR: Thank you very much for your opening remarks. At this point, we go into the Q&A session, where members get to ask questions of the witnesses. I’ll just remind everybody how it works. Basically, I’ll direct the questions through the Chair, so I’ll recognize either the member or the witness and you’ll see your microphone come on. That’s when you know you can speak, and it’ll be translated into Legislative Television.

Each caucus gets 20 minutes per round. There are basically two rounds: 20 minutes for each caucus, and then the second round will be determined by how much time we have left at that point. We’ll try to wrap up questioning around 2:45 and then at that point, if there are closing remarks by witnesses, you’re able to do that as well.

We’ll begin. At this point we’ll start with the Liberal caucus. I believe MLA Maguire has the floor.

HON. BRENDAN MAGUIRE: Thank you for being here today. I will start by saying I think the witnesses - it’s a little bit incomplete. It would have been nice to have somebody from NSHA or the Department of Health and Wellness here, because you’re not going to be able to answer some of the questions we’re going to ask because they are policy questions.

I’m going to go back to February. February to May 1^st was when the government made the big announcements on the pharmacy clinics. I remember being in Estimates and questioning the minister on these announcements. One of the things the minister said was that this is ready to go - we have the staff, we have the resources, and this is going to be a great thing for our community.

We didn’t deny it. My question is: Of the 26 that were announced, are all 26 still

open?

THE CHAIR: Ms. Bodnar.

ALLISON BODNAR: We have currently - 26 didn’t open. We had 25 that opened.

BRENDAN MAGUIRE: And now it’s 26.

ALLISON BODNAR: The 26^th hasn’t opened yet. They’re opening on August 28^th. That’ll take us to 25. The 26^th was open until July 1^st, and then there was a maternity leave that they couldn’t fill over the Summertime. But the other maternity leave comes back in September, so they will reopen in September. By the second week of September, all will be open again.

BRENDAN MAGUIRE: So just yes or no: All of the ones that were announced are still open today? Every single one of them is still open, and has the staff?

ALLISON BODNAR: Again, we will have 26 sites open. One of those sites was switched. When it was announced, Lawrencetown was one of the second phase on May 1^st

-  it was one of the second-phrase pharmacies announced. The staff they had in place at that time took a position elsewhere. They have been unable to fill that position, so we made a call mid-Summer to switch that location to Aylesford, and that is the location that will be opening to fill that position on August 28^th.

BRENDAN MAGUIRE: I just want to read you a message I received from someone in one of those communities over the last couple of days: “Just an FYI, the community pharmaceutical clinic that opened in Amherst has closed very soon after it was opened due to staff shortages at the pharmacy.” You said all 26 of them are still open, yet we’re getting reports from the ground that one was shut down shortly after it was announced. I’m assuming that would be the one at 158 Robert Angus Drive. So how do we square what you just said to what’s happening on the ground?

ALLISON BODNAR: That’s the Amherst location that has the maternity leave that closed down on June 30^th to accommodate that maternity leave. That individual will be back in September, and they are reopening on September 11^th. That’s the twenty-sixth that I referenced.

BRENDAN MAGUIRE: Was the community given any type of information that this was being shut down?

ALLISON BODNAR: I can’t answer specifically what information the community was provided. One of the people who was employed at that clinic actually took a position at the new Nova Scotia Health Authority primary care clinic. The individual who should have been there through the Summer covering the maternity leave took a position with Nova Scotia Health Authority’s community clinic, which just opened up a couple of weeks ago. We have to wait for the maternity leave to come back.

BRENDAN MAGUIRE: This is why it’s important, Mr. Chair, when we pick topics that we get the right people here, and we don’t fight with government over the witnesses. The questions that we ask today, which are extremely important questions about communicating to rural communities in particular - for all the knowledge that the CEOs have here, they do not have that knowledge. We know from people on the ground in those communities that it was not communicated to that community. You’re making announcements on health care. You’re announcing it. You’re running out. You’re celebrating it. Then when things go sideways or there are bumps - where members are leaving to go take other positions - it’s not communicated to the community, and the community is left without primary care.

I will stress - and I would like to have it on the record here today - that this is another lesson for the government on why it’s very important to not hide Nova Scotia Health Authority and the Department of Health and Wellness from this committee, and allow them to appear here because both Ms. Bodnar and Ms. Zwicker are unable to answer these questions.

When something like this happens and the community is left without primary care

-  and I’m almost done and I’m going to pass it over to my colleague. One of the things that

-   I can’t remember if it was Ms. Bodnar or Ms. Zwicker said in their opening speech was: Very proud of the improved access to primary care in our communities. I challenge you to come to Spryfield. We’ve lost three family doctors after I sat there in Estimates, and the Minister of Health and Wellness said that the resources - a nurse practitioner - would be provided to that community. Not only was it not provided to that community, but the retiring doctors, which . . .

THE CHAIR: Order. We have a topic that’s on extended scope of pharmacists. (Interruption)

I would like you to get to it.

BRENDAN MAGUIRE: We do not have a pharmacy clinic in our community. We have walk-in clinics that do not exist in HRM - they just don’t exist. We have family doctors where it’s taking three months to get in to see your family doctor.

One of the questions that I have about these pharmacy clinics - we did a little bit of research, and they seem to be in certain ridings over other certain ridings. Resources are being put into certain communities. It seems to us on the way those communities are voting

-   and I know that has nothing to do with either one of you - but in your opinion, in your communication with the Department of Health and Wellness, how are these being chosen?

Right now, Spryfield and the community I represent is becoming a primary care desert. We have two doctors left. We have a walk-in clinic where it takes three weeks to get into a walk-in clinic. We have no pharmacy clinic. We have a Premier and a Minister of Health and Wellness who pretend everything’s fine. So when I hear things like: We’re very proud of the improved access, to me it’s offensive. It’s offensive to the people in my community. How is the Nova Scotia Health Authority deciding where these clinics go? They’re clearly not going in the communities that need it the most.

ALLISON BODNAR: I think it’s really important to contextualize this. This is a PANS pilot project. It’s just like a pilot project we ran under previous governments, under the terms of our tariff agreement where we are assigned a budget, and then we establish an evaluation plan, we establish an application and acceptance criteria, and we select those internally through our committee.

One of the primary criteria for the application process was based on the Need a Family Practice Registry locations and percentages of populations in those communities. Those with higher populations had priority in our application process. It had to do with making sure all our pharmacy organizations were represented so that we could test various business models. It had to do with who had appropriate staffing in place, who had physical infrastructure in place, and it was a selection of criteria within PANS to make sure that we had represented what we set out to measure in the evaluation framework.

We have a significant evaluation framework that we test - not just system perspective, that’s critically important, the patient perspective, but also our own pharmacy perspective and our pharmacy professionals’ perspective. There was a number of criteria. With Round 1, we had enough funding - not quite enough funding, but almost enough funding - to do 12 sites. As you know, we announced 12 first. We had 40-some-odd applications of people who were interested in opening up a clinic around all sorts of communities in Nova Scotia. We had to select 12, and that was based on the percentage of those populations. Then we went through a similar approach in May where we had another 40-plus apply for the next 12 sites.

We had to limit that because of the funding that was available to the project to where we could go. There are oodles of pharmacies and oodles of pharmacy professionals who would love to practice this way and would love to open up a pharmacy clinic.

BRENDAN MAGUIRE: I’ll finish with this, because you said it was based on criteria and need and things like that. That’s troubling me because we have three pharmacies in the Spryfield area. We have a community within HRM where transportation is an issue. We know that large portions of that community are low-income and they have transportation issues. This is a fact. The Need a Family Practice Registry wait-list in that area has gone up over 500 per cent in the last two years. Five hundred per cent. We had three doctors of the five retire. You’re telling me that based on criteria and need, there are communities that are worse off than what I just described that needed it more than our community?

