Self-regulated professions

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6. Pharmacists

Overview

Role and function

The public's perception of pharmacists is that their main function is to fill prescriptions written by medical doctors. But in recent years, pharmacists have become involved in a broader spectrum of health care concerns, such as giving advice to patients, supporting local health groups (e.g. lung and diabetes associations), offering counselling clinics on specific topics (e.g. smoking cessation, weight loss and diabetes), identifying, resolving and preventing medication-related problems, identifying instances in which medications are insufficient to deal with patients' needs, and ensuring that Canadians receive the best possible drug therapy. This has led pharmacists to see themselves as professionals responsible for patients' optimal use of drugs. ¹

Pharmacists work in a variety of settings: community settings, such as health clinics, hospitals and other institutions (e.g. nursing homes), industry (i.e. pharmaceutical manufacturing companies), government, and education and research. ² Most commonly, pharmacists work in independent, banner (non-franchises with a common corporate identity), franchise, chain, supermarket, and mass merchandiser and department store pharmacies. Pharmacists may be salaried employees or owner-operators. ³

How the profession is regulated

All of the provinces allow pharmacists to self-regulate through governing bodies, most often called colleges or boards. ⁴ For example, the Ontario College of Pharmacists, established and empowered by the Pharmacy Act , the Regulated Health Professions Act , the Drug and Pharmacies Regulation Act , and the Drug Interchangeability and Dispensing Fee Act , sets requirements for registration, licenses pharmacists, defines professional misconduct, sets standards of operation and regulates the practice of pharmacy in Ontario. ⁵ In the three territories, government directly regulates pharmacists.

Provincial or territorial law and each provincial college or board defines the products and geographic areas in which pharmacists may trade. The geographic area corresponds to the province or territory in which pharmacists are located and licensed to practise.

Pharmacists' services are usually defined by the enabling legislation in each jurisdiction, although the precise definition varies. Some jurisdictions do not define the practice of pharmacy at all (Yukon, Northwest Territories, Nunavut, New Brunswick and Saskatchewan), while others (Quebec, for example) define it indirectly by specifying the activities in which pharmacists alone may engage.

The National Association of Pharmacy Regulatory Authorities represents the interests of the provincial and territorial regulators and promotes harmonization of regulations.

Overlapping services

There are no professionals who provide exactly the same services as pharmacists do because no other profession has the principal function of dispensing drugs by prescription. Although other professionals, such as nurse practitioners and dentists, may incidentally perform limited acts of dispensing, selling or supplying prescribed drugs in restricted circumstances, none performs the complete range of essential activities that pharmacists do.

Entering the profession

Individuals seeking to become licensed pharmacists in Canada usually must do the following:

• obtain a bachelor's degree in pharmacy from a Canadian university (there are currently nine Canadian universities with pharmacy schools);
• complete a national examination administered by the Pharmacy Examining Board of Canada (except in Quebec); ⁶ and
• obtain practical experience through a training program (apprenticeship or internship).

Particular requirements vary from province to province, with fluency in either English or French generally being required. ⁷

Market

Demand

Pharmacist services are provided to patients receiving drugs in hospital or as outpatients; therefore, the demand for these services depends on the demand for prescription drugs. As noted, the profession itself is becoming involved in a broader spectrum of health care concerns than ever before. ⁸

The demand is influenced by various factors, including demographic changes, disease patterns, new drug products and prescribing practices. Overall, spending on both prescribed and over-the-counter drugs has steadily risen. According to the Canadian Institute for Health Information, drug expenditures grew by 9.7 percent annually from 1997 to 2004, when they reached $21.8 billion, and were expected to reach $25.5 billion by 2006. ⁹

The geographic market for pharmacist services is likely to be limited, since retail consumers usually fill prescriptions near their homes or receive prescription drugs while in hospital. The only exceptions to this are consumers who purchase drugs from Internet pharmacies.

Supply

Across Canada, as of January 1, 2007, there were 29,699 pharmacists licensed to practise in a patient care setting across Canada (see Table 1) and 7,889 licensed community pharmacies. ¹⁰

 

Table 1: Number of pharmacists in Canada, as of January 1, 2007

Province or territory	Number of pharmacists (percentage of national total)
Total	29,699
Alberta	3,532 (11.9 percent)
British Columbia	4,071 (13.7 percent)
Manitoba	1,136 (3.8 percent)
New Brunswick	648 (2.2 percent)
Newfoundland and Labrador	556 (1.9 percent)
Northwest Territories	23 (0.1 percent)
Nova Scotia	1,087 (3.7 percent)
Nunavut	17 (0.1 percent)
Ontario	10,183 (34.3 percent)
Prince Edward Island	157 (0.5 percent)
Quebec	7,057 (23.7 percent)
Saskatchewan	1,195 (4.0 percent)
Yukon	37 (0.1 percent)

Source : National Association of Pharmacy Regulatory Authorities. ¹¹

According to the National Association of Pharmacy Regulatory Authorities, “the majority of pharmacists work in licensed community pharmacies that are not part of the public health care system.” ¹²

On average, there is slightly fewer than one pharmacist for every 1,000 Canadians. There is some variation in this ratio across provinces and territories, with Nunavut having the lowest and Saskatchewan the highest. ¹³ The two most populous provinces, Ontario and Quebec, have the most pharmacists.

Restrictions and recommendations

Market entry restrictions

Entering the profession

Individuals wishing to practise as pharmacists in Canada must complete one year of predominantly pre-pharmacy science courses and then earn a bachelor's degree in pharmacy from a Canadian university. ¹⁴ There are currently nine pharmacy schools in Canada, with a tenth set to open in Waterloo in January 2008. ¹⁵ This will be the first new pharmacy school in Canada in 20 years; it will also feature the only co-op pharmacy program in Canada. ¹⁶

The pharmacy profession in Canada does not formally place quotas on the number of pharmacies or pharmacists. However, there are limits on the number of students admitted to the university pharmacy programs. For example, in the 2008 admission cycle at the University of Toronto, only 240 students will be accepted from an anticipated pool of more than 1,000 applicants. ¹⁷

Recommendation

In light of the anticipated changing demand for pharmacy services in Canada, universities should regularly review the number of places available in their pharmacy programs to ensure an adequate supply of pharmacists.

