Chapter 4

Previous Reviews

Implementation of recommendations from previous reviews

4.1        Term of Reference (g) seeks to understand the degree to which recommendations from previous reviews have been implemented and the consultation that has occurred with the community controlled Aboriginal health sector about changes to the program.

4.2        The committee has had regard to a number of reviews and evaluations relevant to the section 100 program. Although it has not received detailed evidence in relation to all of the inquiries mentioned below, the committee considers it important to note a number of reviews completed since the program commenced in 1999.

• Aboriginal and Torres Strait Islander Peoples’ Access to Medicare and the PBS across Australia, Keys Young, November 1997 (Keys Young Review) – commissioned by the former Health Insurance Commission (now Medicare Australia) to document Indigenous peoples’ attitudes and experiences in relation to Medicare and the PBS and identify ways in which service delivery and program information could be improved.[1]
• A Summary of the prescribing and dispensing issues and needs in the remote health clinics of the Northern Territory, General Practice Divisions Northern Territory and National Prescribing Service, August 2001 – review to expand the understanding of prescribing practices in remote communities in the Northern Territory and identify issues and needs to make recommendations for changes.[2]
• Report from surveys conducted in Commonwealth funded Aboriginal Health Services and pharmacies supplying services under SECTION 100 pharmacy allowance, Loller, May 2003 – described the outcomes of a project commissioned by the Pharmacy Guild of Australia and NACCHO to visit pharmacies and AHSs operating under the section 100 program in order to gain increased knowledge of the program’s operation, provide support to participants and report on survey findings.[3]
• Evaluation of PBS Medicine Supply Arrangements for Remote Area Aboriginal Health Services Under SECTION 100 of the National Health Act, Cooperative Research Centre for Aboriginal and Tropical Health, Menzies School of Health Research and the Program Evaluation Unit, University of Melbourne, Kelaher et al., July 2004 (Kelaher Review) – DOHA funded review examined the program’s performance and evaluated the impact of the program on pharmacists, AHS staff and AHS clients.[4]
• Aboriginal and Torres Strait Islander Access to Major Health Programs, Urbis Keys Young, July 2006 – study conducted for DOHA and Medicare Australia to provide information about access to current programs by Aboriginal and Torres Strait Islander people.[5]
• Review of the Existing Supply and Remuneration Arrangements for Drugs Listed under Section 100 of the National Health Act 1953, Australian Healthcare Associates, February 2010 (Healthcare Associates Review) – funded by DOHA to assess the effectiveness and efficiency of program arrangements, identify the impact of the supply and remuneration arrangements on community pharmacy and develop options to address any identified problems.[6]
• Evaluation of Indigenous Pharmacy Programs, NOVA Public Policy, June 2010 (Nova Review) evaluation of three Indigenous pharmacy programs to determine the level of need for programs, assess the extent to which the current programs met the needs of Indigenous pharmacy services and assess the efficiency of the administration and delivery of the programs.[7]

Kelaher Review

4.3        In 2004 the Kelaher Review made almost 60 recommendations. In summary, it found that the program had made significant inroads in providing access to PBS medicines but that more needed to be done in relation to QUM activities.

4.4        DOHA states that it has implemented a number of the recommendations from this review which include: [8]

• The introduction of the Expert Advisory Panel on Aboriginal and Torres Strait Islander Medicines (EAP) in 2005 to provide expert advice.
• An increase to the handling fee paid to pharmacies for each PBS item supplied to AHSs to address increases in costs for participating pharmacies. The handling fee is now indexed annually on 1 July.
• A three-fold increase in funding of the section 100 support allowance. This increase was agreed to improve accountability and transparency, and has been extended under the Fifth Community Pharmacy Agreement.
• Establishment by the NPS of the Good Medicines Better Health Program to develop, deliver and evaluate a QUM train-the trainer course for AHWs.
• Establishment by the NPS of the OPRAH Program to provide pharmacists with training, support and resources to promote the safe and wise use of medicines in AHSs.
• Implementing Closing the Gap PBS Co-payment measure from 1 July 2010 to apply in non-remote areas, to reduce the cost of PBS medicines for eligible Aboriginal and Torres Strait Islander people living with, or at risk of, chronic disease.

