Editor's Note: Currently there is a greater focus in repect of Indigenous health. And about time, some would say.
Only very small pockets of the pharmacy profession have attempted to come to terms with this major problem, and they genuinely need your management assistance.
Rollo Manning could well be regarded as the pharmacy expert in indigenous health, and he vigorously defends the rights of indigenous people to enjoy good health - just like the rest of the Australian community.
Rollo's sympathetic insights reflect his long association with, and understanding of, the issues surrounding indigenous health.
By Rollo Manning PhC MPRIA GradDipPR
Consultant to Aboriginal communities in economic and social development.
Let me tell you a story –
…the story of the Pharmaceutical Benefits Scheme and Aboriginal people in urban and remote areas.
Pharmacy services in Australia have evolved over the past 50 years following a model of retail dominance. Emerging from the 1960s when the compounding of medicines in all forms gave way to manufactured product the pharmacy profession ceased to be the wise old man of the mortar and pestle and exchanged this for the emerging technology of retail business management.
For a time in the early 1970s through to the 1990s the shop based dollar turnover dominated through the “front of shop” sales of anything from coffee and asparagus to health and beauty aids. The franchised style of branded chains came out of the individually owned businesses of the earlier “master pharmacists”.
More recently the pendulum has swung the other way and dispensary turnover is exceeding the front of shop due to the enormous change in retail shopping behaviour influenced by the supermarkets. In an attempt to counter this pharmacists’ have turned their stores into supermarkets. With some deft political maneuvering they too have been able to have legislation passed that means it is illegal to have a pharmacy in a supermarket but okay for a supermarket to be in a pharmacy!
The driver of the force that created a unique retail profile combining the retailing with the professional services was driven (and continues to be driven) by the union for pharmacy owners – the Pharmacy Guild of Australia. The organisation is now in its 80th year after having been initiated in New South Wales in 1928 in response to news that the powerful Boots the Chemist chain in the United Kingdom was considering entering Australia to overpower the dominance of a “pharmacist owned” policy. So it happened that bullions of gold were exchanged for political favors and the same principle still applies today as the powerbrokers of the ancient establishment continue to disperse their wealth in successful endeavors to maintain the highly anti competitive practice of retaining the pharmacist only owned policy in all jurisdictions except the Northern Territory.
In that “State” the law allows an Aboriginal health service to own a pharmacy business so long as it has Ministerial approval.
In 2004 the Pharmacy Guild convinced the NT Labor Government that it was out of step with the rest of Australia by not having a pharmacist only ownership rule. In point of fact and following National Competition Policy (NCP) principles it was the rest of Australia that was out of step with the NT (by default) being the only place that conformed to NCP guidelines.
A lobby to retain the opportunity to allow Aboriginal health services to own a pharmacy was successful and with the help of the Independent Member for Nelson, Gerry Wood MLA, the clause to allow this to happen was passed and the NT became the only place in Australia where someone other than a pharmacist could own a pharmacy. The remainder of the restrictions were carried into legislation by stealth following the Pharmacy Guild claims that it HAD to be changed to meet NCP principles.
The fact that the clause allowing AHSs to own a pharmacy has not been utilized to improve the way Aboriginal people access pharmacy services is more because of a lack of understanding of how to make it happen rather than an acknowledged acceptance that it is not needed.
In point of fact the manner in which pharmaceuticals are delivered to Aboriginal clients of AHSs does not match up to National Medicine Policy principles. Aboriginal health services (AHS) could well do with an injection of pharmaceutical know-how through the employment of pharmacists in their primary health services to close the gap between what is available to mainstream Australians compared to Aboriginal clients of community controlled health services.
The Pharmaceutical Benefits Scheme (PBS), the primary funder of essential pharmaceuticals to the Australian community, has discriminated against Aboriginal Australians living in remote places since the introduction of special arrangements in 1999 to allow AHSs in certain remote locations to access a full range of PBS items without having to pay a cost to the client but also without the full dispensing fee allowed to the rest of Australia.
Across Australia there is the legislative requirement to have a pharmacist employed at every pharmacy. This means the PBS supply is supervised by a pharmacist and a “professional fee” is built into the remuneration from the Australian Government to allow this to happen. It is the PBS that is employing the pharmacist through the remuneration structure.
From the 1st August 2008 the fee paid to pharmacists was $5.99 and in addition to that they receive $1.02 to record the safety net for a client on each prescription dispensed - a fee which is meant to be voluntary for the client but rarely offered. If the cost of the PBS medicine is below the threshold for Government subsidy the client pays the lot and the pharmacy builds into the cost an amount of $3.63 simply because it is not being subsidised by the Government. This is also meant to be voluntary and explained to the client but rarely is.
