Chapter 2

Impact of the program

Does the program address barriers to access of PBS medicines?

2.1        Term of Reference (a) considers whether the RAAHS program arrangements adequately address barriers experienced by Aboriginal and Torres Strait Islander people living in remote areas of Australia to access essential medicines through the PBS, and Term of Reference (h) considers access to PBS generally in remote communities

2.2        Submitters agree that the section 100 supply program has been very successful in providing an increased amount of PBS medicines to patients of AHSs. To the extent that the program is a supply arrangement, it has certainly met its objectives.[1] As the Pharmacy Guild of Australia states:

The [section 100 Remote Aboriginal Health Services Program] provides a solid base for ensuring access to medicines, and should be allowed to evolve to offer more Quality Use of Medicines...to patients of remote AHS’s.[2]

2.3        Chart 1 below shows the number of PBS items supplied through participating AHSs as well as expenditure on the program.

Chart 1: Number of PBS items supplied to participating AHSs and RAAHS Program expenditure[3]

2.4        Chart 1 above shows that since the program's commencement there has been steady growth in the number of PBS items supplied to participating remote area AHSs. Studies completed by the AIHW, discussed previously in Chapter 1, confirm that the supply program has had an impact on the amount of PBS items being supplied to remote AHSs.

2.5        The DOHA submission states that a major review of the section 100 supply program published in 2004 concluded that the program had improved access to PBS medicines.[4] In addition:

The...Program has grown over the last 13 years. It now provides access to around 1.4 million PBS items per year at no cost to patients, reaching many isolated communities where Aboriginal and Torres Strait Islander peoples would otherwise experience difficulty in accessing medicines.

In recent years, the number of PBS items supplied to participating AHSs has been relatively steady, at around 1.3 million items annually. The ...Program is meeting a need for essential medicines in remote Aboriginal and Torres Strait Islander communities.

Improvements have been made in many areas, as outlined in this submission. These improvements ensure that the...Program continues to meet the need for affordable access to the PBS for Aboriginal and Torres Strait Islander peoples living in remote communities.[5]

2.6        While there is general agreement that an increased supply of PBS medicines is being provided through participating AHSs, concern has been expressed about the level of access to PBS medicines for some Aboriginal and Torres Strait Islander people living in towns that do not have an AHS approved to supply PBS medicines under the program.

Access to the PBS is variable, most remote communities are reasonably well served by the current arrangements insofar as supply goes, however for [Aboriginal and Torres Strait Islander] residents in Kimberley towns, access can be limited. [6]

2.7        The Northern Territory Government also has concerns about possible inconsistencies in the program, stating that some urban AHSs are able to access the program while some remote AHSs cannot. They recommend a review of the current selection criteria.[7]

2.8        The Aboriginal Medical Services Association of the Northern Territory (AMSANT) has identified a lack of access to general practitioners (GPs) in the Northern Territory as a factor that reduces the impact of the supply program. AMSANT has advised the committee that a shortage of GPs in remote AHSs means that patients have a reduced opportunity to see a doctor and therefore a reduced opportunity to access PBS medicines.[8] Access to health professionals in rural and remote areas is a significant issue that is beyond the scope of this inquiry; however the committee notes that a lack of access to doctors in remote communities is likely to have an impact on access to PBS medicines.

2.9        In summary, the committee has formed the view that the program has been successful in increasing access to PBS medicines through participating AHSs. However, concerns about inconsistent levels of access should be addressed. Issues related to quality use of PBS medicines are explored below.

Clinical outcomes of the program, patient understanding and adherence to treatment

2.10      Term of reference (b) seeks to understand the clinical outcomes that have been achieved under the program and whether an increase in supply has led to a corresponding increase in patient understanding and adherence to treatment.