4.5        NACCHO has advised the committee that the Kelaher Review also found that funding should be provided for DAAs under the section 100 program.[9] This is yet to be implemented, however specific funding under the QUMAX program in non-remote AHSs is provided for the use of DAAs. NACCHO and others argue that section 100 funding should explicitly provide for DAAs.

4.6        Mr Rollo Manning says that recommendations from the Kelaher Review that relate to improved information collection have yet to be implemented. He says this requires immediate attention. Relevant recommendations include that the Health Insurance Commission (now Medicare Australia) provide medicine utilisation data to AHSs to enable them to keep track of their own performance, and that a system to assess the quantum of medicines that expires in AHSs be considered to enable further evaluations. This would help AHSs judge the effectiveness of their inventory management. ‘If such data could be collected in a consistent way it would also assist further evaluation by making it possible to show that increases in medicine utilisation were not due to waste.’ [10]

Healthcare Associates Review

4.7        The Healthcare Associates Review was released in 2010. As a result of this review the handling fee paid to pharmacists was increased from $1.14 in 2008-09 to $2.79 from 1 July 2011, and will now be indexed annually.[11]

4.8        The Healthcare Associates Review also recommended that a streamlined electronic payment system should be implemented to reimburse pharmacists by Medicare Australia. The committee has been advised that to date this is yet to be implemented.[12]

4.9        This review confirmed that DAAs should be funded under the program, and that AHSs should be able to employ pharmacists with possible reimbursement through Medicare Australia.[13]

Australian Pharmacy Council Review

4.10      In 2009 The Australian Pharmacy Council Review examined legislative and remuneration barriers which prevented a full range of pharmacist services in rural and remote regions, and also the section 100 supply program.[14] NACCHO says that this review recommended the following:

• Registering remote health clinics as ‘pharmacy outstations’ so that pharmacists may dispense in these locations. (Including also the labelling, packing of DAAs, provision of medication counseling and other pharmacy services). This would require [legislative] amendments, and there is a precedent in the NT.

• Remunerating remote pharmacists for services though the Medicare Benefits Schedule (MBS). Services to be considered include: medication counselling, patient case conferences with Medical Practitioners, (face to face or by phone), Home Medicines Review (already existing), Nurse and Aboriginal Health Worker medication education.

• Exempting RAAHSs from pharmacy ownership laws if a pharmacist is employed full time to oversee and establish QUM observance.

• For the Federal Government to employ and suitably remunerate a pharmacist for each [RA]AHS.

• Aligning, simplifying and revising State Health Poisons Acts and Pharmacy Practice Acts legislation.[15]

4.11      Ngaanyatjarra Health Service has advised the committee that they understand this review is currently being considered by the Pharmaceutical Society of Australia and advocates for recommendations from this review, including the removal of any legal impediments to the direct employment of pharmacist, to be implemented.[16]

Nova Review of support programs

4.12      The most recent review of the section 100 pharmacy support program, Evaluation of Indigenous Pharmacy Programs Final Report 28 June 2010 by Nova Public policy found that:

The section 100 support program provides an important level of professional support to AHS in the management of section 100 Supply. This is a level of support which is largely valued by the AHS to which it is provided. The program has addressed some significant QUM issues, particularly with regard to the safe storage, handling and dispensing of medicines.[17]

4.13      However this review also found that while the level of improvement in QUM should not be undervalued, the majority of respondents consulted considered that little impact had been made in engaging pharmacists in the primary care activities of AHS. The review found that where pharmacists have been directly employed in the AHS, there was a high level of satisfaction reported. The review also found that the direct employment of pharmacists within AHS is not feasible based on current workforce levels.[18]

4.14      The majority of pharmacists consulted indicated that the program enabled the provision of an important level of support without which there would be serious safety and quality issues in the provision of medications. ‘Pharmacists identified that the critical QUM issues addressed by the program related to labelling, records maintenance and the packing of Dose Administration Aids in clinics.’[19]

4.15      The review made a number of recommendations which were divided into 'best practice', 'accountability and reporting', 'funding', and 'improvement of administrative arrangements'. These are detailed below.