To be licensed, e very graduate from a Canadian pharmacy school must pass the Qualifying Examination administered by the Pharmacy Examining Board of Canada (PEBC) ( except in Quebec, which administers its own examination) . ¹⁸ Through the examination and certification process, the PEBC is responsible for ensuring that pharmacists have a “minimal level of competence to practise at an entry level.” ¹⁹

The final requirements for a pharmacist's licence are practical experience and fluency in either English or French. In most provinces, candidates may meet the language requirement by showing that they are fluent or proficient in either English or French; however, Quebec requires all pharmacists to be fluent in French. ²⁰ Provinces require varying durations of practical experience, from four weeks in British Columbia to 36 weeks in Prince Edward Island and Nova Scotia. ²¹

Given that the roles and responsibilities of pharmacists are essentially the same throughout Canada, there is no apparent reason for the combined duration of education and practical experience requirements to vary across provinces. When the duration of the required experience is longer than necessary, the cost of entry for individuals wishing to be licensed as pharmacists can be needlessly high.

Recommendation

To avoid unnecessarily high practical experience requirements, provinces whose requirements take longer to complete than those of other provinces should look to the experience of those provinces to determine whether an acceptable level of quality could be achieved in less time.

Mobility

Interprovincial mobility

There are no residency requirements to be licensed as a pharmacist in any province or territory. In addition, all provinces except Quebec (and the three territories) signed a mutual recognition agreement (MRA) on April 9, 2000, through the auspices of the National Association of Pharmacy Regulatory Authorities . ²²The intention of the agreement is to remove unnecessary barriers to mobility of qualified pharmacists and establish the conditions under which pharmacists in good standing in one province may have their qualifications recognized in another.

Section 4 of the MRA guarantees mobility to all pharmacists who are licensed in good standing in any signatory province as of July 1, 2001, and to those who meet specific licensing requirements after that date.

The MRA facilitates movement of pharmacists between provinces by greatly reducing, if not removing, registration and licensing barriers. Under the agreement, the signatories must undertake periodic reviews no less than every two years after July 1, 2001, to explore ways to facilitate the non-signatories joining the agreement. Quebec attended the meeting in October 2003 but the territories did not. ²³ The fact that the territories have not signed the MRA does not, however, pose any obstacles to pharmacists outside the territories from relocating there, since to be licensed in each territory, they must already be licensed in a province and pay the prescribed licensing fee. ²⁴ No additional qualifying examinations are required.

Having all provinces sign the MRA would allow pharmacists to provide professional services seamlessly throughout Canada and, thus, respond to changes in demand quickly and effectively.

Recommendation

The National Association of Pharmacy Regulatory Authorities should continue its efforts to have Quebec sign the Mutual Recognition Agreement.

International mobility

A survey conducted in 2005 revealed that 90 percent of the pharmacists practising in Canada had received their pharmacy degree from a Canadian university. Of the remaining 10 percent, three percent were trained in the United States and seven percent were trained outside North America. ²⁵

Pharmacists who were licensed outside Canada must meet varying admission requirements, depending on the province. Most provincial colleges and boards of pharmacy require either graduation from a pharmacy program that is recognized as equivalent to the one in their province or completion of Pharmacy Examining Board of Canada examinations. For example, the Prince Edward Island Pharmacy Board may accept a comparable pharmacy licence from another jurisdiction without additional requirements, whereas in Newfoundland and Labrador, foreign-trained pharmacists must complete a minimum of 32 weeks of practical experience in Canada. ²⁶ In Nova Scotia, foreign-trained pharmacists may be required to complete up to 12 months of practical experience before being licensed. ²⁷

In addition to the standard registration requirements, all foreign-licensed pharmacists wishing to practise in Canada must be fluent or proficient in English or French, or demonstrate that they are proficient to specified standards in each province. ²⁸

Pharmacists whose pharmacy degree is from a country other than Canada or the United States must take the Evaluation Examination before taking the Qualifying Examination. ²⁹ All provinces except Quebec (which administers its own examination) require applicants trained outside of Canada to pass the same qualifying examination, administered by the Pharmacy Examining Board of Canada. ³⁰

Given that the roles and responsibilities of pharmacists are essentially the same across the country, there is no apparent reason for the variation in the admission requirements for foreign-trained pharmacists. When the requirements are higher than necessary, the cost of entry can be needlessly high, resulting in fewer pharmacists entering the profession and, as a result, domestic pharmacists being protected from legitimate competition from qualified foreign pharmacists.

Recommendation

Each provincial college or board of pharmacy should review whether it has minimized its admission requirements for certifying foreign-trained pharmacists who otherwise meet the qualification requirements. Such a review should look to provinces with less onerous admission requirements that continue to meet quality standards.

In other professions, regulators use various mechanisms to assess whether the applications of foreign-educated or -trained professionals may be expedited, including an international qualification approval board, an international bridging program and a national committee on accreditation, all administered by national organizations that assess educational and professional qualifications on behalf of provincial colleges and boards. The pharmacy profession in Canada does not use any of these mechanisms, relying instead on each province to set its own evaluation and entry criteria, and assessment process, as noted above. Professional competence should be the only grounds for assessing foreign credentials; whether the qualified entry candidate is local or foreign should be immaterial.

However, two of the pharmacy schools at the University of Toronto and the University of British Columbia offer bridging programs to help foreign-trained pharmacists qualify for entry into the profession in Canada. Since 2001, more than 525 students have graduated from the University of Toronto program, which boasts a 92 percent success rate for graduates passing licensing examinations. ³¹ This achievement is salutary from a competition perspective because it helps clarify and expedite the process for adequately qualified foreign-trained pharmacists to enter the profession in Canada. Increased competition among qualified pharmacists is thereby fostered, to the benefit of consumers.