Data collection and analysis

2.11      While the committee acknowledges that the program was initially designed to address a problem of supply, evidence presented during the inquiry indicates that the absence of comprehensive data collection and studies to assess the program's clinical outcomes is a missed opportunity. The committee is concerned that there appears to be little or no accurate recording of what PBS medicines patients receive under the program and that if available, this information is certainly not readily available, nor is it being analysed for the long-term clinical impact it may be having.[9]

2.12      In response to this term of reference, DOHA has advised the committee that this research is outside of the scope of the program:

Program data provides information on the number of PBS medicines supplied to participating AHSs, but does not include clinical data. Any study of clinical outcomes and adherence to prescribed treatment would require access to and linking of personal level medicine usage and clinical data in accordance with privacy laws. Such a study would require careful design within the constraints of the data and the need to maintain individuals’ consent and privacy. Such research is outside the scope and resourcing of the RAAHS Program.[10]

Linking adherence to medicines with improved health outcomes

2.13      While the Centre for Remote Health acknowledges that whether the section 100 supply program is associated with improved clinical outcomes would be a complex question in any setting, comparable studies have shown that adherence can be improved by some relatively simple interventions such as improved instructions for patients, counselling about the disease, simplifying dosage regimens, reminders, involving patients in their care and ‘augmented pharmacy services’.[11]

2.14      An Australian study has shown that the cost of medicines is only a secondary determinant of whether people choose to take their medicines, with a North American evaluation of a similar program showing that reducing cost while improving access to medicines had no increased health outcomes.[12] The Centre for Remote Health therefore concludes that it is difficult to claim that the section 100 supply program has any impact on clinical outcomes but rather can be seen as providing financial benefits to AHSs, noting that AHSs in the Northern Territory provided medicines free of charge to their clients even before the introduction of the program.[13]

2.15      Wurli-Wurlinjang Health Service, a remote area AHS, has advised the committee that it is currently attempting to source medicine utilisation data related to its service but cannot obtain it in a manageable format.[14] The Centre for Chronic Disease at the University of Queensland's School of Medicine has also been seeking data from Medicare Australia arising from the supply of PBS medicines under the program. The Centre has advised the committee that ‘[t]his effort has been unsuccessful to date, for reasons which vary according to the agency we are petitioning and within agencies over time.’[15]

2.16      DOHA advises that in relation to the Centre for Chronic Disease's request, data was not provided because it was not releasable under the National Health Act, it could potentially identify personal information (the income streams of pharmacies), and because the Expert Panel on Aboriginal and Torres Strait Islander Health found that the project would not necessarily answer the questions raised.[16]

2.17      The Centre for Chronic Disease has advised the committee of an example of where analysing the impact of supply would be of great use in future practice.

We understand there are many elements in the chain between medicine supply, utilisation and outcomes. Documenting medicine supply is a first step. We are not aware of any data on the outcomes specified above, except for our own assessment during the Tiwi Kidney treatment program in the late 1990s. There was great benefit in that setting, in lowering of blood pressure, slowing of kidney disease progression, and reductions of all-cause natural deaths and in kidney failure. Two thirds of treated people took their medicine most of the time. There were major savings in costs of dialysis avoided. All this is in the peer reviewed scientific literature. Most recommendations have been incorporated into the [Central Australian Rural Practitioners Association] treatment manual, the bible of indigenous primary health care in remote Australia. However, without any handle on medicine supply or uptake, there is no mechanism against which to assess patient adherence, impact on community health profiles, hospitalisation rates, dialysis starts, premature deaths and costs. This is what we intend to do if we have access to SECTION 100 data.[17]

2.18      DOHA has advised the committee that it is the responsibility of AHSs to record the PBS items supplied to patients, and that it does not hold data about particular medicines provided to their patients. However it may, on request, provide individual AHSs with the number of each PBS item supplied to them. DOHA has also advised that it has no current plans to link the supply of PBS medicines with clinical outcomes. [18]

Recommendation 1

2.19      The committee considers that to the extent that compliance with privacy laws and obligations can be maintained, Medicare Australia and DOHA should facilitate the release of information to parties requesting it to ensure that opportunities to understand the impact of the program are not wasted.

Adherence to prescriptions

2.20      The committee received considerable evidence to indicate that adherence to medicines is a major issue affecting chronic disease in remote Aboriginal and Torres Strait Islander communities. Indeed some submitters argue that it is the issue in chronic disease control in Aboriginal and Torres Strait Islander populations.[19]

Remote community aboriginal patients are a very different group of people from suburban [even suburban aboriginal] patients. In general...the level of health literacy is very poor, understanding of the concept of preventive care is non‐existent, the motivation to use ongoing medication is low and the concept of regular dosing is a mystery of no personal relevance.