When a medicine listed on the PBS prices out at $20 it means that more than half the cost is going to the pharmacy in fees without even the cost of the medicine being covered. If that cost is less than $5.00 (which can easily be the case) the gross profit margin to the dispensing pharmacy is 300%.
Such charges are being incurred by Aboriginal clients across Australia who live in urban areas and access medicines through a retail pharmacy or from their AHS which in turn is paying these fees to their supplying pharmacy.
In remote areas the situation is different again and in most respects worse. Unlike the rest of Australians who access PBS through an approved pharmacy to dispense PBS the AHS will have a “pharmacy” of its own which accesses, stores and dispenses medicines under State/Territory legislation. The acquisition of the PBS medicines to the AHS is at no cost and the retail pharmacy (that is approved) will supply in bulk the medicines and not contribute to the dispensing process. In fact the supplying pharmacy will only receive $1.14 an item compared with the rest of Australia’s fee of $6.50 ass outlined above.
The question can well be asked “what happens to the difference?”
The difference between $5.99 and $1.14 (= $4.85) is the amount the Australian Government saves when a PBS medicine is supplied to an Aboriginal client attending a remote health clinic.
National Medicines Policy
Addressing the National Medicines Policy (NMP) it is possible to determine how well the pharmaceutical service supply function to Aboriginal client’s matches up to that provided to the rest of Australia visiting a general practice clinic, multi purpose health service, GP Super Clinic or similar health service delivery facility. The pharmaceutical service will be supplied by a retail pharmacy or in a few instances a private pharmacy business on the site of the health facility.
The Department of Health and Ageing website states the following re the NMP:
The overall aim of the National Medicines Policy is to meet medication and related service needs, so that both optimal health outcomes and economic objectives are achieved. The Policy has four central objectives:
- timely access to the medicines that Australians need, at a cost individuals and the community can afford;
- medicines meeting appropriate standards of quality, safety and efficacy;
- quality use of medicines; and
- Maintaining a responsible and viable medicines industry.
ACCESS – on the question of access there can be no dispute. Aboriginal clients in both urban and remote locations have ready access to PBS medicines through a nearby retail approved pharmacy.
STANDARDS – there should be no question of doubt on quality as State/Territory Poisons legislation requires proper adequate and safe storage situations for all human medicines.
QUALITY USE OF MEDICINE – this relates to the manner in which the client is supplied the medicine and whether they are assisted in understanding matters such as why it has been prescribed; what it will do; whether there are side effects; how it will assist them get better; the importance of dose related times and circumstances; and why it is essential for improving the diagnosed disease together with any co-related measures such as diet, exercise or avoiding foods, alcohol and other substances. In the management of acute illness this is crucial especially with infections and antibiotics or topical treatments.
In the case of chronic disease the QUM process will well make the difference between extending the life span of the individual or an early and premature death.
A prescription for medicines in the treatment of chronic disease is usually a prescription for life and must be understood as such if the measure to “close the gap” to be successful. It should be of interest in this discussion that the responsibility of Government in the National Medicines Policy is stated as being:
Governments, their agencies and committees are responsible for:
• developing and implementing the National Strategy for QUM;
• coordinating relevant government programs; and
• investigating and developing appropriate structures, funding mechanisms, legislation and environments that support QUM.
RESPONSIBLE AND VIABLE INDUSTRY
A “responsible” industry, both retail and manufacturing, should have some social responsibility apart from the required financial motive in its dealings. The fact that both sectors allow the current state of pharmacy services to Aboriginal people to continue with no proactive support in bringing about change indicates a lack of concern for this marginalised sector of the population.
It could well be said that Governments have failed to hold up their end of the NMP and QUM agreement when it comes to Aboriginal Australians in both urban and remote environments. In addition the retail and manufacturing sector have allowed a situation to continue which would simply not be tolerated if inflicted upon mainstream Australians in urban areas. The total thrust behind change for Aboriginal clients for the PBS must come from those sectors that know how it should be being provided. The AHSs themselves have never experienced a “good” pharmacy service and thus do not know what they don’t know.
The essential planks of a good pharmacy service at an Aboriginal Health Service could thus be summarized as follows:
- ACCESS – ready access to all PBS medicines to provide optimum treatment for its clients.
- STANDARDS – storage and transport of products in a safe and secure manner
- QUALITY USE OF MEDICINES - information added to ensure client is able to take advantage of medicine to extend life expectancy
- INDUSTRY co-operation to enhance the value of the pharmacy service from both the manufacturing and retail sectors of the pharmaceutical industry. Academia can also play a part in practice research to evaluate best practice models and evidence based outcomes.
Continual dialogue is needed between the Aboriginal health sector and Government policy makers. If the gap is to be closed pharmacists can play a big role in making it happen.
So far there is little evidence that this is taking place.
For further information contact the author
Rollo Manning, PO Box 98 Parap NT 0804
Tel: 08 8942 2101 or 0411 049 872