ALLISON BODNAR: I can’t speak to every specific community. I can tell you that we were provided by health cluster the percentage of those communities that were on the Need a Family Practice Registry. We did not look at physicians who were retiring or about to retire. We looked at that registry, and then in addition to what I’ll call our normal pilot project criteria that we have in order to select the sites that we think are able to successfully deliver a project. Again, I can tell you, they were about seven months apart, those two selections. That registry changed significantly, which is why in Phase 2, there were significantly more in HRM than in Phase 1.

Again, that’s how we’ve been doing it. When we look at a permanent rollout to this, which I hope we will be, and we look at how we select - because obviously there’s not going to be enough budget to put 300 community pharmacy clinics next Spring - we’ll have to come up with a permanent selection. It won’t be a pilot anymore. It won’t be necessarily PANS alone making those choices. It will have to be system choices as to where the greatest need is. I get calls every day: Can you put something in Parrsboro? Can you put something here, can you put something there? We’re desperate, our family physician just retired, our nurse practitioner has just left. We don’t control that budget.

We would love to expand. We have some workforce issues that need to be addressed, and how we recruit more professionals into the province like nurses have done and physicians are doing. If we can solve that problem, we have the willingness to go where all our pharmacies are located and then beyond that, because you don’t need to be attached to a dispensary.

THE CHAIR: MLA DiCostanzo. You have eight minutes.

RAFAH DICOSTANZO: Not enough. We’ll do Round 2 as well. If I may start with that, it’s the shortage of pharmacists and shortage of pharmacy technicians that is a huge issue. I believe you said you had 1,450 pharmacists, but only 250 technicians. That is incredible, because technicians can do 80 per cent of the technical work while the pharmacists should be doing the actual prescribing and dealing with patients. That is the dream of a pharmacist, as you mentioned as well. So what are you doing to increase the number of technicians, and why are we still at just 250?

[1:30 p.m.]

BEVERLEY ZWICKER: This is something that we’ve been actively working on for the last couple of years. We initiated some regulation changes with government in 2020, which were just passed in January. It’s enabling us to open up a licensing stream so that those pharmacy assistants who currently aren’t licensed, but who have had extensive experience in pharmacy - a minimum of 2,000 hours - who have acquired competencies and skills through that work are eligible to complete a bridging education program and then be eligible for licensure.

This is the first in the country - quite innovative. It’s actually a relaunch of a licensing stream that was available from 2013 to 2019, which proved to be very effective. Unfortunately, change takes time, and neither the system nor pharmacy was necessarily ready or positioned to incorporate a new group of health care professionals into the profession, and to do that switch of roles. The system hadn’t begun to use pharmacists fully so there wasn’t a felt need for pharmacists to hand off the technical work involved in dispensing to a technician.

There were many things that happened, but right now that licensing stream has been opened. We’ve been working and supporting one of our community colleges that provides education to technicians. They will launch a bridging program. My understanding is it’s going to launch this Fall. Based on our survey, our understanding is that approximately as many as 150 assistants right off the bat are anxious to enrol in the program with another 150 or more in subsequent cohorts, with a tremendous interest from those across the country as well. That is one significant initiative that we have under way that’s going to help shore up the number of technicians who will then be able to free up pharmacists to take on more of the clinical work.

We’re also helping to support the Department of Advanced Education in looking at how the delivery of pharmacy technician training programs are delivered for people right out of school, who have never worked in a pharmacy, so that they are delivered in a format online, somewhat asynchronous. Then they don’t have to relocate and find housing in Halifax, leave their job in order to take the program. They’re able to take the program while still in their rural community and while they’re still employed.

Those are a couple of significant initiatives. The licensing is certainly ours. The others were just supporting the work of government on that.

RAFAH DICOSTANZO: I’ll stay on that just for a second more. What I understand is the pharmacist technician is a two-year course while the assistant is anybody off the street who comes and helps, so there’s no actual education. Is this bridging a one-year, six months? What is your target number of technicians that you need? Have you forecast what the need is here, especially now that we’re getting fewer pharmacists into the field?

To me, it should be double the number of pharmacists, just as we have with LPNs and RNs. We’re actually hiring more LPNs than we are hiring RNs, and we should be doing the same in this field, but when I saw this number, I thought, whoa, that is so low. How long will it take you to have that many technicians?

ALLISON BODNAR: Certainly, we’re doing forecasting. We’ve identified - at the pharmacist, pharmacy technician, and pharmacy assistant - a huge deficit in our current capacity, as well as our projected education capacity, hence the bridging program for the assistants, and re-looking at the technician Royal College general program.

The other thing is there are other policy decisions that have been made that have significantly impacted our technician supply over the last couple of years. I just want to speak to it because it had a huge impact to us. When we were desperately in need of CCAs at the beginning of COVID to address long-term care, and a decision was made to increase their salary to a minimum of $25 and to make their education free - they are the direct comparable. Their education is offered at the same institutions as technicians. When that happened, technician enrolment in those classes dropped to almost nothing. We have had very few technicians to even be available to pharmacy in the last couple of years.

I’m going to visit the Eastern College class that used to have a couple of classes. I’m going to visit the class of seven for this year in a couple of weeks, of which maybe half will go to licence, and then some will go elsewhere. We’re talking three or four people coming out of that class, slightly more - I think the last time I was at NSCC, their class - again, their one class - was 12. We’re not graduating anywhere near the number of technicians.

When it drops off because you’ve made CCA free - and I know we needed that, but understanding the ripple effect that that had elsewhere - and to the point that Bev made, this means our pharmacists are spending a lot of time doing technical work that they shouldn’t be doing and, quite frankly, are not as good at as our technicians are. We have to solve these problems. Why aren’t our Pharm D classes full? That’s why I said earlier that it’s complex. I don’t want to place blame on anyone, because our pharmacy organizations certainly own some of it, and the system owns some of it. Just how it’s evolved with financial cuts over the last 12 years is part of it.

It doesn’t really matter how we got here. We’re here. We know the potential for pharmacy to impact the system, so how do we work together to solve these problems and make sure we have these pharmacy professionals here and ready to go?

THE CHAIR: MLA DiCostanzo, you’ve got about 40 seconds.

RAFAH DICOSTANZO: All right. I do have another big question. I don’t want to start that one.

I thank you for the answer. I hope you will expand the seats as much as possible. It is the private sector that’s paying the salary of the technician. It’s not the government who’s deciding what they get, unless they’re working in hospital, correct?

When will the two major corporates be paying the technicians higher salaries? If we have time.

THE CHAIR: We’ve got four seconds. Maybe we can come back to that question.

(Interruption) I didn’t think so. Thank you, everybody. The Liberal time has expired.

We’re going to move on to the NDP caucus. I see MLA Burrill.

MLA Burrill, you may begin.

GARY BURRILL: I think my question, Ms. Bodnar, is for you - my first question. If I’ve misunderstood that and you want to contribute, please, Ms. Zwicker, that would be great.

I’m thinking about the whole landscape of fees and how it relates to the new primary clinics. It seems to me that a lot of the excitement about the new clinics is not just the expanded access, it’s expanded access within MSI - expanded MSI, expanded access, not having to pay.

I wanted to ask you first: Have I understood this correctly, that MSI covers every new service/procedure within the primary care clinics, or are there exceptions? Can you kind of characterize the landscape of fees in the new clinics?

THE CHAIR: Ms. Bodnar.

ALLISON BODNAR: Again, it is a pilot program, so it has a unique funding model because it’s a pilot. I will explain the pilot funding - that’s to pharmacies, how it’s funded - and then I’ll speak from the patient perspective, what they pay for or don’t pay for.

From a funding perspective, because this is a pilot, we set a funding model based on what we expected to be the cost and revenue earned in the project. Pharmacies weren’t looking to make a profit on a pilot. They understand that there’s an investment in a pilot to get to a permanent, long-term funding model.