The result is that compliance/adherence is a big issue, I daresay the MAJOR issue, in the control of our rampant chronic disease. It requires huge effort from the health providers, requires constant follow‐up and re-education for success, and is inevitably not very successful in remote communities.[20]

2.21      The Pharmaceutical Society of Australia refers to a recent AIHW publication that reported that 80% of the life expectancy gap between Indigenous and non-Indigenous Australians could be attributed to chronic disease.[21] Combined with lifestyle factors, long-term medicine treatment is usually needed to reduce disease progression.

2.22      The committee received evidence that a lack of understanding of the effect and utility of medicines on the part of patients, as well as the lack of integration of advice on medicine use has the potential to put Aboriginal and Torres Strait Islander people at risk of harm. The committee was presented with an example of an infant being administered a double dose of antibiotics, leading to serious consequences, as well as prescription drugs being shared and inappropriately used. [22]

2.23      While there is a wide level of agreement that the program has certainly increased supply, the Society of Hospital Pharmacists argues that there needs to be a more complete response to addressing barriers affecting the use of PBS medicines:

All of the issues and barriers must be specifically addressed if medicines are to be used effectively by individuals. This requires an ongoing dialogue between individuals and a health care professional, ideally a pharmacist, about:

• the individual’s belief system

• the individual’s understanding of their condition and health literacy

• the use of Western style health care

• the use of medicines in general

• using medicines to prevent disease

• using medicines in acute diseases

• using medicines to manage chronic diseases

• ways to support the individual to improve their medication adherence.[23]

2.24      The Centre for Remote Health agrees:

...the section 100 program has improved access to PBS medications in remote Aboriginal health services...while access to support for quality use of medicines...in the remote Indigenous population remain desperately under-resourced. Supply alone does not ensure quality use of medicines.[24]

2.25      Professor Patrick Ball, the Foundation Professor of Rural Pharmacy at Charles Sturt University has advised the committee that for people living in a remote community with a chronic disease, medication assumes a disproportionate importance when compared with those living in urban areas where there may be a range of other therapeutic interventions available. Professor Ball says that to be effective, medication to address chronic disease requires four steps:

1.      The patient is seen by a doctor or other appropriate health professional and a diagnosis established

2.      Medication is prescribed and supplied

3.      The medication is taken regularly, every day as directed

4.      Any adverse effects of the medication are followed up on.[25]

2.26      It is Professor Ball's view that steps one and two above are being addressed but that steps three and four require more attention.

When metropolitan Australians receive their medication they are entitled to advice from a pharmacist at the time of supply, but remote living Aboriginals receiving supplies under the present arrangements not only have time to forget what the doctor, nurse or Aboriginal health worker told them, they are handed a package with no explanation and little opportunity for follow up on any difficulties they have in understanding what to do with their medications or if their medication causes adverse effects.[26]

2.27      While the section 100 supply program has clearly been successful in creating opportunities for access to PBS medicines, the low adherence rates, as well as the absence of clear evaluation of the clinical impact of the program is of great concern to the committee. As a number of submitters point out, even though there is evidence that the section 100 supply program is delivering an increased amount of medicines to patients of AHSs, there is an absence of evidence to show whether or not this has any impact on improved health outcomes. The committee considers that the Commonwealth Government should develop a clear plan to test the assumption that more medicines equals better health outcomes for patients of remote area AHSs.

Recommendation 2

2.28      The committee recommends that the Commonwealth Government undertake an evaluation to ascertain whether the increased supply of PBS medicines provided by the program is having a clinical impact on the health of Aboriginal and Torres Strait Islander people in remote communities.

The degree to which QUM has been achieved by the program

2.29      Term of Reference (c) seeks to ascertain the degree to which quality use of medicines, or QUM, has been achieved, including the amount of contact with a pharmacist available to these patients compared to urban Australians.

