Chapter 3

Compliance and Funding Distribution Issues

Legislative compliance for recording, labelling and monitoring of PBS medicines

3.1        Term of Reference (d) seeks to determine the degree to which state and territory legislation has been complied with in respect to recording, labelling and monitoring of PBS medicines.

3.2        One submitter describes the standards of practice in relation to the labelling and recording of medicines as ‘appalling’.[1] Evidence presented during the course of the inquiry indicates that there is a desperate need for computer systems and standardised technology to be available to all remote area AHSs so that accurate and legible labelling and recording can be completed, and that computer record systems allow for data collection that can be provided and used by both the Commonwealth as well as the individual AHSs.[2]

3.3        Ngaanyatjarra Health Service recommends that software providers of electronic patient management systems should urgently incorporate dispensing modules into their systems so that improved labelling to meet the minimum standards can occur.[3] These systems could be used to complete electronic ordering of medicines, reducing some of the red tape and the frustration currently being experienced by participating AHSs and community pharmacies.

3.4        KAMSC provided the committee with an example of an electronic system that is working well.

All the KAMSC and KAMSC affiliated clinics in the Kimberley have been using an internet based electronic health information system called MMEx for recording, labeling, stock management and monitoring of medications. MMEx is a comprehensive electronic system which maintains a record of all current, dispensed, archived medications, Websterpaks and their supply to patients. Adhesive medication labels which comply with WA Poisons Regulations are generated using MMEx.[4]

3.5        The Pharmacy Guild of Australia has advised the committee that many pharmacists responding to their survey advise that if recommendations from previous program evaluations were implemented, problems with legislative compliance could be addressed. Out of five relevant recommendations from the Kelaher Review of 2004, the Pharmacy Guild of Australia says that few have been addressed since the report was released in 2004.[5]

3.6        These recommendations are detailed below:

• DOHA to examine mechanisms for providing more extensive support to ensure that [the program] is implemented in a way that is compliant with state and territory legislation and regulations.
• A self assessment tool addressing legislative compliance issues should be made available to AHSs to complete with their supporting pharmacists.
• DOHA to develop a central resource for program participants to enable sharing of information and lessons.
• DOHA in conjunction with state and territory governments, the Pharmacy Guild of Australia and NACCHO, should develop a resource that clearly states how laws and regulations should be applied to remote AHSs.
• DOHA to work with state and territory governments, Pharmacy Guild of Australia and NACCHO to identify ways of facilitating the operation of approved AHSs in jurisdictions where there are legal and regulatory barriers to program implementation.[6]

3.7        It is the view of the Pharmacy Guild of Australia that if participating pharmacists were able to visit AHSs more often, they would be able to provide more support to increase legislative compliance. On this basis the Pharmacy Guild of Australia recommends that transport costs for community pharmacies servicing remote area AHSs should be separately funded based on a model which reflects actual costs.[7]

Recommendation 6

3.8        The committee is surprised to note that there is no universal system in place to provide for accurate and legible labelling and recording of medicines. The committee therefore recommends that the Commonwealth Government urgently support the development and introduction of efficient standardised systems for accurate labelling of medicines in remote area AHSs, and that these systems are developed to ensure accurate collection of medicine data and use.

Distribution of funding

3.9        Term of Reference (e) deals with the distribution of funding made available to the program across the approved pharmacy network compared to the Aboriginal Health Services obtaining the PBS medicines and dispensing them on to its patients.

3.10      The Commonwealth does not fund remote area AHSs to supply PBS medicines and dispense them to their patients. The current system involves a reimbursement to the community pharmacy or hospital authority for each PBS item supplied to an AHS approved to participate in the program. It is done on the basis of an approved price to pharmacists, plus a mark-up (the level of mark-up that is applied to the medicine is determined by the cost of the medicine), plus a handling fee which is indexed annually (from 1 July 2011 the handling fee is $2.79).[8]

3.11      This level of funding is less than the $6.42 dispensing fee that a community pharmacist dispensing in the general community is reimbursed. DOHA explains this reduced dispensing fee in the following way:

The RAAHS Program handling fee of $2.79 is lower than the dispensing fee paid to community pharmacists recognising that under the RAAHS Program, the activity required to facilitate supply is not equivalent to, and not as intensive as, dispensing to an individual in a community pharmacy context.[9]