Recommendation

Each provincial college or board of pharmacy should make efforts to identify foreign jurisdictions whose trained pharmacists meet admission requirements. In addition, all provinces should work towards a nationally recognized, formal bridging program, similar to the ones offered by the University of Toronto and the University of British Columbia.

Overlapping services and scope of practice

There are no other professions that are primarily involved in the same functions as pharmacists, principally because it is usually an offence for someone who is not registered and licensed as a pharmacist to practise pharmacy. It is also the case because pharmacists usually dispense all prescriptions, regardless of who writes them. ³²However, some provinces and territories do have legislative exceptions that allow optometrists, physicians, nurse practitioners and dentists to dispense or administer particular drugs under certain conditions. ³³ In Manitoba, physicians in remote communities may compound and dispense drugs. ³⁴ In Nunavut, medical practitioners and dentists may supply drugs; nurses may also supply specified drugs when directed or supervised by a medical practitioner or dentist. ³⁵From a safety perspective, restricting who may possess, handle and dispense drugs (some of which are poisons) meets a legitimate public safety objective. It also ensures that licensed pharmacists supervise the work of pharmacy technicians, who have fewer professional qualifications.

Pharmacy technicians may provide services that complement those of pharmacists. Pharmacy technicians help pharmacists fill prescriptions and operate pharmacies. ³⁶ Whether they have formal training (e.g. at a community college) or receive on-the-job training, pharmacy technicians are restricted by law as to what they may do and must perform their activities under the supervision and guidance of a pharmacist, who is responsible for their conduct. ³⁷

In Alberta, pharmacy technicians working under the “indirect supervision” of pharmacists may help check repackaged drugs and may also compound drugs. ³⁸ In Quebec, pharmacy clerks (the functional counterpart of a pharmacy technician in that province) may sell medications under the supervision of pharmacists and may prepare medications when they have five or more years of experience. ³⁹

In Ontario, pharmacy technicians are not permitted to perform any of the controlled acts that occur during the professional aspects of operating a pharmacy. ⁴⁰However, recent amendments to Ontario's Pharmacy Act, 1991 (once they come into force) will create a new class of certificate of registration within the profession that allows the Ontario College of Pharmacists to license and regulate pharmacy technicians. ⁴¹ The amendments will also protect the title of pharmacy technician in the same way that the title of pharmacist is now protected.

The role of technicians varies slightly depending on the specific location of employment. For example, in a traditional pharmacy setting “technicians help licensed pharmacists provide medication and other healthcare products to patients. Technicians usually perform routine tasks to help prepare prescribed medication for patients, such as counting tablets and labelling bottles. Technicians refer any questions regarding prescriptions, drug information or health matters to a pharmacist.” ⁴² However, in hospitals, nursing homes and assisted-living facilities, technicians have additional responsibilities, such as reading patient charts and delivering medicine to patients, after the pharmacist has checked the prescription. Specifics about hospital pharmacy operations vary slightly by province and territory.

In Canada, the permitted ratio of pharmacists to pharmacy technicians varies widely, from 1:1 (Saskatchewan, Newfoundland and Labrador) to 1:4 (Quebec). ⁴³ The reason for limiting the number of technicians working under a pharmacist is to ensure a pharmacist is not supervising too many technicians at once. ⁴⁴ However, p harmacy technicians are very adept at the mechanical tasks of filling prescriptions (such as counting pills and mixing lotions), since they do this regularly and often, and higher ratios allow pharmacists to devote more time to patient-oriented services, such as counselling. ⁴⁵ Further, at least one provincial regulator has adopted the position that “establishing an arbitrary pharmacist-technician ratio does not achieve” the goal of ensuring “safe, effective and quality pharmacy services,” which is the intent of the restriction. ⁴⁶

Changing patient demographics (i.e. an aging population that is increasing in size) and medical advances are placing greater demands on pharmacists' time and professional knowledge. This has caused pharmacists to become increasingly dependent on pharmacy technicians (who are increasingly performing more duties of pharmacists) to help them meet growing prescription drug demands and administrative needs. However, pharmacy technicians are largely unregulated in Canada, and the provincial colleges and boards of pharmacy that seek an expanded mandate to regulate pharmacy technicians are aware of the potential for conflict with pharmacists. ⁴⁷ Although the general movement appears to be towards direct regulation of pharmacy technicians by pharmacists, the further issue of the need to standardize the number of pharmacy technicians working under the supervision of a pharmacist is still being debated within the pharmacy profession. ⁴⁸ No matter whether or how pharmacy technicians are regulated or what the acceptable pharmacy technician to pharmacist ratio is, pharmacists are and will continue to be ultimately responsible, under the rules that govern them, for the work done by employees they supervise.

Within those parameters, though, employing a greater number of pharmacy technicians should allow pharmacists to spend more time on qualitative patient needs (such as counselling on drug use and interaction), thereby increasing the likelihood that the quality of pharmacists' services will correspondingly improve. It should also permit the pharmacy to fill more prescriptions, thereby increasing efficiency.

Recommendation

In order to increase efficiency while still maintaining adequately safe pharmacy operations, provincial colleges and boards of pharmacy should allow individual pharmacists to decide the number of pharmacy technicians they will employ in their pharmacies. The colleges and boards that stringently limit the use of pharmacy technicians in pharmacies should consider the provinces that allow for the greatest use of pharmacy technicians as having taken the least restrictive approach, which they should adopt.

Market conduct restrictions

Advertising

The provincial colleges and boards of pharmacy tend to restrict advertising for pharmacists' services. None of the three territories has enacted rules governing advertising by pharmacists or pharmacies, so this activity is subject only to the restrictions under the federal Food and Drugs Act and Controlled Drugs and Substances Act relating to contraceptives, narcotics and other controlled substances. ⁴⁹

Restrictions on price advertising are very broad across the provinces. In both Ontario, and Newfoundland and Labrador, price advertising of a single drug is prohibited. Advertisements in Newfoundland and Labrador must include prices for at least 15 drugs; a similar restriction in Ontario requires prices for 10. ⁵⁰ According to the Ontario College of Pharmacists, this restriction is intended to prohibit pharmacists from advertising a single drug as a loss leader. ⁵¹ However, the net result has been that the restriction has diminished the effectiveness of the message drug advertisements convey and constrained consumers' ability to easily make price comparisons between competing pharmacies.