2.30      While the committee acknowledges that there are several programs in place that are designed to support appropriate use of medicines, it has received significant evidence to show that more effort needs to be applied to deliver quality use of medicines.

2.31      DOHA's submission states that QUM is supported primarily through the section 100 pharmacy support allowance previously discussed. Changes to the program now mean that support can be delivered by a pharmacist outside of the section 100 supply arrangements, and in remote areas where community pharmacies are unable to provide support services this can be provided by a hospital authority. DOHA advises that at present there are 172 remote area AHSs approved to participate in the program with 123 receiving support from 23 pharmacists. [27]

2.32      Expenditure across the program is illustrated in the tables below. Table 3 shows funding for program under the Fourth Community Pharmacy Agreement 2005-2010. Table 4 shows funding available under the Fifth Community Pharmacy Agreement (2010-2015).

($ million GST Exclusive)						Total $ million
Funding	2005-06	2006-07	2007-08	2008-09	2009-10
Actual	0.37	0.45	1.34	2.39	1.79	6.33

Table 3: SECTION 100 Support Allowance funding under 4CPA (2005 – 2010)[28]

($ million GST Exclusive)						Total $ million
Funding	2010-11	2011-12	2012-13	2013-14	2014-15
Allocation	2.5	2.7	2.8	3.0	3.4	14.4

Table 4: SECTION 100 Support Allowance funding under 5CPA (2010 – 2015) [29]

2.33      DOHA advises the committee that activities under the support allowance are focused on:

• providing advice and support on pharmacy services relating to QUM management, and staff training;
• providing improved access to the services and expertise that pharmacists can provide through increasing the awareness and understanding of medicines;
• addressing cultural and other issues that may affect the effectiveness and acceptability of pharmacy services; and
• developing cooperative arrangements with Indigenous communities that pharmacists service.[30]

2.34      The ability for remote area AHSs to negotiate a work plan with the pharmacy providing the support is seen by DOHA as flexible enough for the AHS to tailor services to their needs. For example, activities could include assisting with procedures and protocols for managing section 100 supply arrangements, establishing and maintaining a medicine store, providing assistance with DAAs, participation in regular meetings with health staff, review of patient medications, and education services to clinical and support staff on medicines and their management.[31]

2.35      DOHA has advised the committee that payments to section 100 pharmacy support providers range from $8000 to $337 000 per provider, based upon 2009 figures, and are dependent on how many clinics or outstations the remote area AHS services.[32]

2.36      In its evidence to the committee, DOHA has not directly addressed the issue of the amount of time with a pharmacist available to patients of remote area AHSs when compared with urban Australians. However other evidence presented to the committee has led us to conclude that access is far less than that provided to urban Australians, and in many instances non-existent. 

2.37      While the committee considers that there is certainly a need for AHSs to be supported by pharmacists to do important work such as help devise and maintain appropriate stock management control systems and medicine stores, train staff in the use of medicines, and attend meetings with staff, the committee is very concerned that this program is not providing patients with increased and direct access to a pharmacist. It is also concerned to note that while the program funds pharmacists to assist AHSs, the corresponding resourcing required of the AHSs is not funded:

From the point of view of the Aboriginal Health Service, the Section 100 program covers the cost of the medicine for their clients and provides a reliable channel for the supply of medications. It does not cover the costs to the Aboriginal Health Service for the time of the front line workers, including nurses and Aboriginal Health Workers, in helping people to understand about their medicines and the importance of following the dosing instructions.

Further, the Section 100 Scheme does not cover the costs of equipment for standard computer generated dispensing labels with relevant instructions and warnings, or the cost of dose administration aids to help people with chronic conditions and multiple medications to take their medicines as prescribed. Any additional support or equipment the Aboriginal Health Service provides must come from core funding.[33]

2.38      The committee has formed the view that significant work has been done to establish relevant guidelines and tools to assist pharmacists in the provision of services funded under the section 100 pharmacy support allowance and that other supporting initiatives such as OPRAH and Good Medicines Better Health programs (discussed earlier) provided by the NPS are offering opportunities for up-skilling pharmacists to work with staff of AHSs. However, it appears that there are few examples of pharmacists being able to provide direct support and continuing advice to patients when it is required.