Best practice

4.16      The review identified variability in the quality and type of support provided by pharmacists to AHSs. While this was found to be inevitable given the variety of services, development of standards were recommended to provide a benchmark against which performance may be measured.

4.17      The review also found that there is currently no mechanism for the sharing of knowledge and expertise between participants in the program and recommended a yearly conference occur for this purpose, with organisation of the conference to be shared between the Pharmacy Guild of Australia and NACCHO.

Accountability and reporting

4.18      The review recommended improving accountability of pharmacists to AHS by transferring responsibility for subsidy payments to AHS and refining program reporting.

Funding

4.19      A consistent QUM issue identified through the review was the lack of labelling equipment in AHS.  It found that significant improvement in safety and quality could be achieved if all services had such equipment available to them.

4.20      The highest priority identified by participants in the review was for staff training. If additional funds were available to the program it would be appropriate that these be quarantined for training purposes.

4.21      Suggested improvements included providing an option of cashing out existing subsidies to make possible direct employment of pharmacists, providing a subsidy or grant for the purchase by AHS of labelling equipment and establishing a dedicated funding pool specifically for AHS staff training purposes.

Improvement of administrative arrangements

4.22      The review found that governance and responsibility arrangements between various stakeholders, including DOHA, the Pharmacy Guild of Australia and NACCHO are unclear and should be made explicit and communicated to all participants. Added to this, information sharing and coordination between DOHA, the Pharmacy Guild of Australia and NACCHO should be increased to ensure ongoing improvements of the program. The review recommended establishment of a coordinating body.

Status of recommendations

4.23      DOHA has advised the committee that the Community Pharmacy Agreement Consultative Committee, which oversees the operation of the Fifth Community Pharmacy Agreement, has had ‘relevant’ recommendations referred to it for implementation. [20]

4.24      The recommendation of the Nova Review that accountability of pharmacists be improved is supported through the evidence received by the committee. The Society of Hospital Pharmacists suggests that the business rules for the program allow for services not provided to be claimed for, and that there is no option to withhold money for services not provided.[21] The committee is keen for these business rules to be reviewed and amended if required to ensure that maximum efficiency is being obtained from the program.

4.25      Kimberley Pharmacy Services suggests that the development of minimum service standards for the section 100 pharmacy support allowance is essential and that outcomes from each visit should be reported to improve accountability and the level of service provided by pharmacists.[22]

4.26      The committee is concerned to note that even though this review, as well as the previous Healthcare Associates review, found that training by pharmacists for AHS staff was very highly regarded, funding to provide an increase in this type of service has not been specifically provided.[23]

4.27      It is the view of many submitters, including Ngaanyatjarra Health Service, [24] that very few of the recommendations from previous reviews have been implemented. They point out that there appears to be poor communication between stakeholders and program funders and providers. The committee is concerned that after several reviews of the section 100 supply and support programs, similar recommendations are being made in consecutive reviews but are not being acted upon.

4.28      This is confirmed by the Pharmacy Guild of Australia who states that the program is unable to realise its full potential for positive impact due to lack of funding and the fact that many of the review recommendations have not been progressed.

4.29      The committee agrees with the Pharmacy Guild of Australia that the Healthcare Associates’ recommendation of 2010 that relates to improving program oversight and integration should be acted upon. This could be done in the form of an intergovernmental and stakeholder committee to oversight program operation.  The committee also notes that further recommendations on this issue were made by the Nova Review in 2010. This review recommended a coordinating mechanism for agencies and stakeholders.

4.30      The committee is concerned that after so many reviews and repeated recommendations, program participants are not experiencing continued enhancements to the program. The committee considers that the Commonwealth Government should commit to a schedule of implementation for recommendations, and advise all stakeholders of the process that will be undertaken to implement the recommendations, including the opportunities they will have to participate in the process.

Recommendation 7

4.31      The committee recommends that the Commonwealth Government publish information on the status of recommendations from previous reports, making it clear which recommendations will be implemented, timeframes and responsibility for implementation.

Recommendation 8

4.32      The committee recommends that the Commonwealth Government ensure that participants in the section 100 program have sufficient opportunities to participate in the implementation process.

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