We looked at a model with a full-time pharmacist and a full-time assistant of needing $14,000 to $15,000 per month just to cover those costs. Not rent, not a percentage of overhead, none of the extras - pure labour. What was the minimum they needed? When we built it and we were designing assumptions, we looked at what’s currently funded in the system. Things they were already able to bill for, like renewals and contraception management, and things like that. We made a variety of assumptions on what we thought they’d be able to bill directly. We came to the conclusion that they’d be able to bill around $7,000 a month in billable services. Therefore, we needed to provide a stipend of $7,000 to cover their costs.

That assumed that about 50 per cent of the services patients would want would be billable, and about 50 per cent of the services patients would want would be currently unbillable - within our scope, but not there’s no code to bill. Anything that didn’t have a code to bill was covered by that stipend.

It turns out that patients really like the services that are in scope but not funded. At the end of the day, pharmacies are only actually billing funded services in the $3,000 to $4,000 mark, but still only getting their $7,000 stipend, so therefore not covering their costs. That’s not a long-term funding model. We know it, we work weekly with the government to see what we can do to help support our teams through the rest of the pilot while we negotiate a long-term funding model. Assumptions are assumptions, and sometimes they don’t work out and you have to adjust. We’re doing that as we go along.

From the patient perspective, any service that’s within a pharmacist’s scope that’s currently covered by MSI is provided at no charge. There are services in there that are not in scope, and probably the biggest ones are travel vaccines. If you want to get a vaccine, or even a shingles vaccine - it doesn’t matter if you go to your physician or you go to the pharmacy - that’s not covered. Anything that’s not currently covered by MSI, patients would still be billed for. Otherwise, if it’s within the scope and it’s covered today, there is no fee for a patient at the clinic.

GARY BURRILL: Thank you, that’s really clear. I’m thinking also about then the pharmacies that are not within the pilot, which also offer primary care services, often with a fee. Can you also then characterize the fee landscape for the part of the pharmacy world that is not primary within the new primary clinics, and distinguish it?

ALLISON BODNAR: As I mentioned, we have a current list of funded services in pharmacies. This means any pharmacy in Nova Scotia can bill for prescription renewals, contraception assessment, medication reviews for certain eligible populations - it’s quite a limited set, I’m not going to get through all the criteria for that - prescribing for Lyme chemoprophylaxis, prescribing for herpes zoster. Again, any of those services that have a current billing code. No patient is charged for those services. They’re covered under our MSI.

Everything else - the things I referred to as the patients really liking in the clinics - other pharmacies can do most of that too, but it’s not currently billable to government, so they do charge a fee for those services. What we’re trying to do with this project is get to the point where we recognize the full scope of pharmacy practice, and all pharmacies will eventually be funded to provide the full scope of pharmacy practice. We won’t be cherry-picking this small subset of services for funding, leaving the rest to be paid privately.

[1:45 p.m.]

THE CHAIR: I see Ms. Zwicker’s hand up. Ms. Zwicker.

BEVERLEY ZWICKER: I just want to add that at the college, as we’ve authorized scope of practice in new areas, one of our concerns has been equitable access. The issue that you’re alluding to - its availability to everybody, but not everyone can afford it and that affects access - is something that we’re certainly aware of. I am encouraged by advances that have been made and are going to be made as pharmacy is repositioned in primary care. That rethinking happens in more of a service delivery-focused fee scheduling versus paying for that service provided by one health care professional and not another. I think that’s really critical in terms of ensuring that there’s equitable access to the large number of services that pharmacists can now provide.

GARY BURRILL: That is what I’m trying to understand, the equity of access. I’m trying to get a clear grasp of: Are there services for which one might normally expect to have to pay a fee if your pharmacy were not within the new primary project, which, if you were within the pilot, you would not have to pay a fee? What might those be? What would be the landscape?

ALLISON BODNAR: There are a lot of them. I gave a very short list of what’s funded. The biggest, most popular items in the clinics that are not currently covered in what I’ll call a regular pharmacy - number one, strep assessment. That is something that’s very specific to this pilot program and is only available in the pilot program. You just can’t get it at a community pharmacy. It’s not available - not even for a fee at this point in time because there are some changes that have to happen.

The second biggest one would be minor ailments. The thing I mentioned earlier. It’s been part of our scope of practice since 2011. Patients have been paying out of pocket for that since 2011, but as part of our clinic, if you go to the clinic, it’s covered as part of the clinic. Others would include chronic disease management, so pharmacists within these clinics can order lab tests. You can’t order lab tests in the other pharmacies yet. We’ve been waiting since 2013 to get that in place. They can order lab tests. They can prescribe if they have a diagnosis.

They can really help patients manage their chronic disease conditions, particularly patients who don’t have any other access point. They have the full scope to manage things like COPD, asthma, hypertension, and diabetes - things that cost our system huge amounts of money. They’re able to do that.

Those things today - because we’re not through our pilot and we haven’t put a long-term plan in - are currently not available at no charge out in the remaining pharmacies, but the top three services at our clinics right now are prescription renewals, strep assessments, and minor ailments.

GARY BURRILL: I think the picture you’re painting is one where at this pilot stage, there is a differential access to services relative to fees that, depending on whether or not the pharmacy that you’re close to is within the primary care project, one might have to pay for some things or not have to pay for some things. I’m wondering: Is it fair to say that at this moment with the pilot where it is, we are having a two-tier system of access to the primary care that’s available within our pharmacies? If you are within a community that’s being served by the pilot pharmacies, no fee, but otherwise very likely a fee. If this is so, is it problematic from the point of view of the profession?

ALLISON BODNAR: Again, as a pilot program, we have to test new practice models. I think we’ve had these arrangements with government for 10-plus years in a small subset of our pharmacies, we go in and test new models of care. That’s what we’re doing here. I understand it’s gotten much higher profile. There’s a lot of interest and there’s a lot of need for it, but at the end of the day it’s still a pilot. To test something new, you are creating something that’s a differential from what exists.

Absolutely, it’s different, but does it necessarily create two tiers? Well, I think that would depend on what else is available in the community. Do they have physicians? Do they have a primary care clinic with NSHA? What else is available to them? Again, we would love to have every pharmacy service that’s to our fullest of scope covered so that our teams don’t have to think about which round hole to put a square peg in to try to build the right service. It takes a lot of administrative capacity, and it takes a lot of time and effort to try to figure out how you can help this patient and be reimbursed for it. We would much prefer a simpler model that covers our full scope that pharmacies and pharmacists are adequately compensated for, and where patients can get care.

We’ve come a long way, and this model - we started advocating for this in 2017, and it took until 2022 to get it approved, and in place in 2023. We've been working at this for a long time. I think what we see here is this huge demand and interest in these clinics, and the next step is to figure out how to make these sustainable in the long term for our pharmacy teams and our pharmacy owners who invest in these.

THE CHAIR: MLA Burrill, you have about seven minutes.

GARY BURRILL: I guess the idea of a pilot is that, just as you say, it is evaluated on a path to its universalization. Could you characterize what the evaluation looks like in this early stage of the pilot? I’m thinking about what some of the things are that government needs to see - or that you need to see, that the profession needs to see - in order for this to move on a path of universalization.

ALLISON BODNAR: I can’t answer what the government needs to see. I can answer what we are looking at in the evaluation. We are looking at pure objective data: how many services, what kind of services, what’s the demand, what’s the time frame to perform these services - all of that type of pure objective data. We are getting patient feedback. We know already that 98 per cent of them rate the service at an 8 or 10 or higher; 89 per cent of them rate it 10 out of 10. Right there, we know that patients like this. They’re all saying it’s getting them care faster and it’s keeping them out of other centres. For me, that is probably the most important piece - this works for patients.

The next piece for me, as a representative of pharmacists and pharmacy professionals, is that it works for our teams. Our teams love it. We need to make sure. If we look at the quadruple lane in health care, it’s got to work for our professionals as well. It is working for our professionals. They like being able to separate out the thought process around dispensing from the thought process around clinical services. Separating those out makes life better for the teams in both areas, let’s be clear. We’re also evaluating how this changes the dispensary. Presumably it makes it easier and more efficient in the dispensary too, because you have fewer interruptions.