In Newfoundland and Labrador, Ontario and British Columbia, advertisements that list prices must also include the drug cost, markup, professional fee and total charge for the prescription. ⁵² In Manitoba, and Newfoundland and Labrador, professional fees may not be listed on their own in advertisements. ⁵³ In Prince Edward Island, any markup must be stated in advertisements. ⁵⁴ Only the full retail price for prescriptions is allowed to appear in advertisements in New Brunswick. ⁵⁵ No price information is allowed in Saskatchewan, except on a sign provided or approved by the Council of the Saskatchewan College of Pharmacists. ⁵⁶

Although coupons are mostly unregulated, Quebec prohibits all discounts, gifts, rebates, coupons or other bonuses when selling medicine. ⁵⁷ According to the Ordre des pharmaciens du Québec, the prohibition is designed to prevent pharmaceutical companies and pharmacists from using commercial incentives to promote the use of drugs, since pharmacists are required to be guided by patient needs rather than commercial interests. ⁵⁸ In Ontario, attaching bonus points, coupons or other incentives to the sale of prescription medication is prohibited. ⁵⁹ Manitoba allows coupons under certain conditions. ⁶⁰

Recent court cases have clarified restrictions on coupons in the pharmaceutical industry in Ontario and New Brunswick. According to the outcomes of two cases, pharmacists may not distribute food coupons redeemable at grocery stores to their customers (Ontario), but they may provide rebate coupons redeemable at the pharmacy on the cost of prescriptions (New Brunswick). ⁶¹

Product price is the primary tool firms use to compete in open markets. Price restrictions inhibit this competition, thereby frustrating one of the purposes of the Competition Act , namely to provide consumers with competitive prices and product choices. No rationale justifying the prohibition on low price ads (and ads for a single product, in particular) was provided, and the Bureau is unaware of direct evidence of harm to consumers when pharmacists have been allowed to advertise low prices.

Recommendation

Colleges and boards of pharmacy should remove restrictions on price advertising unless they can show a clear link to a meaningful reduction in consumer harm by such restrictions.

All the provinces prohibit advertisements that are not in good taste, compare services or abilities, promise more effective service or better results, or lower the honour or dignity of the profession. ⁶² Also, six provinces ban advertisements that contain unverifiable assertions or testimonials, and two provinces prohibit endorsements. ⁶³

Every province greatly restricts comparative advertising by pharmacists that relates to their abilities or the services they offer. Newfoundland and Labrador, Nova Scotia and Prince Edward Island have banned the use of specific words in advertising, including qualifying words such as professional , trusted , licensed , accurate , fast and cheap . ⁶⁴

Other restrictions focus on specific aspects of pharmacists' business:

• British Columbia does not allow the title of specialist or information about the effectiveness or indications for the use of prescription drugs to be in an advertisement. ⁶⁵
• Manitoba bans advertisements that describe the method of drug preparation. ⁶⁶
• Ontario forbids the advertisement of brand name equipment used to provide prescription services. ⁶⁷
• Saskatchewan prohibits signs that are flamboyant, grandiose or sensational, or that demean the profession. ⁶⁸

Existing advertising prohibitions leave very little to no room for pharmacists to promote themselves other than by name, contact information and business hours. Instead, pharmacists are left to rely on the advertising, image and promotion of the retail enterprise in which they are situated. Promotion is viewed as somehow undignified and unprofessional, with sanctions in place for those who tarnish the image of the professional through the crassness of commercial promotion.

False and misleading advertising prohibitions do serve the valid purpose of protecting the public from fraud; however, consumers are already protected from false and misleading advertising under the federal Competition Act as well as various provincial consumer protection laws that require advertisements to be truthful and verifiable. Advertising restrictions that go beyond this do not serve the consumer interest well, since they result in consumers being denied the information they need to make fully informed decisions and choices about the services they require. ⁶⁹ The restrictions may also protect relatively inefficient incumbents from competition from new entrants.

Prohibitions on comparative advertising function to restrict the incentive of more efficient service providers to develop their services. They also have the potential to reduce the returns associated with innovation and relative quality improvement and thus diminish the incentive to engage in these improvements in the first place.

Recommendation

Provincial colleges and boards of pharmacy should eliminate all restrictions on advertising that go beyond protecting consumers from false or misleading advertising, including prohibitions on all forms of comparative advertising.

Pricing and compensation

Retail pharmacists derive their income in part from charging a handling or dispensing fee per prescription. Additionally, many health plans and drug formularies limit the fees pharmacists may charge health plan participants or are reimbursed by the health plan. ⁷⁰ While dispensing fees may vary by the location of the pharmacy, the overall average dispensing fee is $9.16. Table 2 shows the distribution of average dispensing fee by type of pharmacy in 2005.

Table 2: Average dispensing fee by pharmacy type, 2005

Pharmacy type	Dispensing fee
Overall	$9.16
Supermarket lock and leave	$6.25
Supermarket	$6.25
Mass merchant or department store	$6.49
Banner	$9.32
Chain	$9.40
Independent	$9.48
Franchise	$9.57

Source : Rogers Publishing, Trends and Insights , p. 28, www.mckesson.ca/documents/Trends_2005.pdf .