2.39      Overwhelmingly the evidence presented to the committee indicates that more direct access to a pharmacist is required by both AHSs and their patients in order to support better use of PBS medicines. Kimberley Pharmacy Services suggest that a first step to achieving this is to increase the frequency of visits that pharmacists make to AHSs under the section 100 pharmacy support allowance. They also suggest that funding should be based on a needs model, arguing that clinics with a high number of complex chronic disease clients should be able to access greater funding than those with less complex clients.[34] The Pharmaceutical Society of Australia and the Pharmacy Guild of Australia agree that the current situation where current program funding covers one or two pharmacist visits per year is inadequate.

One to two annual pharmacist visits are usually insufficient to provide effective QUM services to the AHSs and their outstations. The majority of these visits relate to establishing ordering, dispensing and stock management systems, rather than QUM initiatives or staff education.[35]

2.40      The Pharmacy Guild of Australia suggests that a review of the section 100 pharmacy support allowance program be conducted in order to ascertain the optimum number of visits to that would support and deliver QUM.[36]

2.41      High transport costs associated with visiting remote area AHSs is a recurring theme throughout submissions, with some submitters suggesting that pharmacists providing support under section 100 pharmacy support allowance program should be able to claim the actual cost of travel and accommodation, rather than receive a predetermined sum.[37] The Pharmacy Guild of Australia collated responses from pharmacists providing services under this program and provided an example of the complexity and distance involved in providing a face-to-face QUM service. A pharmacist at the Thursday Island Pharmacy states:

...the current funding is not adequate to allow me to visit my 20 AHS’s more than one day per year. If you study a map of the AHS’s I visit, review the current schedule of flights and the cost of those flights available in my area, combine this with a study of which communities have accommodation and food...you will realise why I had to purchase a ship to allow me to service my AHS properly.[38]

2.42      Rollo Manning explains the role that building good relationships with communities can play in improving use of medicines.

It takes time to get to know a community, be accepted by the Aboriginal workers at the health centre and as a pharmacist be accepted as a part of the primary health care workforce. This requires positive contributions that can only be developed over time. A two day visit every six months is by no means enough and yet this is what the section 100 'Support Allowance' provides for the supplying pharmacy.[39]

2.43      Another issue associated with the current funding model raised during the inquiry is the cost of dose administration aids or DAAs. DAAs such as ‘blisterpacks’ or 'Websterpacks’ are seen as a useful tool in managing patient dosage however the committee understands that pharmacies are not funded specifically to dispense PBS medicines to AHSs in this way. Instead, they can use part of the section 100 pharmacy support allowance, or DAAs requested by remote area AHSs can paid for using other AHS funding sources. Several submitters argue that DAAs should be specifically funded from current program arrangements, or as an additional arrangement to assist with medicine adherence and QUM.[40]

2.44      As Ngaanyatjarra Health Service points out, DAAs as a standalone measure do not increase health literacy or a patients’ understanding of their medication but they can free up staff time and encourage patients to take the correct dose. They present data from the Tiwi Islands Pharmacy project, which supplied DAAs to patients. The supply of DAAs resulted in an increase in the pickup rates of medicines from the Tiwi Health Service Pharmacy. Of a possible 160-180 patients, regular collection increased from 18 to 105 patients over a 21 month period.[41] In this service, DAAs had been prepared for patients to collect, waiting time was minimised for the patient and staff were on hand to discuss the patient’s medication, providing an opportunity for improved understanding of the medication and its purpose.

2.45      Although DOHA has advised the committee that there are no plans to provide specific funding for DAAs,[42] the committee considers that adequate funding for DAAs and appropriate QUM activities to accompany use of DAAs should be specifically provided through the section 100 program.

Recommendation 3

2.46      The committee recommends that the Commonwealth Government provide specific funding for remote area AHSs to be able to provide dose administration aids (DAAs) to their patients.