We’re looking at patients, we’re looking at providers, we’re looking at the economics around it, and how we create a long-term, sustainable model. We’re looking at the system. How does it support the system and other providers in integrating with primary care? We laugh - I’m not sure if she cries or laughs, my project manager - we have expanded this evaluation multiple times. We keep growing and looking at - now we have all public health immunizations in there, so we added an evaluation framework around that.

We’re also looking at the utilization of electronic medical records in pharmacy. As part of getting access to labs, we had to implement EMRs into pharmacy. They’re not really made for pharmacy. How do they work, and how can they be made better? How do we use those to better communicate with other providers?

The evaluation framework is huge, and everything we see from it indicates that we need to go forward, but there are pieces that we need to solve, like this inter-collaboration and communication with other providers that I mentioned earlier. We need to get to a common record, period.

THE CHAIR: I see Ms. Zwicker’s hand up as well. Ms. Zwicker.

BEVERLEY ZWICKER: The project that is under way is happening under a standard that the college has created that allows us to research new and innovative care delivery models and areas of care for pharmacists. We will be using the evaluation from the project to inform whether amendments need to be made to our standards. We set standards for practice and standards for pharmacy so that we can ensure that if there are safeguards needed, they’re in place for the larger rollout to all pharmacies.

We’re looking at those factors that relate to the public interest of the quality of care and access to care. We’re looking to see if practitioners need specific resources or tools or supports, again, as safeguards to ensure that when this is rolled out to all pharmacies and to all pharmacists, the public can expect to receive quality care.

THE CHAIR: MLA Burrill. You have about a little more than two and a half minutes.

GARY BURRILL: Ms. Zwicker, I wanted to ask a question about professional practice. We hear a lot about the fracturing of care. People are going to walk-in clinics for this, and receiving virtual care for that, but there’s a lack of overall management of the patient’s file when people don’t often have a primary care physician or are not attached to a clinic.

I’m wondering about the professional experience of the pharmacists who are working in the primary clinics in this initial stage, who surely must be experiencing something of this. Is this problematic? Is this difficult? Is it a thing, and is it being addressed?

THE CHAIR: Ms. Zwicker.

BEVERLEY ZWICKER: I’m going to respond and then I’m going to allow my colleague to speak further to the actual experiences of what’s happening in the pilot, because she’s having the conversations.

I can say that the need for a patient-centered record in community is critical. We’ve been advocating and encouraging that this technology be established for years, with some urgency over the last couple of years. The reality is that, even for someone like me who has a family physician, I may move, or my physician may move, and the record should really be a patient record that is centrally located, that all health care professionals are able to document their care provided and that any other health care professional who provides care to that person can access.

I am encouraged by conversations that are happening now that would suggest that this is something that is being worked on. Certainly, we hope that it will be set up as quickly as possible. It is really a key piece to the redesigned health care system where we are able to provide care to Nova Scotians and have the right person providing the right care at the right time - that it is a patient-centered record that is centrally located.

THE CHAIR: Ms. Bodnar, you’ve got 15 seconds.

ALLISON BODNAR: I think there’s a lot to unpack with that. First of all, I fully agree, and I’ve said it multiple times. We absolutely have to have a common record where all providers can write to and all providers can see. This isn’t just about pharmacy. We have mobile care now. We have virtual care.

[2:00 p.m.]

THE CHAIR: Order. The NDP time has elapsed. Again, another opportunity, maybe, for further conversation in a minute.

It is now time for the PC caucus. MLA Barkhouse, I see that your hand went up.

You may begin.

DANIELLE BARKHOUSE: I know that a comment was made about two-tier, but if I’m not mistaken - say I lived in Spryfield, I could go to a Pharmasave in another community and use their services for immunization. Am I correct on that, Ms. Bodnar.

THE CHAIR: Ms. Bodnar.

ALLISON BODNAR: Yes, you can go wherever.

DANIELLE BARKHOUSE: MLA Maguire, that makes a good point. In rural Nova Scotia, you have to drive pretty much anywhere to get anything you want, so it kind of doesn’t make sense to put that point forward. MLA Maguire, I get a kick out of you, actually, because you’re making faces at me and being sarcastic. (Interruption) When we did the agenda-setting, you made a big fuss about ERs . . .

THE CHAIR: Order. Please do address through the Chair. (Interruption)

Order. MLA Barkhouse has the floor.

DANIELLE BARKHOUSE: Mr. Chair, I’m just making a valid point that when we did the agenda-setting, there was a big discussion from the Liberal caucus about the deputy minister coming in with regard to ER closures, but nothing about this case or this topic. I just think that point should be on record.

Back to the questions of the panel. There’s a bit of a mind shift when you start using pharmacists. Now, mind you, you go to Chester-St. Margaret’s, most of the people back in the day would go see Randy the pharmacist for everything. It didn’t matter - they were going to see Randy before they went to the doctor because he seemed to know everything.

I’m wondering - and you’ve touched on this a little bit - can you elaborate on the skills and the experience of pharmacists, which puts them in a great place to address a lot of these health issues that they are doing, and maybe what you could see them do in the future? That goes to both of you.

THE CHAIR: Who would like to take it on first? Ms. Zwicker.

BEVERLEY ZWICKER: As I’ve indicated in my introductory remarks, pharmacists have at least a minimum of six years of university education in health care. It’s intensive in the pharmaceutical sciences - the pharmacokinetics, pharmacogenomics, and therapeutics, which certainly prepares pharmacists, more so than anyone else, to understand what the right medication is for each person, tailored for their unique circumstances. But that education is much broader and deeper. It also incorporates all of cardiology, endocrinology, respiratory, enabling them to integrate their understanding and their education in the pharmaceutical sciences in health care.

They really are health care professionals. In an ideal system, there would be conditions where a pharmacist could diagnose initially. There are common conditions that pharmacists are diagnosing every day now, even before expanded scope, and were providing an over-the-counter product. Now they are able to prescribe.

There are certainly other more complex medical conditions where there should be a physician or nurse practitioner who diagnoses, but then once that diagnosis is made, the pharmacist should be prescribing the drug therapy, continuing to monitor that drug therapy, and managing it and adapting it and changing it so that that person realizes the optimal outcomes from the medications that they’re taking, and is able to realize optimal health outcomes generally. A physician or nurse practitioner would be diagnosing and a pharmacist would really take the ownership for the drug therapy management.

THE CHAIR: Ms. Bodnar.

ALLISON BODNAR: I think what we’ve both said throughout here is that pharmacists have a really broad scope of practice. It’s about the system figuring out how to utilize the role of prescription renewals most effectively, the role around immunization, the role around medication management for a whole host of complex diseases. These are all things we can think about and we can do.

I’ll use minor ailments as a simple example of thinking a little bit differently. In the U.K., because of the way they’re set up - not in all places, but in some places - they have a program called Pharmacy First. They’ve identified a list of ailments for which you must go to the pharmacy first. It’s kind of like how today, you can’t go to the orthopaedic surgeon when your knee hurts. You have to go to your GP first. They triage and decide whether you need to go elsewhere. The U.K. has implemented this program where you have to go a pharmacy first for certain conditions.

If we think about how that may evolve, whether that’s around immunizations or flu shots - why are we paying physicians to do flu shots? I’m sorry. A technician can do flu shots. A pharmacist can do flu shots. We don’t need to waste their time and their appointment times on giving flu shots.

I think it’s about thinking about and understanding the full scope that pharmacists have, or pharmacy teams have - it’s not just about pharmacists - and how we best integrate them into the system and use them. I think there’s a lot that we can do without going any more expanded scope. Not that we’re not always looking for a little scope here and there. As NSCP knows, I send a lot of letters asking for more scope, but for the most part, like I say, those are little things compared to what we already have and what we could be doing to maximize the role of pharmacists.