3.12      The current distribution model is criticised by some submitters as being too inflexible to provide the best outcome for patients of AHSs, with current business rules for participation in the program restricted to community pharmacies. The Society of Hospital Pharmacists advocate creating greater flexibility within existing programs so that broader participation can be allowed.[10]

3.13      The Centre for Remote Health agrees that more access to pharmacists should be given to AHSs but cautions against a move that would simply transfer funding from community pharmacies to health services, suggesting rather that a system of collaboration and flexibility should be encouraged.[11]

3.14      The Pharmacy Guild of Australia has advised that the system of community pharmacies already in existence is regarded by pharmacists as the best way of providing direct services to AHSs.[12] One pharmacist participating in the scheme cautions against comparing the section 100 supply program with the wholesale model of supplying medicines:

You have to be careful not to compare the section 100 [program] to the wholesale model. This model implies merely sending medicines to AHS’s without any professional involvement whatsoever. A storeman in a warehouse can send medicines to an AHS whereas a pharmacy sending medicines to an AHS will be overseen by a pharmacist who will pick up anomalies such as “Do they need this quantity?”, “Do they have this many patients who qualify for this medicine under PBS conditions”, “Are these medicines likely to be used or will they just go out of date”. The section 100 [program] as it exists encourages remote pharmacies to exist, and in turn creates employment, develops training opportunities for pharmacy students, pharmacy assistants and creates employment opportunities for indigenous Australians...[13]

3.15      The Pharmaceutical Society of Australia makes the point that as a $2.74 handling fee per dispensed item is paid in relation to PBS medicines supplied under the program, there is a saving of $3.68 from the normal dispensing fee of $6.42 per item that would ordinarily be paid if the item were provided to an individual through a community pharmacy. ‘The Government therefore saves $3.68 per item dispensed to remote Aboriginal Australians’. This is referred to as the ‘dispensing fee gap’.[14]

3.16      Mr Rollo Manning has suggested that it is possible that an approved pharmacy supplying a high volume of PBS medicines to a single AHS under the section 100 supply program could make a gross profit of $450 000 per year.[15]

3.17      KAMSC states that revisiting the current funding models under the program would be welcome, especially the development of models that recognise the contribution that AHSs make in medication handling, and envisage changes that could vastly improve the amount of time pharmacist could spend supporting QUM.

For example, should remote AHSs receive adequate remuneration from Medicare in the form of a dispensing fee for each PBS item, section 100 Support payments together with pharmacy incentive payment for clinical services, services would be well-placed...to enable employment of a pharmacist, whether on a full time basis, part-time basis, or under a shared arrangement across a number of contributing services.

Unfortunately current pharmacy ownership laws in WA preclude remote AHSs from being registered for the purpose of dispensing medicines. Similarly dispensing by pharmacist in unregistered premises i.e. remote clinics is prohibited in WA. It is a curious situation that enables...GPs to dispense but pharmacists who are specialised in this role are prohibited.

Options are for a change to the regulations (section 94 Health Act) or for an exemption to be applied for ACCHS and remote AHSs to enable pharmacist to be permitted to dispense from remote clinics and outstations, as is the case in the Northern Territory.[16]

3.18      The Centre for Remote Health also raised the issue of tying the provision of the section 100 pharmacy support allowance to a supplying pharmacy unless that pharmacy declares it is unable or unwilling to provide the service. The committee has considered evidence to indicate that the level of service provided to participating AHS under the section 100 pharmacy support allowance provides varying degrees of assistance to improve QUM.[17]

3.19      One measure that could raise the standards of service or the amount of time that pharmacists can spend in AHSs would be to untie the funding of this program. The Centre for Remote Health advocates flexibility so that AHSs could choose to contract with their preferred provider if they wish to do so.[18] The Centre says that recent amendments to the method of payments to support pharmacists providing services to residential aged care facilities provides a precedent for a system that separates supply and QUM services.[19]

3.20      The committee agrees with the Centre for Remote Health that a flexible funding system should be adopted, with improved accountability and transparency of what the money is being spent on. As the Centre says:

Any system that channels funding to any of pharmacies, AHS, state/territory governments or individual pharmacists is likely to meet the needs of some but not all AHS. Providing adequate safeguards against misdirection of funds are in place, funding should not be limited to any one group.[20]

3.21      The committee considers that flexibility in the system should be created so that AHSs, pharmacists and other stakeholders can design and tailor services to suit their client base, and which promotes innovation and collaboration. The committee also notes that there will be many AHSs that have no desire to run a pharmacy.