Increasing access to pharmacists

2.47      Many submitters present compelling arguments for locating pharmacists within remote AHSs, with several existing models showing that it can work well. DOHA acknowledges that in terms of achieving quality use of medicines, the location of pharmacists within AHSs is desirable. However it is the Department’s view that this cannot be achieved due to workforce shortages:

Whilst the Australian Government acknowledges that from a QUM perspective it may be desirable to have a pharmacist employed at all AHSs, given current rural workforce levels across all areas of the health workforce, it is not practical to expect that this would occur at all participating AHSs and their outstations/outreach clinics. It is difficult to attract and retain pharmacists and general practitioners to many remote areas.[43]

2.48      It is clear to the committee that there is a high degree of frustration amongst submitters about the lack of direct access to a pharmacist that is available for remote AHS patients. Given the volume of medicines being prescribed through the program, submitters question why money can't be invested to increase the efficacy of the medicines prescribed. Dr Peter and Dr Jan Bowman put it this way:

The rate of chronic disease in aboriginal communities is several times that of a typical white Australian community, and the total volume of medicines prescribed is commensurately higher.

...

As doctors, we cannot help speculating that there must be enough money associated with this huge volume of medicine to provide funding for front‐line pharmacist service. A town of 1800 people elsewhere in Australia can support a full‐time private pharmacist. How is it that this volume of medicine cannot support even a part time pharmacist in remote communities?[44]

2.49      Many submitters suggest that there is no substitute for the type of advice and assistance that a pharmacist can provide,[45] with some suggesting that Indigenous and non-Indigenous Australians should have equal access to a pharmacist irrespective of where they live.[46] Many submitters also suggest that high rates of non-adherence are caused by the lack of connection between pharmacist and patient.

2.50      The possible grave consequences of non-adherence to prescriptions was described in a 2008 Report on the Home Medicines Review Program commissioned by DOHA, and cited in the submission of the Society of Hospital Pharmacists.[47]

The extremely high incidence of medication misadventure, non-adherence and resulting hospitalisation among Indigenous consumers as well as the flow-on effects such as organ damage and amputations were matters of grave concern to those respondents who work with Indigenous consumers. The co-morbidities because of the lack of adherence to medications were considered to be as high as three to four times that of non-Indigenous consumers.[48]

Maintaining a standard drug list

2.51      Ngaanyatjarra Health Service advised the committee that one of the most important public health programs provided by a health service is the imprest or standard drug list ‘...so patients can be treated according to protocols and medical practitioners can prescribe with confidence knowing the range of drugs they select from are available at the clinic(s) run by the health service.’[49] While this activity is possible under the section 100 pharmacy support allowance program, Ngaanyatjarra Health Service raises concerns about the ability of participating pharmacists to actually supply and maintain stock control appropriately according to the list because of the distance from the health service.[50] The service is concerned about the waste of medications that is occurring under the system which they say is due to poor stock control,[51] as well as the inability for individual services to access their own supply data. Ngaanyatjarra Health Service states that ‘...[d]ue to a paper based claim system and the cost of the medications known only to pharmacies and Medicare, health services have no indication of the cost of medications supplied under the program.[52]

2.52      Ngaanyatjarra Health Service says that having a pharmacist located at their health service results in cost saving to the Commonwealth as it provides more appropriate and more reflexive stock control. An evaluation of the in-house pharmacy service at Ngaanyatjarra Health Service showed that with an imprest list in place the amount of PBS medicines supplied was reduced, resulting in a cost saving of 14% in the first year. There was also a reduction in expenditure on non-PBS medicines, paid for by the health service. These rates were a reduction of 7% in the first year and 40% in the second year. Ngaanyatjarra Health Service says that these savings can be used to directly fund increased patient care.[53]

2.53      The service points out the flow on effect of operating a more efficient stock control system. Transport and freight costs for moving expired drugs out of the clinic are reduced, the amount of stock on the imprest shelves is reduced therefore lowering the risk of inadvertently supplying the wrong drug or drugs that have expired.[54]