DANIELLE BARKHOUSE: I’m hearing great feedback, by the way, both from some pharmacists and constituents. I’ve used it personally for my tetanus shot and rabies shot, interestingly enough.

We’ve talked a little bit about this. I think you said they had 41,000 visits, 10,000 for strep throat. There are 315, I think you said, in the province that are Pharmasaves, with 26 of them, other than the one with a short little stint of maternity leave. I’m lucky enough to have four in my constituency that are operating.

I’m just wondering, for my question to Ms. Bodnar: How do you feel the community response is so far? I know you’ve touched on it, but we’ve never actually spent an actual question talking about it because that’s the really important thing. Change is hard on some people, so yes, I’d like to know from you.

ALLISON BODNAR: Sure. I referenced some of the statistics a little earlier. Monthly, we do a post-service survey with patients, and they’re given the opportunity to provide feedback online. Then our external research collects that and reports to us as the pilot organizer once a month. As I mentioned, 98 per cent of them rate the service an 8 or 10 or higher, and 89 per cent rate it 10 out of 10. The communities are responding really well. They like the improved access. They like the comprehensive care provided by pharmacists. Of course, the clinics - more are needed. We get the calls: Why isn’t there one in our community? Again, this is a pilot. We know the patients. The patients are liking it.

The one downside is - and this is a pharmacy problem - we have very narrow, specific scopes of service. We could assess for strep throat, but we can’t assess for an ear infection. You’re almost asking patients before they come to know what’s wrong with them. That’s some of the work we’re trying to do now: How do we make it a little bit easier for patients?

We spend a lot of time trying to triage those appointments before they come so that they don’t waste time, and our sites are really good at that. That is probably the biggest piece of constructive feedback on how we could do better. How do we make it easier for the public to know what the scope is, and how do we make it easier for pharmacists to deliver the care they need to deliver when we have all these very distinct - it’s very different for a physician. You book an appointment with the physician, and no matter what you want to talk about, that physician’s going to get paid for that appointment. You can come in and you can talk about whatever you want to talk about.

That’s not how the pharmacy reimbursement model was built, so now we need to start thinking differently. How do we change that so that we’re putting less onus on the patient to find that right service, going down the list of 38 services when they’re trying to book an appointment and pick the right one?

Those are some of the things from a constructive - how do we evolve and get better?

That’s the big piece that we’re starting to look at now: How do we make this easier?

BEVERLEY ZWICKER: Just to help further - when we set scope, we look at research to determine what other jurisdictions may have by project, and look to see whether or not pharmacists could provide it. Then we consider whether it could be undertaken by a pharmacist in consideration of their competencies, building on that either with some incremental learning or support of tools.

There is a very structured process that we go through when we determine, for instance, if a pharmacist can assess for an ear infection - just so that we’re fulfilling our responsibility to the public to make sure that whatever we authorize pharmacists to do has been thoughtfully and intentionally researched to make sure that it can be provided safely, and to the same standard of care that they would receive from another health care professional.

DANIELLE BARKHOUSE: This is my last question, and I think it’s going to be easy. Out of my four Pharmasaves, one of them - the Chester branch - is actually one that is a pilot project. From the numbers you’re seeing - and not just specifically in Chester but in all 26 branches - how can you see this grow? It seems to be working out quite well. I would just like to hear your thoughts on that.

ALLISON BODNAR: As I mentioned, we have more pharmacies that want to be able to do this. Their teams want to be able to split that workflow. We want to be able to recruit across the country and really focus on our unique and advanced practice scope for pharmacy. There’s a lot of interest. What do we have to do with that? Well, we have to come up with a plan. How do we fund these? What’s the rollout look like? These have to be sustainable. This project model with a stipend and fees, and hoping that people might come isn’t a sustainable model when you want people to invest in a clinic, and you want them to staff it full time, and the rest of it.

There’s still work to do, but there’s so much interest and so much need for these. You could easily see tripling or quadrupling the number of clinics that we have over the next couple of years as we work on bringing the appropriate HR into the province and building the appropriate funding models to support investment into these clinics.

BEVERLEY ZWICKER: Just to add, we need a change-management plan to help support that it happens intentionally. We need to be communicating what is currently available and what the long game is so that the public has an understanding of what they’re hearing and where it’s evolving to. That other health care professionals have an understanding that this is the road map, that this is how we are going to redesign the delivery of health care so that people get the right care from the right person at the right time.

It is going to mean a change in the way the public thinks about where they access care, to your point. Deeply entrenched ideas. It’s going to take a change in the way physicians understand their role to be and the care that they’ll provide. It’s going to change in the way pharmacists think about what they do every day that they’re providing health care. There’s a lot of change, so a change-management plan is critical.

THE CHAIR: MLA Barkhouse, are you finished? Yes? Okay, MLA Palmer, I saw your hand up.

CHRIS PALMER: This is a great topic today, and I’m happy that we have you ladies in with us today to share some of your experiences from your perspective. I will say that I spent time with my local pharmacist, Heidi Caldwell, at Chisholm’s PharmaChoice about a month ago on a pharmacy with the MLA day, and I spent time behind the counter. I can tell you - and anybody watching - that the role of pharmacists and what they do as partners in the health care team - anyone who just thinks they’re allied health care professionals, to your point, they are so much more. They’re professionals, and I give a shout-out to everybody working at pharmacies who would be willing to take this project on. I just want to start with that.

I guess my first question here is for Ms. Bodnar. I guess it could be yes or no. It could be a four-second answer for you. Can you clarify one more time who chose the sites that were for the pilot? Can you just let us know again, one more time, who chose that?

THE CHAIR: Ms. Bodnar.

ALLISON BODNAR: Sure. It’s our PANS project team.

CHRIS PALMER: Would you consider PANS a non-political, apolitical organization?

ALLISON BODNAR: Yes.

CHRIS PALMER: Thank you. So there could be assertions made here at the table that this is a political decision and PC ridings have all the pilots, but you gave a little bit of an explanation of some of the reasons for the locations you chose around the province. You chose things like access to primary care or physicians on wait-lists and that type of thing.

Can you talk a little bit about some of the other conditions, aside from the Need a Family Practice Registry, and some of the conditions for upgrades for those pharmacies, and how you chose those locations? Expand on that a bit more, please?

[2:15 p.m.]

ALLISON BODNAR: Sure. I can tell you it didn’t include who the MLA was for the riding, for sure. That was not on our list.

Once we had the priority lists of communities with the highest percentages of people on the Need a Family Practice Registry, we then looked at making sure there was a representation across all four health zones - North, East, Central, and Western - making sure that we had good representation from all of our brands of pharmacy. They all have different business models and they all have different practice models, so we wanted to make sure that what we are doing - as in every project - is going to work for all of the different business models, and if it doesn’t, why not and how do we fix that?

We looked at the staffing complement at the pharmacies. Did they have the staff in place? Were they going to need to hire somebody? We looked at their physical layouts. Did they have - it was a minimum requirement of two counselling rooms. Many pharmacies only had one. So did they have two counselling rooms? Could they get two counselling rooms within a fixed period of time? Were they willing to hire an administrative assistant full-time for the clinic, and were they willing to make this investment into a project knowing that it was, at best, a cost recovery?

Those were the conditions that we looked at. At the end of the day, we made selections and, quite frankly, couldn’t pick many locations that were excellent candidates for the project.

CHRIS PALMER: Thank you for that. As I see it, one of the great things about pharmacies is how they’re integrated into our communities right on Main Street and that bit of a localized access to care. I know in places like Aylesford and areas like I represent in rural Nova Scotia, that long-time GP whom they’ve always relied on with the pharmacist maybe isn’t there anymore. This program that is going to be going into Chisholm’s Pharmacy, for example, is going to fill a bit of a hole, and I think it’s going to be well accepted.