3.22      The committee also acknowledges that there is a wide level of agreement that the section 100 supply program utilising the existing network of community pharmacies is operating well, but that much more effort needs to be put into improving the use of medicines. The committee has found that it is not that pharmacists are unwilling or even unable in some circumstances to provide the support, but that the system as it currently operates does not provide sufficient direct contact between pharmacists and AHSs and their patients.

Support for Aboriginal Health Workers

3.23      Term of Reference (f) seeks to discover the extent to which Aboriginal Health Workers in remote communities have sufficient educational opportunities to take on the prescribing and dispensing responsibilities given to them by the PBS bulk supply arrangements.

3.24      The committee would like to clarify that AHWs do not prescribe or dispense medicines to patients. Under Northern Territory and Queensland legislation AHWs are able to supply some medications.[21]

3.25      The committee notes that the section 100 supply and support programs do not confer any specific training responsibilities on participating AHSs or pharmacies. However the committee acknowledges the important role that AHWs play in the supply of PBS medicines to clients of AHSs and discusses evidence related to this term of reference below.

3.26      The Centre for Remote Health provided the committee with detailed information about training required to comply with Northern Territory legislation.[22] While it appears that considerable work is being done in the Northern Territory to support AHWs in their work, it is clear to the committee that more support in other jurisdictions is required.

3.27      The committee was pleased to be provided with information about the Good Medicines Better Health program being implemented nationally in collaboration with the National Prescribing Service and NACCHO, referred to earlier, which aims to increase the capacity of AHWs to provide training in QUM to their colleagues.

3.28      The committee understands that the Commonwealth funds two schemes designed to improve the relevant workforce pool, the Aboriginal and Torres Strait Islander Pharmacy Assistant Traineeship Scheme, with sixteen places per year, and the Aboriginal and Torres Strait Islander Pharmacy Scholarship Scheme which offers three places per year.

3.29      The committee sought further information on the operation and uptake of these schemes. DOHA advised that the pharmacy assistant traineeship scheme funds 16 traineeships per year and provides $10 000 a year to the pharmacy owner to employ the trainee. Since the program began in 2008, 83 placements have been funded. Twenty six are currently active with 35 completed and 23 who withdrew part way through the traineeship.[23]

3.30      The scholarship scheme provides $15 000 per year for up to four years for Aboriginal and Torres Strait Islander students to undertake pharmacy studies. Twenty three scholarships have been awarded since the program began, with 13 graduates commencing work as pharmacists. There are currently 10 scholarships in place. Both programs are administered by the Pharmacy Guild of Australia, which does not track participants in the program.[24]

3.31      While the committee is pleased that there are opportunities for improved participation of Aboriginal and Torres Strait Islander people in the pharmacy workforce, they have received considerable evidence to indicate that AHWs are not sufficiently supported in their current roles related to providing PBS medicines. One measure to improve support would be to provide greater direct access to a pharmacist. Many submitters agree that face-to-face support from a pharmacist located within, or who visits the service often, offers the best option for improved support to AHWs.[25]

3.32      The Pharmacy Guild of Australia notes that in 2012 the Australian Health Practitioner Registration Board (APHRA) will assume responsibility for the registration of AHWs. They suggest that this is an opportunity for nationally consistent standards to be set for the registration and continuing education of AHWs.[26]

3.33      The Northern Territory government considers that visiting pharmacists provide very little support to AHWs and that dedicated resources should be allocated to increase AHWs training in relation to QUM.[27]

3.34      Given the importance of the work being done by AHWs in remote AHSs, the committee considers that much greater effort should be put into training and support for AHWs, and agrees with the Pharmacy Guild of Australia that the commencement of APHRA offers an opportunity for a national training framework for AHWs to be implemented. The committee is very concerned that any new or increased requirements would have to be adequately supported and funded.

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