Models for providing direct access to pharmacists

2.54      The Pharmaceutical Society of Australia proposes a model whereby a pharmacist would be located in an AHS, but with PBS medicines still dispensed from the community pharmacy. In this model the pharmacist would focus on supervising the ordering of medicines, labelling and recording, as well as give advice, patient education and medication review. The cost of this model could be offset by the savings provided by adherence, reduced wastage of medicines and reduced hospital costs associated with poor control of chronic disease.[55]

2.55      The Centre for Remote Health describes the example used by Central Australian Aboriginal Congress to provide 1.5 pharmacists and two full time pharmacy technicians in this AHS. The pharmacists and pharmacy technicians are employed by a community pharmacy but the AHS has contributed significant funds to the operation of the pharmacy service, not relying on section 100 funds.[56]

2.56      Another current working model of a pharmacist located in a remote area AHS operates in the Kimberley region of Western Australia, where the section 100 pharmacy support allowance is redirected by contract with the approved pharmacist to the Kimberley Aboriginal Medical Services Council (KAMSC), which then employs its own pharmacist to deliver QUM services according to the business rules of the allowance.[57] KAMSC advises the committee that their single pharmacist provides a variety of direct services to support QUM of across 14 clinics and 440 000 square kilometres. These are services such as audit and quality improvement activities, training of clinic staff including, training for Medication Assistants and a major contribution to the development and review of the Kimberley Standard Drug List.[58]

2.57      The Queensland Department of Health has advised the committee that the Cairns and Hinterland Health Service District funds one full-time pharmacist and one pharmaceutical assistant to provide supply and outreach services to 12 000 Aboriginal and Torres Strait Islander people in the ten primary health care services operated by the Cape York Health Services Division. This enables the outreach pharmacist to be available by phone, and visit each clinic for a few hours two to three times per year. Queensland Health states that the purpose of the visit is primarily to provide QUM education and training for clinic staff but does not allow for contact between clients and the pharmacist.[59]

2.58      Another example of a pharmacy business operating successfully in a remote Aboriginal and Torres Strait Islander community was provided by Mr Rollo Manning. This involved the establishment of a pharmacy on Bathurst Island in the Northern Territory that met the legal requirements for approved pharmacies. Mr Manning provided the committee with analysis of remote communities with a population of 1000 or more in the Northern Territory which, based on his analysis, would be able to sustain a full time pharmacist.

The PBS item volume would be likely to be in the order of 20,000 a year which in itself would generate an income of $70.000 a year. By the time additional fees for items such as Home Medication Reviews are added in this could well mean [an] income in excess of $100,000 to meet the cost of a pharmacist.[60]

2.59      AMSANT offers another suggestion for locating pharmacists within AHSs in the Northern Territory.

At present, a resourced pharmacist could easily fit into the multidisciplinary model in at least six existing regional health services, with two more [Health Service Delivery Areas] closing fast as regional Aboriginal Community Controlled Health Services. Other proposed [Health Service Delivery Areas], a number of which have a mixed balance of Government and Aboriginal community controlled health services, could have pharmacists “hubbed” into these...as they move, over time, to regional control.[61]

2.60      The committee is satisfied that there are a number of AHSs that wish to and have the capacity to host or employ a pharmacist as part of the primary health care team; for example the Wurli-Wurlinjang Health Service in the Northern Territory has developed a substantial project proposal to fund a full time pharmacist within their service.[62]

2.61      The committee considers that services able to employ their own pharmacist should be supported to do so. With the existence of functioning and successful models available, the committee considers that more support should be offered to remote area AHSs to develop their own models for the location of pharmacists within services, and that DOHA and other relevant stakeholders should provide guidance for AHSs on options for the establishment of in-house pharmacy services.[63]

2.62      NACCHO proposes a system whereby responsibility for the payment of QUM related pharmacist services is transferred to remote area AHSs. Pharmacists would then be added as additional allied health professionals under the Practice Nurse Incentive Program. This program was announced in May 2010 and will contribute $390.3 million to general practices and ACCHSs to employ practice nurses and/or Aboriginal Health Workers. Funding will allow ACCHSs to employ a part-time allied health professional, such as a physiotherapist, dietician and occupational therapist, instead of, or in addition to, a practice nurse and/or Aboriginal Health Worker. DOHA has listed the types of allied health professional eligible under this measure; however, NACCHO noted that ‘pharmacists’ and ‘dentists/assistants’ were not listed, and has recommended that the program be amended to include pharmacists.[64]