Usually health plans reimburse pharmacists on a fee per prescription-dispensed basis, but in Saskatchewan, Prince Edward Island, Yukon and Northwest Territories, pharmacists are reimbursed as a percentage of the price of the prescription dispensed. ⁷¹ Quebec pharmacists are reimbursed for the cost of the drug plus a professional fee. ⁷²

In addition to dispensing prescription drugs, pharmacists are also qualified to provide a limited number of specialized services, such as weight loss or smoking cessation counselling, the fees for which vary widely, since, unlike dispensing fees, fees for other services are not capped by provincial drug plans or formularies. For example, the average fee for diabetes management is $18.59, $27.17 for medication management and $42.76 for smoking cessation; however, the vast majority of pharmacists do not charge fees for these services. ⁷³

Several provincial pharmacy associations (including the Ontario Pharmacists Association) have created and promoted s uggested fee schedules for professional services, although these fee schedules are not publicly available and their contents are unknown. ⁷⁴ Fee schedules that are entirely voluntary and do not carry adverse consequences for members who choose not to comply with them (e.g. discipline or financial disadvantage) do not contravene the Competition Act . However, their very existence causes concern about their influence on competition. Fee schedules can potentially facilitate collusion in price setting, either overtly or tacitly, by signalling acceptable prices and, thereby encouraging pharmacists to set their prices accordingly.

The costs imposed on consumers by these restrictions are higher than they would be in a free market, as is the potential for lower quality service. The Bureau is not aware of any rationale for the use of fee schedules that is linked to the public interest, which means that fee schedules impose costs without any apparent benefit to consumers.

Recommendation

In provinces where suggested fee schedules for pharmacists exist, they should be removed.

Business structure

Restrictions on the business structure of Canadian pharmacies vary by province, but in general, govern who may own and manage pharmacies. Table 3, below, shows some of the restrictions on the business structure of Canadian pharmacies by province.

Table 3: Restrictions on business structure for pharmacies by province

	Alta.	B.C.	Man.	N.B.	N.L.	N.S.	Ont.	P.E.I.	Que.	Sask.
Pharmacy must be managed by a pharmacist	X	X		X	X	X	X	X	X	X
Pharmacy must be owned by a pharmacist or pharmacist partnership							X		X
Drug prescriber may not own or operate a pharmacy		X					X
Pharmacy may not be located in an establishment that sells tobacco products						X	X	X	X
Pharmacy must surrender licence when ownership or manager changes			X		X	X		X
Pharmacist may only manage one pharmacy						X
Pharmacy required to be open a minimum number of hours			X	X	X
Majority of shareholders or directors in a corporation must be pharmacists		X					X		X	X

Sources

Alberta: Pharmacy and Drug Act , R.S.A., 2000, c. P-13, as am'd; Pharmacists Profession Regulation , A.R. 129/2006; Pharmacy and Drug Regulation , A.R. 240/2006.

British Columbia: Pharmacists, Pharmacy Operations and Drug Scheduling Act , R.S.B C. 1996, c. 363; College of Pharmacists of British Columbia, consultation submission, July 5, 2007; British Columbia Pharmacy Association, consultation submission, June 11, 2007.

Manitoba: Pharmaceutical Act , C.C.S.M., c. P60; Pharmaceutical Regulation, Regulation 56/92.

New Brunswick: Pharmacy Act , S.N.B., 1983, c. 100; C.S.N.B. 2005, c. 100; New Brunswick Pharmaceutical Society, Regulations and General By-Laws .

Newfoundland and Labrador: Pharmacy Act , S.N.L., 1994, c. P-12.1; Pharmacy Regulations , N.L.R. 80/98; Interchangeable Drug Products Formulary Regulations , 1998, N.L.R. 75/98.

Nova Scotia: Pharmacy Act , S.N.S., 2001, c. 36; Practice of Pharmacy Regulations , N.S. Reg. 193/2003; Nova Scotia College of Pharmacists, consultation submission, July 6, 2007.

Ontario: Drug and Pharmacies Regulation Act [formerly Health Disciplines Act ], R.S.O., 1990, c. H.4; Regulated Health Professions Act , S.O., 1991, c.18, including the Professional Code ; Health Professions Procedural Code , S.O. 1991, c.18; Bureau communication with the Ontario College of Pharmacists, September 6, 2007 .

Prince Edward Island: Pharmacy Act , R.S.P.E.I., 1988, c. P-6; Authorization Regulations , P.E.I. Reg. EC575/92; Prince Edward Island Pharmacy Board, consultation submission, June 1, 2007.

Quebec: Pharmacy Act , R.S.Q., c. P-10; Regulations , R.Q. c. P-10, r.1, r.3.2, r.4, r.5, r.6.1, r.8.1, r.8.2, r.12.1, r.19, r.20.1; Professional Code , R.S.Q., c. C-26; Ordre des pharmaciens du Québec, consultation submission, July 6, 2007.

Saskatchewan: Pharmacy Act, 1996 , S.S., 1996, c. P-9.1; Saskatchewan College of Pharmacists, Bylaws , made under the Pharmacy Act, April 2006, s. 14(2)(l).

Of particular note are restrictions on who can participate in the ownership of a pharmacy: specifically, Nova Scotia restricts pharmacists to managing only one pharmacy, while Quebec requires the pharmacy to be owned by a pharmacist or pharmacist partnership, and British Columbia prohibits drug prescribers from having an ownership interest in a pharmacy.

Ontario has taken a step to foster competition by allowing pharmacies to be located in buildings that also house walk-in medical clinics, sometimes even sharing the same commercial space. Pharmacies in Ontario may also be located in supermarkets or department stores.

Restrictions on business structure are intended to maintain the independence of pharmacists from other professionals in order that commercial pressures associated with multidisciplinary ownership and management do not compromise pharmacists' professional practice or judgment. Aside from trying to avoid conflicts of interest when drug prescribers, such as doctors, dispense drugs, it is difficult to understand why some of these restrictions exist.

The concern about such rules from a competition perspective is that they force many pharmacists into the same business model. This has the effect of ensuring that pharmacists face a similar cost structure, making meaningful competition less likely to occur and possibly preventing entry of new market participants.

Recommendation

The provincial colleges and boards of pharmacy should review their restrictions on the ownership and business structure of pharmacies with a view to eliminating unnecessary obstacles to efficient business models.

Conclusion

Many of the restrictions the provincial colleges and boards of pharmacy have put in place result in increased costs to consumers. Therefore, the colleges and boards should review these restrictions from a competition perspective to determine whether their objectives can be met at lower cost to consumers. When they can, the colleges and boards should revise them accordingly.

