Chapter 5
Other issues
5.1
Term of Reference (j) provides for the consideration of any other
related matters.
Program integration and complexity
5.2
Program and system complexity is an issue that was raised by a number of
submitters, with concern being expressed about the lack of integration between
relevant programs,[1]
as well as narrow business rules within programs that do not allow for the best
use of funding, or for innovation to occur.
5.3
While it is outside of the specific terms of reference for this inquiry,
the committee has considered evidence in relation to the Closing the Gap PBS co-payment
measure, which provides for the removal of the co-payment for patients of
Aboriginal Community Controlled Health Services in rural or urban areas. This
co-payment is not available to patients when they attend a remote area AHS or a
public hospital.[2]
The Centre for Remote Health states that there are now three programs providing
access to PBS medicines: section 100, QUMAX (Quality Use of Medicines maximised
for Aboriginal and Torres Strait Islander peoples, which is available for
clients of Aboriginal Community Controlled Health services only) and the Closing
the Gap co-payment measure.[3]
While each may have evolved to deal with separate issues, there appears to be
no overarching program governance. The Australian Medical Association (AMA) considers
that a disconnection between these programs means that access to medicines may
be prevented if Aboriginal and Torres Strait Islander people are using a
private general practice or an AHS that is not community controlled.
5.4
On this basis the AMA recommends that the section 100 program be
broadened to apply to all AHSs regardless of their location, as well as to
mainstream general practices that have a demonstrable Aboriginal and Torres
Strait Islander population.[4]
5.5
The South Australian Department of Health also raised a practical issue
with the Closing the Gap PBS co-payment measure. While they say that removing
the co-payment in remote areas through the section 100 supply program, and in
urban and regional areas through this measure is welcome, there is no way for
health services to identify
patients who receive the Closing the Gap PBS co-payment. Consequently
when patients participating in the scheme present at a public hospital, they
are required to pay the patient co-payment for their discharge medicines.[5]
This issue is also raised by Ngaanyatjarra Health Service which suggests that
public hospital pharmacies should have access to the section 100 scheme when discharging
Aboriginal patients. As they state in their submission:
With section 100 supply of pharmaceuticals to remote health
services, the QUMAX program and now Closing the Gap prescriptions providing
access to medications for Indigenous Australians across Australia it is ironic
that the only place medications need to be paid for are on discharge from a
public hospital.[6]
5.6
SA Health recommends that consideration be given to the development of a
‘single, universal, multifaceted program’ for all Aboriginal and Torres Strait
Islander patients regardless of the service they are accessing and in what
location so that equity of access is achieved across the continuum of care.[7]
The Pharmacy Guild of Australia and the National Rural Health Alliance agree that
a mechanism for ensuring the interoperability of the schemes is needed.[8]
The increasing mobility of people living in remote areas should
be recognised along with their need to travel for specialist treatment and
hospitalisation. Initiatives to improve ATSI people’s access to PBS benefits in
urban areas (QUMAX and CTG co-payment relief) have been successful. Mechanisms
are needed to allow patients to travel between remote and urban areas and
between hospital and home and still have access to their PBS medicines.[9]
5.7
Another possible unintended consequence of the Closing the Gap co-payment
measure is that it may be inadvertently drawing patients away from AHSs that
can offer a greater level of QUM support specifically tailored to meet the
needs of Aboriginal and Torres Strait Islander people.[10]
NACCHO recommends that participation in this measure be made available to
remote area AHSs in circumstances where patients have access to a community pharmacy
in order to dispense the prescription. NACCHO says that this would reduce some
of the burden of maintaining in-house stock in locations where patients had
ready access to a community pharmacy as well as an AHS.[11]
5.8
The Queensland Aboriginal and Islander Health Council (QAIHC) agrees,
stating that the often unconnected and unintegrated nature of these programs
add to complexity for primary health care providers, requiring greater
coordination within primary health care settings. Both QAIHC and NACCHO suggest
that the dispensing fee gap of $3.68 could be used to fund the introduction of
a scheme:
...to allocate QUM budgets to [Aboriginal Community
Controlled Health Services] from which services can draw from, and negotiate service-specific
activities with community pharmacy or academic pharmacists. The difference
between the SECTION 100 program handling fee ($2.79) and the PBS dispensing fee
($6.42) per item comprises a PBS under spend that could be used to fund a range
of service specific QUM initiatives within ACCHSs.[12]
5.9
While pharmacists may be able to provide extended clinical programs such
as medicine use reviews, dose administration aids, disease state management for
conditions like diabetes and asthma, and health promotion, it appears that
funding for the exclusive provision of these services is limited to members of
the Pharmacy Guild of Australia. The committee considers that where AHSs wish
to, and have capacity to do so, provision should be made for these services to
be provided by the AHS directly by using the funding to place a pharmacist within
an AHS.[13]
5.10
A related program supporting improved adherence to medicines is the Home
Medicines Review (HMR). The Society of Hospital Pharmacists says that access to
this program is in practice not available to patients of AHSs by rules which
require referral from a GP and for the review to be conducted via a community
pharmacy. These are rules developed by the Pharmacy Guild of Australia and
Medicare Australia.[14]
As previously discussed, the 2008 evaluation of the HMR program found that Aboriginal
and Torres Strait Islander people are amongst those least likely to receive a
HMR but are amongst those in greatest need of one, and that it was rare for a
HMR to have been conducted for those most in need of access to the program. ‘Overall
the research confirmed that those in greatest need of a HMR are the least
likely to receive one...’.[15]
Recommendation 9
5.11
The committee would like to see greater integration of existing programs
to provide complementary services to patients of AHSs. The evidence the
committee received during the course of this inquiry supports this. Therefore
the committee recommends that DOHA develop a process for integrating existing
programs, and that a clear policy and program logic is published to show how
these programs will work together.
Aboriginal and Torres Strait Islander patients in remote aged care
facilities
5.12
Ngaanyatjarra Health Service advised the committee that there is some
doubt as to whether Indigenous patients in remote aged care facilities are
covered under the section 100 program. The service has been advised by DOHA
that it is not possible for patients in aged care facilities to be covered by
the program as it is only available through AHSs or other participating primary
health services.[16]
5.13
Ngaanyatjarra Health Service owns and runs an aged care facility called
Kungkarrankalpa and says that this situation means that technically a patient
in an aged care facility has to be taken to the remote clinic, seen by an
appropriate practitioner and be given medications from the clinic. ‘It also
means a remote aged care facility cannot access section 100 pharmacy support
allowance funds which would allow greater pharmacist input and systems.’[17]
Recommendation 10
5.14
The committee recommends that the Commonwealth Government clarify the
application of the section 100 supply program to remote aged care facilities,
and advise operators of these facilities accordingly.
Royal Flying Doctor Service
5.15
The committee was also presented with evidence from the Royal Flying
Doctor Service that while it could not access the section 100 supply program,
nor the Closing the Gap co-payment measure, it estimated that up to 40 percent
of its patients are Aboriginal and Torres Strait Islander people.[18]
DOHA has advised the committee that the RFDS is unable to participate in the
program because it does not meet the legislative requirements for
participation. DOHA states that the RFDS received $247 million in the
period 2007-08 to 2010-2011 in order to provide health care clinics, primary
aero-medical evacuations, medical chests and remote consultations.[19]
5.16
The committee suggests that the Commonwealth Government consider whether
the RFDS should be included in the RAAHS program.
Senator Rachel Siewert
Chair
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