2.63      In addition, NACCHO proposes that a more systematic and coordinated approach to existing QUM budgets could be used to leverage greater benefit within the system. For example, QUM budgets could be used to subsidise the purchase of labelling equipment or provide QUM training for staff, or employ sessional pharmacists. Regional or state and territory ‘QUM Pharmacists’ could be employed within services (as is currently provided under the QUMAX program) to provide local support.[65]

2.64      The Northern Territory government agrees that QUM services should be transferred to AHSs:

Such QUM initiatives have been trialled and established in health services in regional and remote settings, where a pharmacist is directly employed to work with health centre staff to:

• provide onsite clinical review
• assist in meeting legislative requirements,
• and undertake continuous quality improvement activities.

Directly funding the health service to provide this service could also incorporate the use of interpreters and community liaison officers to support pharmacist services, either on site or during visits. This would promote cultural safety and greatly improve the delivery of QUM to clients.[66]

2.65      Several submitters offer solutions to issues of workforce supply. The Society of Hospital Pharmacists contends that it is easier to attract pharmacists to a team environment, which could easily be provided by AHSs.

Experience in the hospital sector with locum pharmacists in rural areas has taught us that it is easier to attract pharmacists to a team environment where they have access to usual employment conditions and workplace support than it is to attract sole practitioners who must continually look for the ‘next job’ with fluctuating cash flow and no allowance for leave, attending professional development activities etc.[67]

2.66      While the committee notes the comments of DOHA, as well as the finding of the Evaluation of Indigenous Pharmacy Programs, completed for DOHA by Nova Public Policy in 2010 (Nova Review) that direct employment of pharmacists within AHSs is not possible within current workforce levels,[68] the committee considers that more can be done to support direct employment of pharmacists, or provide vastly increased time for pharmacists to spend with AHWs and other health professionals in AHSs, as well as the time that patients can spend with pharmacists.

2.67      The Society of Hospital Pharmacists supports the recommendation from the Nova Review that AHSs be permitted to cash-out existing subsidies in order to fund greater access to, or direct employment of pharmacists.[69] The Society estimates that 125 full time pharmacists are needed to provide adequate services to remote communities through AHSs, and suggests that a combination of strategies outside of the current sole reliance on the community pharmacy model would go some way to providing this.[70]

2.68      The Pharmaceutical Society of Australia says that pharmacy schools have recently doubled their intake of pharmacy students, which will lead to a much greater supply of trained pharmacists.[71] Given the evidence provided to the committee of alternative models as a way of making rural and remote pharmacy practice a more attractive career option for graduates, the committee is keen for the Commonwealth to put more effort into supporting a range of options for the employment of pharmacists in remote area AHSs.

2.69      The committee has noted that there may be legal barriers to the immediate and direct employment of pharmacists by AHS. As NACCHO states:

Legislation inhibits pharmacists in most States from dispensing outside a registered pharmacy. Thus, career/academic pharmacists employed by the RAAHS, who do not want to own a pharmacy, are legally unable to label/dispense medicines or pack a DAA, or receive remuneration for this service through regular channels. An exception to this exists in the NT.[72]

Recommendation 4

2.70      The committee agrees with submitters and recommends that program flexibility be implemented to give remote area AHSs increased and direct access to the services of a pharmacist. This could be done by AHSs engaging a pharmacist directly or in collaboration with other stakeholders or service providers. Options for funding and operating these services could include cashing-out existing program funding, access to alternative funding measures, expansion of the Practice Nurse Incentive Program to include pharmacists, remunerating remote pharmacists for services though the Medicare Benefits Schedule, and removal of legislative barriers that prevent the operation of pharmacy businesses in remote areas.

Recommendation 5

2.71      The committee recommends that the Commonwealth Government establish a consultative body of relevant stakeholders to develop proposals and options to increase direct access to pharmacists for remote area AHSs, consult program participants and others, and provide support to AHSs to allow them to make informed choices about options.

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