In the pharmacy profession, restrictions on conduct have emerged that raise concerns from a competition perspective because they are likely to increase costs to consumers. Problematic conduct restrictions relate to advertising, specifically comparative and price advertising. Advertising is an important aspect of competition and provides consumers with valuable information on which to base their choice of service and service provider. Restrictions that perpetuate asymmetric information only serve to further withhold information from consumers that will help them make informed choices.

Additional restrictions on conduct that deserve attention include restrictions on pricing and business structure. Fee schedules are problematic because they could foster tacit collusion, reducing consumer welfare. Restrictions on business structure are a concern because they limit pharmacists to operating in business models that stifle meaningful competition.

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¹ Canadian Pharmacists Association, “How to Become a Pharmacist,”
www.pharmacists.ca/content/about_cpha/
about_pharmacy_in_can/how_to_become/index.cfm .

²Ibid .

³ Rogers Publishing, Pharmacy Group, Trends and Insights , pp. 17, 20,
www.mckesson.ca/documents/Trends_2005.pdf .

⁴They are the College of Pharmacists of British Columbia, the Alberta College of Pharmacists, the Saskatchewan College of Pharmacists, the Manitoba Pharmaceutical Association, the Ontario College of Pharmacists, the Ordre des pharmaciens du Québec, the New Brunswick Pharmaceutical Society, the Nova Scotia College of Pharmacists, the Prince Edward Island Pharmacy Board and the Newfoundland and Labrador Pharmacy Board. See Canadian Pharmacists Association, “Directory of Pharmacy Associations,” www.pharmacists.ca/content/about_cpha/
about_pharmacy_in_can/directory/associations.cfm?main_heading=
Provincial$Regulatory$Authorities .

⁵ Ontario College of Pharmacists, “Who We Are,” www.ocpinfo.com/client/ocp/OCPHome.nsf/
web/About+OCP .

⁶ Ordre des pharmaciens du Québec, consultation submission, July 6, 2007.

⁷ National Association of Pharmacy Regulatory Authorities, “ Specific Provincial and Territorial Requirements and Application Information for Licensure,” www.napra.org/docs/0/94/109.asp . In Prince Edward Island, a jurisprudence examination covering federal and provincial regulations, and practice standards is required (Prince Edward Island Pharmacy Board, consultation submission, June 1, 2007).

⁸ To this end, the National Association of Pharmacy Regulatory Authorities and the National Advisory Committee on Pharmacy Practice undertook a two-year review to make recommendations on the feasibility of a national specialty recognition program because there is currently no certified specialist program in the profession, although patients may request and pharmacists do provide specialized services. National Association of Pharmacy Regulatory Authorities, “A Regulatory Framework for Recognizing and Certifying Pharmacist Specialists in Canada—May 2003,” www.napra.org/docs/0/95/715.asp .

⁹ Canadian Institute for Health Information, National Health Expenditure Database, “Drug Expenditure in Canada 1985 to 2006,” pp. 6 and 5, http://secure.cihi.ca/cihiweb/products/
Drug_Expenditure_in_Canada_2007_e.pdf .

^10# National Association of Pharmacy Regulatory Authorities, “National Statistics,” www.napra.ca/docs/0/86/363.asp . Patient care setting refers to setting where pharmacists come into direct contact with patients, for example, retail, hospital and nursing home pharmacies. Licensed community pharmacies are retail pharmacies open to the public, unlike hospital pharmacies, which only serve the needs of hospital patients.

¹¹ The figures cited above from the National Association of Pharmacy Regulatory Authorities may vary from figures provided by various provincial organizations. For example, according to the consultation submission from the Ordre des pharmaciens du Québec (July 6, 2007), there were 6,908 pharmacists in Quebec as of March 31, 2006. Likewise, the Ontario College of Pharmacists consultation submission (June 26, 2007) indicated that on December 31, 2006, there were 10,713 pharmacists licensed in that province. The Prince Edward Island Pharmacy Board consultation submission (June 1, 2007) reported that the province has 158 licensed pharmacists. The consultation submission of the Alberta College of Pharmacists (August 17, 2007) reported that the province had 3,500 registered pharmacists. In communications with the Bureau on November 3, 2006, the Canadian Society of Consultant Pharmacists stated that there were 1,200 licensed pharmacists in Manitoba in 2006.

¹² National Association of Pharmacy Regulatory Authorities, note 8, above.

¹³The per capita figures were determined using data from Statistics Canada for the most recent full census.

¹⁴ Admission into a university pharmacy program in Canada requires successful completion of at least one year of a pre-pharmacy science program, with certain courses being mandatory: Bureau communication with the Canadian Pharmacists Association, October 2, 2006, and Canadian Council for Accreditation of Pharmacy Programs, September 19, 2006. See also, for example, University of Toronto, “Section 1—Admissions Overview,” www.pharmacy.utoronto.ca/undergrad/admis/index.jsp .

¹⁵ University of Waterloo, “Welcome to the School of Pharmacy,” www.pharmacy.uwaterloo.ca . Currently, each province has one pharmacy school, with the exception of Quebec (which has two) and New Brunswick and Prince Edward Island (which have none). Canadian Pharmacists Association, “Canadian Faculties and Schools of Pharmacy,” www.pharmacists.ca/content/about_cpha/about_pharmacy_in_can/
directory/associations.cfm?main_heading=Canadian
$Faculties$and$Schools$of$Pharmacy .

¹⁶ University of Waterloo, “Pharmacy,” www.findoutmore.uwaterloo.ca/programs/
full_description.php?program=Pharmacy , and “Welcome to the School of Pharmacy,” ibid.

¹⁷ University of Toronto, note 14, above.

¹⁸ Pharmacy Examining Board of Canada, “About Us,” www.pebc.ca/EnglishPages/General/AboutUs.html .

¹⁹Ibid.

²⁰Regulation respecting the terms and conditions for the issue of permits by the Ordre des pharmaciens du Québec , R.Q. c. P-10, r.8.1, s. 1(6).