Places like Greenwood, they’re not only serving people in Kings West, my constituency, but they’re also serving many people from Annapolis County, whom I don’t represent. Those locations - I appreciate you giving us an idea on how that works. As far as the community-based care model, can you talk a bit more about that, and the importance of people being able to access those primary care places in their communities?

THE CHAIR: Ms. Bodnar.

ALLISON BODNAR: Sure. To the extent that you can bring care closer to where people are, the better our system is going to be. Forcing people to travel long distances or wait long times, people will opt out of it. They just won’t go, which means conditions advance, and then they need more expensive health care. We absolutely need investment in primary care in communities close to people.

What do pharmacies add to that? Well, as we know, there are 315 of them, so there’s a huge physical footprint across Nova Scotia that we can benefit from. They have extended hours. They’re open on weekends. From a system perspective, there’s so much we can lean into. We don’t need to recreate these primary care centres everywhere. We need to lean into the infrastructure that already exits that’s in communities and people like to use.

In pharmacy, we have a history of doing that. As you mentioned, we’re on Main Street. Our pharmacists are part of the community. They tend to live there. They tend to be involved with the community. Patients know them. As much as I like virtual care, isn’t it better to have your renewals done by your pharmacist in community than the physician that’s sitting in Ontario? We need to rethink about where it’s best for patients to get care, and how we achieve that by maximizing the role of all of our health care professionals.

THE CHAIR: MLA Palmer, you have nine seconds.

CHRIS PALMER: Thank you very much for everything. I appreciate you being here today.

THE CHAIR: Order. The time for the PC caucus has elapsed. We’re going to do about 8 minutes and 30 seconds per caucus. I saw your hand up, MLA DiCostanzo, so you may begin.

RAFAH DICOSTANZO: My question is about OPOR. We’re all so excited. Were you at the table? How were pharmacists and family doctors not included? What’s the value of OPOR without the family doctors or the clinics that you’re opening - that they have no access to this information? How does this affect the liability issue to the pharmacist, as they prescribe and have no history or no knowledge of what else that patient has gone through? If you can describe that.

THE CHAIR: I see Ms. Zwicker had her hand up first. Ms. Zwicker.

BEVERLEY ZWICKER: I’ll just begin. For clarity, my understanding - and I believe I’m correct - is that One Patient One Record is not aimed at serving as a communication hub, if you will, in the community. It’s about connecting the documentation and the records in acute care in hospital. For that reason, certainly pharmacy - community pharmacy - was not involved in those conversations.

What is needed is that there is what we are calling OPOR community as a subsequent and parallel project to be launched without delay so that we do have that. To your point, absolutely, the criticalness that those who have a view to what a redesigned health care system needs to look like in medicine, pharmacy, and nursing are involved in the planning and design of that important communication platform.

THE CHAIR: MLA DiCostanzo.

RAFAH DICOSTANZO: What I’m asking here is: Will the pharmacists have access even to look at those records? Will they be available? I know right now the information is going from the doctor one way, with the pharmacy as well. There is such complication when it comes to the system. What is being looked at so that pharmacists who are now going to be prescribing and consulting almost as a physician in certain aspects, and have no access to information?

THE CHAIR: Ms. Bodnar.

ALLISON BODNAR: It’s not just as between pharmacists and physicians. This is a system issue that we have. When you go on VirtualCareNS, no physician can see that. When you go to mobile care, no physician can see that. None of us - no health care provider in community - can see the information prepared by any other provider. This is why the creation of a true OPOR - and I will say a true OPOR is not allowing providers to pick which part of the record they record into the central record. It is a record - one record - where we all write and read to. That’s my hill to die on.

It’s such a critical piece. There are physicians who are upset about the clinics, and they tag this as the biggest issue - we don’t see what you’re doing, we don’t have this information. This is not unique to pharmacy. This has existed between specialists and physicians, this has existed between physicians themselves when the patient sees multiple, and now with all these extra access points, it’s becoming very apparent that the priority needs to be on a community-based OPOR that all providers can see in real time, because it’s best for the patient.

You say, your pharmacist, what do they do? They spend an awful lot of time and effort recollecting information from the patient that they shouldn’t have had to collect to do their job properly. They’re going to do their job properly, so they’re going to spend the time to get that information, and they shouldn’t have had to. They should have had that information.

As a patient in the system who’s a fairly highflier, unfortunately, I can’t stand the fact that I have to repeat my history to every single person that I speak to, because nobody has access to the other information. It’s a pain for patients and it’s a waste of system resources re-asking those same questions over and over.

THE CHAIR: MLA DiCostanzo, you have four minutes.

RAFAH DICOSTANZO: This is just a comment because I want to ask the other question as well. It’s the liability issue that also worries me, because patients don’t remember what they’ve done or what they’ve had. They don’t keep track of everything that is medical. We’re depending on the patient to give information. Sometimes that is not accurate, and here is the pharmacist who is now liable by prescribing - or the physician. This happens a lot.

My concern is also for how we pay the pharmacist and how much of this expanded scope has really trickled down to the pharmacist. How much benefit, and what other jurisdictions that you know - I know in the States, for example, the pharmacist can bill directly to MSI and can work for the private sector. I believe that’s how they do it. They can do both.

What is your vision of how you’re going to help pharmacists to be paid for all these extra services that they’re doing for expanded scope?

ALLISON BODNAR: That’s a big question. I’ll start with, we represent pharmacists and pharmacy technicians who work in a variety of environments, and in particular in community. They have been hourly waged employees for a very long time. There are only so many hours in a day, so whether you’re doing a dispensing service or a clinical service, you’re still just working those hours a day. The question for me is, if you’re going to remain a salaried employee or an hourly employee, what is the right hourly wage?

Even though they’re individually employed, that’s a system question. If we look at a physician’s base minimum hourly wage, it’s $180. It goes up from there. A nurse practitioner, their new contract starting is $69 an hour. We look at RNs at around $50. Where does pharmacy fit in there? Where does a pharmacist fit in the system, and how, as a system, do we work to get us there?

I can tell you that the current average wage in Nova Scotia for a pharmacist is $48. That’s ridiculous. It’s been $48 for 10 years. What also has happened in that 10 years? It’s been completely flat, but we’ve taken out millions and millions of dollars from the pharmacy system. The pharmacists who work at the big national corporation make the same per hour as the ones who work at the independent mom-and-pop. There is no differential between these.

We have to find a solution that works for the whole system, and understand that if we think they are between - and I’m just picking names out of hats here - an RN and an NP in terms of their skillset and investment into their education, then how do we, as a system, get from $48.50 to $65? The system pays pharmacy. All of the revenue from pharmacy comes either directly from the provincial contract or indirectly from private contracts that are based on the provincial contract. Every private contract automatically adjusts when the provincial one adjusts.

So how do we get to the point as a system to recognize their value and to put in maybe unique solutions to ensure that people are adequately compensated? Billing numbers is an option, and we’ve certainly been looking at it. I can tell you that in Ontario, pharmacists turned it down. They didn’t want their own billing numbers because it came with other pieces - accountability directly for the practice, recordkeeping, audit requirements. Some of the feedback was: If I wanted to be a pharmacy owner, I would have done it. I just want to be an employee.

We have to come up with models that work for everybody. Right now, we are in a pivotal moment with the primary care system. How we evolve . . .

THE CHAIR: Order. The time limit for the Liberal questioning has expired. Great answer.

MLA Burrill, you have eight and a half minutes.

GARY BURRILL: I wanted to ask a couple of questions about cost and cost of drugs, since it’s so crucial to the whole world of access, which is what the expansion of pharmacare is about. I’m thinking about how in the pharmaceutical profession, a case is always made, I think rightly, that pharmacists are directly connected to the patients, and they’re front line in a way that isn’t true of all health care professionals, that they’re very aware of where people are. I think that’s all true.

I’m thinking about in the present context of the overall cost of living crisis, pharmacists must be experiencing the weight of the cost of drugs on their patients. We hear physicians speak pretty commonly about prescriptions that they write not being able to be fulfilled, that people can’t afford them - that this is worse than it was at one time and it’s having a real effect on the delivery of care.