²¹ British Columbia: College of Pharmacists of British Columbia, Bylaws of the Council of the College of Pharmacists of British Columbia , s. 6(1)(d)(i); Nova Scotia: Nova Scotia College of Pharmacists, consultation submission, July 6, 2007; Prince Edward Island: Prince Edward Island Pharmacy Board, consultation submission, June 1, 2007.

²²Mutual Recognition Agreement for the Profession of Pharmacy in Canada , www.napra.org/pdfs/professional/mra.pdf . In 2003, Ontario and Quebec signed an agreement to facilitate recognition of training of each other's members. See Ordre des pharmaciens du Québec, consultation submission, July 6, 2007, and P rotocole d'entente entre: L'ordre des pharmaciens du Québec et L'Ontario College of Pharmacists ,
www.opq.org/fr/media/docs/m.o.u._
version_finale_fran_aise.pdf .

²³ See October 17, 2003, notes for workshop at which the parties to the MRA reaffirmed their goal of having the non-member jurisdictions join them, www.napra.org/pdfs/licensing/031022MRA
workshopreport-final.doc . See also National Association of Pharmacy Regulatory Authorities, “Overview,”
www.napra.org/docs/0/94/106.asp .

²⁴ See, for example, Pharmacy Act, R.S.N.W.T. 1988, c. P-6, s. 3(2), 4(1)(a); Pharmacists Act , R.S.Y. 2002, c. 170, s. 2, 3, 4.

²⁵ Rogers Publishing, note 3, above, p. 20; Human Resources and Social Development Canada, Report on Implementation of the Labour Mobility Chapter of the Agreement on Internal Trade–July 2001 , www.rhdsc.gc.ca/en/cs/sp/hrsdc/lmp/mobility/
2001-000049/page00.shtml . Of the 10,274 pharmacists sent surveys, 1,613 responded.

²⁶ Prince Edward Island: Pharmacy Act , R.S.P.E.I., 1988, c. P-6, s. 9(3): Newfoundland and Labrador: National Association of Pharmacy Regulatory Authorities, “Requirements for Initial Licensure in Newfoundland and Labrador, Jan. 1, 2004,” www.napra.org/docs/0/94/109.asp#new . See also Marie Berry, Canadian Pharmacy Law , (Canada Law Book: Aurora, Ont., 1995) vol. 1 at 8.110, p. 8-13.

²⁷ Berry, ibid.

²⁸ Standard registration requirements are passing a provincial jurisprudence exam and the Pharmacy Examining Board of Canada qualifying exam, and completing a practical training requirement.

²⁹ Pharmacy Examining Board of Canada, “The Evaluating Examination: Introduction,”
www.pebc.ca/EnglishPages/EEX/
EEXIntroduction.html .

³⁰Pharmacy Examining Board of Canada, note 18, above , and “The Qualifying Examination: Introduction,” www.pebc.ca/EnglishPages/QEX/QEXIntroduction.html , as well as Berry, note 26, above, 8.120, p. 8-14 .

³¹ University of Toronto, “International Pharmacy Graduate Program,” www.ipgcanada.ca ; University of British Columbia, “Canadian Pharmacy Practice Programme,” www.pharmacy.ubc.ca/cppd/programs/CP3_Program.html .

³²For example, see Alberta Association of Registered Nurses, “Nurse Practitioner Fact Sheet” for listed exceptions,
www.nurses.ab.ca/pdf/NP pdfs/Fact Sheet -
Prescribing & Distributing Guidelines for NPs.pdf .

³³ See, for example, Alberta, Pharmacy and Drug Act , R.S.A. 2000, c. P-13 as am'd, and Ontario, Drug and Pharmacies Regulation Act , [formerly Health Disciplines Act ] R.S.O., 1990, c. H.4, s. 149, 165.

³⁴ Manitoba, Pharmaceutical Regulation , Regulation 56/92 s. 27(1).

³⁵ Pharmacy Act , R.S.N.W.T., 1988, c. P-6, as am'd by An Act to Amend Certain Acts Concerning Health Professions , S.Nu. 2001, c. 10, s. 2(c).

³⁶ Pharmacy Choice, “Pharmacy Technician Careers,” www.pharmacychoice.com/careers/
pharmacy_technician_career.cfm .

³⁷ Ordre des pharmaciens du Québec, consultation submission, July 6, 2007; Alberta, Pharmacy and Drug Act , R.S.A. 2000, c. P-13, as am'd, and Pharmacists Profession Regulation , Alta. Reg. 129/2006; Pharmacy and Drug Regulation , A.R. 240/2006; Council of the Alberta College of Pharmacists, Minutes , March 22, 2007, Edmonton, Alberta, subsection 2.5.1, “Resolutions Committee—Pharmacy Technician Ratio,”
https://pharmacists.ab.ca/downloads/
documentloader.ashx?id=4387 ; Manitoba, note 34, above, s. 17 (2), (3) passed pursuant to the Pharmaceutical Act , C.C.S.M., c. P60.

³⁸ Alberta College of Pharmacists, consultation submission, August 17, 2007.

³⁹Pharmacy Act , R.S.Q., s. 2.01 and 2.02.

⁴⁰ Bureau communication with the Ontario College of Pharmacists, August 18, 2006.

⁴¹Health System Improvements Act, 2007, S.O. 2007, c.10, s. 18. The statute was introduced in the Ontario Legislature as Bill 171 and received Royal Assent on June 4, 2007. However, the part of the statute affecting the health professions, including pharmacists, will only come into force upon proclamation by the Lieutenant Governor.

⁴² Pharmacy Choice, “Pharmacy Technician Careers,” note 36, above.

⁴³ Berry, note 26, above, at 8.530 (p. 8-43). Berry notes that Alberta, British Columbia and Ontario have no set ratio of pharmacists to pharmacy technicians.

⁴⁴ College of Pharmacists of British Columbia, White Paper on Pharmacy Technicians: A Discussion for Council , March 2006, paras. 3.1, 3.7, www.bcpharmacists.org/Portals/0/PDF/Resources/CPBC/
WhitePaperFinalMay2006.pdf .