I’m wondering if either of you can say anything about the impact of the high cost of drugs - particularly in this present intensely inflationary environment - on the patients of pharmacies in Nova Scotia.

THE CHAIR: Ms. Bodnar.

ALLISON BODNAR: I can try. Some patients have always, and continue, to struggle with the cost of medications - particularly those patients who don’t have an adequate insurance plan in place. Even those who have an insurance plan, they’re not all created equal. This is what the national pharmacare discussions are a bit about: how do we solve that inequity in access? If we look even at the provincial pharmacare formulary - and my numbers are probably out of date, but I think the last time I looked, it had about 3,500 products on the formulary. If we look at a province like Quebec, it has almost 6,000. So if you live in Quebec and you’re on the provincial program, you have better access than if you are in Nova Scotia, and Nova Scotia has better access than if you live in P.E.I., as an example. This is a national issue.

[2:30 p.m.]

In terms of the cost of drugs themselves, on a pan-Canadian basis, governments have been doing a lot in the last 10 years to change the price of drugs. The price of generic drugs has come down probably by about 70 per cent since its height. You are now down at a cost that is very comparable across international. Then if we look on the brand side of things, similar things are happening on the brand side. Pan-Canadian-wise, the Council of the Federation and the pan-Canadian Pharmaceutical Alliance are working on negotiating these.

That’s totally outside of pharmacy. The cost of drugs is totally outside of pharmacy, but to your point about the impact on patients, we absolutely see it. Our pharmacists look at, a lot of time, can they substitute a different product? We have a therapeutic substitution scope of practice, and financial means is part of that. If somebody can’t afford it, can we find a cheaper drug that can do the same thing? Working with the prescribing physician, are there other options?

We’re not at the table. We’re not even invited to provide feedback on those discussions between the provincial governments and the drug manufacturers about what is or should be the price of drugs. Again, pull on one string and a lot of things change. We need the research. We need the R&D. We want drugs to be brought to market in this country. If you look at countries that do very little R&D and have very restrictive formats, they don’t have the drugs that we have here in Canada. We need to understand the issue fully, and I think it’s going to become very highlighted over the next six months, because the federal government has a deal in place with the NDP that they need to bring forward a national pharmacare process before the end of 2023 or they’ll lose their support.

We’re going to see something this year, in the next few months. We’re going to see a direction that government is trying to take on this to improve access and improve affordability.

THE CHAIR: Ms. Zwicker has her hand up as well. Ms. Zwicker.

BEVERLEY ZWICKER: For any individual, what it costs them is certainly about the cost of the drug and about the number of medications that they take. I think that’s where the repositioning of pharmacy really does put an element of how the cost of drugs is impacting people in the control of the pharmacist. Right now, pharmacists really are, by and large, the editors, if you will, of prescribed drug therapy. They’re not the authors. They don’t turn their mind to what medications you need. We know that polypharmacy is a problem, and pharmacists are extremely busy.

Could we do better as a profession in ensuring that you’re only on the minimal number of medications that you need and that they’re the best medications and the most cost-effective? Pharmacists could absolutely do better if they were positioned to that being the focus of their work and not also on the dispensing and the accuracy of the prescription and all the other responsibilities that they’re tasked with.

THE CHAIR: MLA Burrill, about two and a half minutes.

GARY BURRILL: I also wanted to ask specifically about the cost associated with hormonal birth control prescriptions. We know that the heavy hitters in this field, the Canadian Medical Association, the Society of Obstetricians and Gynecologists of Canada, the Canadian Paediatric Society, are all calling for this to be free. I wonder if the college or the Pharmacy Association have given any thought to entering this discourse, this discussion, and weighing in with a position on this question.

THE CHAIR: Ms. Zwicker.

BEVERLY ZWICKER: I’ll just begin by saying we absolutely support improving access to contraception, which is why we were one of the first provinces to include that as a scope of practice for pharmacists, that they could provide comprehensive contraception management to individuals. In terms of access to that care, I believe the association worked with government so that it was a funded service, and then it really is a government decision about - we’re going to say yes to pay for this, presumably you’re saying no to something else.

That’s certainly a decision of government, but would we weigh in on it? We haven’t yet, but if it were helpful, we certainly recognize and support the importance of addressing any barriers that individuals may have in being able to access contraception.

THE CHAIR: Ms. Bodnar.

ALLISON BODNAR: Again, I’ll just reiterate that we haven’t as an organization turned our mind to it since the Province of B.C. announced that they were going to be providing access at no charge to the drugs. Certainly, having pharmacists play the important role they’re playing has increased access to this. Again, deciding what drugs should be covered and what drugs shouldn’t be covered is really not our role, and we’ve tried to stay out of that. We get a lot of requests from patient organizations to support the listing of a particular product on a formulary, and to date, we’ve stayed out of that. Certainly, we support the idea of improved access to care in this area, and if this financial piece is a reason that it’s not being accessed, then we can certainly see . . .

THE CHAIR: Order. The NDP time for questioning has elapsed. Again, I’m catching you halfway through a question or an answer. We’re going to move on to the PC caucus. I see MLA White’s hand up, so MLA White, your eight and a half minutes.

JOHN WHITE: First, I want to say that my wife has been a pharmacy assistant for about 20 years, so we have a lot of pharmacist friends. We party with them, of course. I’ve got to say, I’ve got the utmost respect for their professionalism. Our daughter, Robyn, is now a pharmacist here in the Halifax area - and you’re quite literally saving lives.

Robyn started a new job in January. A couple of days on the shift, someone came in and said there was somebody unconscious out front. She went out and administered naloxone, and got the girl back to life. So you are quite literally saving lives. I don’t know where she got that in her because she’s not that kind of person. I’m a firefighter. She’s not interested in that.

I do want to say, listening to her and Junie and their friends, I really am concerned about the human resource aspect of pharmacists. I know you talked a bit about it today. I know we’re loading some more work, but that’s cautioned with the pride that comes with working to your full training. I get that. When you take training, you want to use it - I see that. Knowing the training that Robyn went through - oh my God, it probably would have been easier to be a doctor.

Anyway, I understand both of you are on a pharmacy workforce working group with the Department of Health and Wellness. I really want to know if you can tell us a little bit about the role of that program and what you hope to achieve from that group to help pharmacists.

BEVERLEY ZWICKER: That really is a bit of a collaborative coordination of recruitment efforts, the focus of that group. It’s bringing together the various organizations that are attempting to shore up the pharmacy workforce in the province to make sure that we are not duplicating our efforts, and that we are addressing all of the various factors that impact why somebody would become a pharmacist or a pharmacy technician - why they would do so in Nova Scotia, how we can keep them here, and how we can educate them.

I can say that for the Nova Scotia College of Pharmacists, we have several initiatives under way aimed at shoring up the pharmacy workforce. We are actively involved in streamlining licensing requirements. At the same time, we are also working on a recruitment campaign with a marketing firm to let everyone know that in this very noisy health care environment that exists globally, Nova Scotia is where you want to come to practice pharmacy. It’s where you want to come to live. We’re hoping to launch that in the Fall.

The other important piece in this that we also have under way is a project that we’ve had under way for a few years, which is aimed at establishing a minimum staffing level for all pharmacies based on the amount of work that they are providing - to your point that we don’t have pharmacists and pharmacy technicians trying to provide a level of care that they just can’t sustain with the workforce that they have in that pharmacy. These together, we’re really hoping will set Nova Scotia apart as somewhere that pharmacists will want to come practice. You can practice and not necessarily feel like you’re leaving 150 per cent more than you have at the end of the day, and that you’re able to practice in the way that you were trained.

ALLISON BODNAR: It is something we think about every day and every night - what we can do to solve or contribute to solving this issue. We’ve identified a huge need to go out and be proactive and solicit pharmacy professionals in other jurisdictions to tell them about what the opportunities are. These clinics are unique. I’m getting calls from every province in this country about what we’re doing and how this can roll out across the country.