⁴⁵In communications with the Bureau on August 18, 2006, the Ontario College of Pharmacists commented on the tasks pharmacy technicians are suited to doing. Regarding ratios, see College of Pharmacists of British Columbia, i bid, para. 3.6.

⁴⁶ Council of the Alberta College of Pharmacists, Minutes , note 37, above.

⁴⁷ College of Pharmacists of British Columbia, White Paper, note 44, above, pp. 1, 12.

⁴⁸ Council of the Alberta College of Pharmacists, Minutes , note 37, above.

⁴⁹Food and Drugs Act , s. 3 , Controlled Drugs and Substances Act , S.C. 1996, c. 19, s. 3-4.

⁵⁰Newfoundland and Labrador, Pharmacy Board Standards of Pharmacy Practice: Guidelines on Advertising for Community Pharmacies (September 20, 1999, updated October 2005), s. 7(2); Ontario, Ontario Reg. 202/94 as am'd, s. 38(3).

⁵¹ Bureau communication with the Ontario College of Pharmacists, August 18, 2006.

⁵² Newfoundland and Labrador: Newfoundland and Labrador Pharmacy Board, Guidelines on Advertising for Community Pharmacies , September 20, 1999, s. 7(1); British Columbia: Bylaws of the Council of the College of Pharmacists of B.C. , s. 34(7); Ontario, O. Reg. 202/94 as am'd, s. 38(4).

⁵³ Manitoba: Manitoba Pharmaceutical Association Code of Ethics , s. 14(6); Newfoundland and Labrador: ibid, s. 9.

⁵⁴ Prince Edward Island Pharmacy Board, Advertising Regulations , s. 6.

⁵⁵Regulations of the New Brunswick Pharmaceutical Society , s. 13.04.

⁵⁶ Saskatchewan College of Pharmacists , Bylaws , made under the Pharmacy Act , April 2006, s. 14.12.2, 14.12.4.

⁵⁷Code of ethics of pharmacists , R.Q. c. P-10, r.5, s. 3.05.07.

⁵⁸ Ordre des pharmaciens du Québec, consultation submission, July 6, 2007.

⁵⁹ Ontario Pharmacists' Association, consultation submission, July 5, 2007.

⁶⁰ Manitoba, note 53, above, s. 14(7).

⁶¹Stenzler v. Ontario College of Pharmacists , [1998] O.J. No. 681; Nicholson v. New Brunswick Pharmaceutical Society , [1994] N.B.J. No. 270.

⁶² See, for example, Alberta, Pharmacy and Drug Regulation , A.R. 240/2006, s. 24.

⁶³ See, for example, Bylaws of the Council of the College of Pharmacists of B.C. , s. 34(3), and Regulations of the New Brunswick Pharmaceutical Society , s. 13.04

⁶⁴ See, for example, Prince Edward Island Pharmacy Board, Advertising Regulations , paras. 2(a), 2(b).

⁶⁵Bylaws of the Council of the College of Pharmacists of B.C., s. 34(4), (6), (7), (8). This prohibition also exists in Nova Scotia, but an exception in that province is made for pharmacists who have acquired a specialist certification approved by the Nova Scotia College of Pharmacists Council. Nova Scotia College of Pharmacists, consultation submission, July 6, 2007.

⁶⁶ Manitoba, note 53, above, s. 14(1).

⁶⁷ Ontario, O.Reg. 202/94 as am'd, made pursuant to the Pharmacy Act , 1991, s. 38(2)(g).

⁶⁸ Saskatchewan College of Pharmacists, note 56, above, s. 14.12.3.

⁶⁹ European countries span the range of advertising restrictions, from effective prohibition (e.g. France, Greece, Luxembourg, Portugal and Spain) to allowing some advertising (e.g. Germany, Netherlands, Poland, Sweden and the U.K.). France, Hungary and Luxembourg were undertaking reforms in this area in 2004. See EC Commission, Progress by Member States in reviewing and eliminating restrictions to Competition in the area of Professional Services , Staff Working Document SEC 1064, Brussels 5.9.2005, www.eco.public.lu/attributions/cconc/staffworkingdoc.pdf , Annex 4, pp. 35, 36.

⁷⁰Saskatchewan charges health plan participants under the Prescription Drugs Act , s. 4(1), 5(b), (c), (d), 9(1), and Prescription Drugs Regulations 1993, s. 3, 3.2, 4-12. The consultation submission from the Ontario Pharmacists' Association, July 5, 2007, noted the point about health plan participants being reimbursed.

⁷¹ According to the British Columbia Pharmacy Association consultation submission of June 11, 2007, pharmacists in all jurisdictions charge a professional fee as part of the prescription cost. Specific examples taken from Elias Mossialos and Monique Mrazek, “ The Regulation of Pharmacies Abroad ,” Annexe C of The control of entry regulations and retail pharmacy services in the UK: A report of an OFT market investigation, a report prepared for the Office of Fair Trading, January 2003, p. 61, www.oft.gov.uk/shared_oft/reports/comp_policy/
oft609annexc.pdf .

⁷² Ordre des pharmaciens du Québec, consultation submission, July 6, 2007.

⁷³Rogers Publishing, note 3, above, p. 23.

⁷⁴British Columbia Pharmacy Association, consultation submission, June 11, 2007; Bureau communication with the Ontario College of Pharmacists, September 6, 2007, and Canadian Pharmacists Association, consultation submission, September 29, 2006. See also British Columbia Pharmacy Association, Professional Fees , position statement, February 6, 2004, p. 2; Human Resources Development Canada, A Situational Analysis of Human Resource Issues in the Pharmacy Profession in Canada , July 2001, 4.2.4, p. 32 and 4.4.2, pp. 40–42; Ontario Pharmacists Association, “Reimbursement Rate for Pharmacists' Professional Services,” www.opatoday.com/documents/Reimbursementrate.pdf ; and Pharmacy Gateway, “Pharmacy on the map: State of the Industry Report,” in particular, “Ontario: Top Advocacy Issues” www.pharmacygateway.ca/pastissue/content/phpost/
2000/07-00/pharm_map.jsp .