We have a unique opportunity right now to sell the practice of pharmacy. We’re looking at how we develop that marketing campaign, getting a website where people can land that will have all the information that they need, licensing wise, and then quite frankly having a recruitment navigator. So we would have, in my shop, somebody who could help a person who’s interested in Nova Scotia to connect with the right groups that they need to connect with, whether that is a licensing question or the jobs themselves or a community group.

We would love to see the community-funded physician-recruitment committees expand their mandate to include pharmacists. We need to think more globally as we’re thinking about health care in Nova Scotia. We’ve been very well focused on physician recruitment and nursing recruitment over the last year and a half. We need to be equally focused on pharmacy professional recruitment. We are looking at using a lot of our own budget to do this, which would be outside both of our mandates - but we’re going to go ask for it anyway.

We’ve also put in a proposal for some additional support to be able to shore up recruitment and make sure we’ve got people flowing into this province to fill those positions so that our technicians are working to full scope and, as you point out, doing 80 per cent of the dispensing. Then our pharmacists can do work to full scope and offer these clinics across the province.

There’s a lot of work under way. There’s just no magic bullet that’s going to get us there tomorrow.

THE CHAIR: MLA White, about three minutes. Oh, I see MLA Smith’s hand up.

MLA Smith.

KENT SMITH: Thank you, Mr. Chair. You said about three minutes?

THE CHAIR: A little less now.

KENT SMITH: My thunder was stolen for the final question. It was going to be about what are we doing to recruit, promote and attract new pharmacists, and what advice would you give to young Nova Scotians who are deciding between CCA work or EPA work or going into pharmacy? You’ve shared some of the things that you’re doing, so I won’t ask you to expand on it just yet, unless we need to fill up the rest of the time.

That being said, I’ll go back to my second-last question that I was going to ask first. The expanded scope of pharmacy is something that, Ms. Bodnar, you said you’ve been advocating for something like this since 2017, and it was finally in 2023 when we were able to put it in place. Personally, I’m proud to be part of a team that makes things happen, especially when organizations like yours are asking for it for years and years and years, and it didn’t get done.

We as MLAs have health care conversations all the time. People ask us what’s going on, sometimes they’re critical, and oftentimes - rarely - we get a nice positive message. So I wanted to share with both of you a positive message that I received that you can share within your organizations.

There’s a preamble about losing a family doctor, not getting an NP, and the troubles of a senior trying to find care. I will share the whole email with the committee, but I wanted to share this.

After the preamble, it says:

“I saw the beautiful and competent pharmacist at 11:50 on Monday, July 17, 2023. I took my medications with me. She asked a lot of questions, made lots of notes, and took my blood pressure. In the end, she was able to give me a blood requisition for my bloodwork, corrected how I should be taking one of my medications, and could renew my three prescriptions. She will get the results of my bloodwork and will call to discuss it. What more could I ask for? Nothing.

This pilot project makes a whole lot of sense. I am hoping that other seniors like me and other people who take advantage of this pilot project will let you know how easy it is to use, how thorough the pharmacist is, and that you should make it a permanent program with a proper amount of funding.”

So there’s a good-news story to end the committee.

You talked a little bit in the last answer about marketing and using some of the money you have maybe for recruitment. MLA Palmer and I were chatting about the fact that we need to be promoting these pharmacy clinics much, much more. Are your organizations spending money on marketing it broadly and not just . . .

[2:45 p.m.]

THE CHAIR: Order. The time for the PC caucus has elapsed. I will ask MLA Smith to table that email. (Interruption) MLA Smith, I’m just reminding you that you do have to table what you read into the record as well.

That concludes our question and answer. As you can tell, there’s probably lots more that people have to say. This is an opportunity for you to have any closing remarks, if you have some. I will offer to both of our witnesses.

Ms. Bodnar.

ALLISON BODNAR: No formal comments, what I would like to say is that if there is any information that I haven’t disclosed today or any other questions that you have, please feel free to reach out. There is so much opportunity to rethink how we deliver health care. Pharmacy is just a piece of that, but it’s a piece that can play a very important role. It’s our job to figure out as a system how we make that happen.

So many times I’ve heard, “But they’re privately employed.” So what? We can do lots by contract and agreement, and we can do a whole lot of things to make this work for the system. That’s what we need to focus on now: How do we evolve the system so that we are fully utilizing pharmacists and our pharmacy teams, as well as other health care providers, to their maximum scope for patients?

THE CHAIR: Ms. Zwicker.

BEVERLEY ZWICKER: I’ve appreciated our time here today, and I think it will have been successful if you leave here thinking differently about the profession than you did when you started, encouraged and confident in the opportunity to further improve both access to care and quality of care by furthering the repositioning of pharmacy in primary care delivery.

I just want to pause on that for a minute. It’s not just about pharmacists testing and treating strep or minor ailments. That’s certainly an important service that they provide, but more important to the long game of ensuring that there’s better quality of care is that pharmacists are repositioned to be the authors of drug therapy, that the prescribing of medications, from the first prescription and ongoing, is the primary role of the pharmacist.

That’s going to take rethinking. It’s going to take disrupting some entrenched ideas about whose role it is to do it in the primary and whose role it is to do it in the secondary - who authors it and who edits it. Drugs are sophisticated and complex, much more so than they were years ago. It really does take expertise to be able to use them appropriately so that we’re getting the most from our drug budget line, but more importantly, so that we as Nova Scotians realize the health outcomes that we can and the best possible health care that we can.

This is not going to be a small undertaking. It requires all of us to change what we think, how we talk about health care, and what we do in our individual roles. At the college, we’ve needed to rethink what it is that pharmacists do and what pharmacy technicians do and allow that delegation, let technicians take on a larger role in dispensing. Government and system designers need to rethink who’s at the table, who’s planning the long redesign, who’s involved in that. Practitioners need to rethink what practice looks like, and the public needs to rethink.

Change is hard, but I have a director on my staff who’s a doctorate in behavioural science. She says, “Yes, change is hard, but change is possible. We just need to start saying yes.” Change being hard doesn’t mean that we don’t do it. It just means that we need to be intentional about doing it.

I’m really encouraging you fellow Nova Scotians to rethink what the role of pharmacy is to get to where we need to be for a redesigned and sustainable health care system.

THE CHAIR: On behalf of the committee, thank you to our witnesses for attending. We have a bit of committee business. We’ll take a four-minute recess and then return back to do that committee business. Once again, thank you for coming.

We’ll take that four-minute recess.

[2:49 p.m. The committee recessed.]

[2:52 p.m. The committee reconvened.]

THE CHAIR: Order. We’ll call the meeting back to order for committee business.

We have one item on there, and I’ll bring up another item as well.

The witness request for virtual participation at the October 19^th meeting on mental health supports for First Nations communities: witness Lindsay Peach of Tajikeimɨk has asked whether one or more of her colleagues may take part via Zoom. I just wanted to put that out to everybody. We don’t necessarily have to do that here, but I wanted to make sure everybody was comfortable with that.

MLA DiCostanzo.

RAFAH DICOSTANZO: Fine with that. Go ahead.

THE CHAIR: We have consensus? Thank you.

The other item that I just wanted to bring up is that we did get a piece of correspondence. I don’t know if everybody it, but there was an email sent out to committee members yesterday. In light of that, maybe we’ll put it on the agenda for the next meeting. Is that all right for everybody? So everybody will have an opportunity to look at that correspondence.

Any other business? Hearing none, the date of the next meeting is Tuesday, September 12^th, from 1:00 p.m. to 3:00 p.m., and the topic is Implementation of Additional Mental Health and Addictions Supports. The witnesses include the Office of Addictions and Mental Health, the Mental Health Foundation of Nova Scotia, and the Canadian Mental Health Association.

With that, our meeting is adjourned.

[The committee adjourned at 2:54 p.m.]