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- Issue 81: April 2009
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Mirixing the Pot - Professor Lloyd Sansom & Others

Neil Johnston
Management Consultant Perspective

Issue 77: November 2008
Page: 1 of 1 Author's Profile | Send to a Friend | Printer Version

At the recent PAC Conference, delegates received a jolt in the form of an address by Professor Lloyd Sansom, who is chair of the Pharmaceutical Benefits Advisory Committee (PBAC) and the Australian Pharmacy Examining Council.
He stated that he believed that pharmacy was not ready to take up the responsibilities of an expanded primary health care role.
This of course is at odds with various activities that are already in train for the provision of clinical services from community pharmacies, driven mainly by the PGA.

Lloyd Sansom quoted a number of reasons for community pharmacy unpreparedness:
* The current structure of community pharmacy is incompatible with the vision of a primary health care centre held by minister Nicola Roxon.
* The current restrictions on PBS licences and the high cost of existing licences.
* The resulting establishment of certain ownership structures.
* The current structure which is heavily reliant on drug distribution
* The projected images and performances of certain banner groups.

All of the above reasons, individually or in combination, act to restrict innovation and development in pharmacy practice that would promote pharmacy as a legitimate partner in new primary health care delivery models.
Lloyd Sansom drove the point home further by commenting that he was unable to look at pharmacy as a primary care centre (he thought of them as 50% off discount warehouses) and he couldn’t find a health care practitioner in a pharmacy (but he could find an iridologist).

While those comments are at the extreme end of the equation, there is no doubt that there is considerable substance.
However, some of the points are not completely correct and some are unfair on pharmacy.
To provide a balance:
The statement “...I don’t see health care practitioners in pharmacy....” is incorrect.  
For example, Australia’s relatively late adoption of universal national health insurance (Medicare in 1984) with the resulting comparatively belated passing of primary care coordination to GPs has left a firm tradition  of  ‘first contact’ primary care in Australian pharmacy,  the community’s 20 million non-dispensing consultations pa  via the National Health Surveys from 1977 to 2005 confirm the magnitude of this activity, managers and owners nationally in the 2002 National Pharmacy Database Project reported over 80 million pa primary care activities, with comparatively  high public access of potent non-prescription medicines facilitated by Australia’s scheduling system, and the yearly Morgan polls rank pharmacists highest of the Primary Care professions.
Also, pharmacy’s access to the public has been whittled down by the PBS limiting time available for Primary Care.
I would add a further comment in the form that Australian pharmacy graduates in recent years have been of oustanding quality. I know because I have been actively engaged in mentoring a small number of the total.
Unequivocally, they are prepared and in a position to provide quality Primary Health Care services immediately – it is only the peak bodies (PSA and PGA) that are not prepared.
Given the “sausage factory” environment they are graduated into, it is little wonder we lose a substantial and unnecessary percentage of them to other professions.
We are also graduating students that will be surplus to requirements if we don’t generate new and meaningful jobs for them.

It is pleasing that someone with the stature of Lloyd Sansom agrees in principle with the basic commentary that flows from i2P each month, which highlights the duplication and wasteful, dominative, and destructive efforts that the PGA inflicts on their fellow pharmacists (not being PGA members).

A number of i2P writers have pointed out on numerous occasions that the various PGA ventures in developing IT-based clinical services put them in an area where conflict of interest is very apparent.
We ask again, “How can the PGA work in the best interests of its members when it duplicates at a very high cost, IT infrastructure that already exists?”
Specifically, the e-prescription initiative that is now being rushed to an early trial, after the collapse of the previous consortium.
Why did the consortium collapse?
Because the two major parties pulled out of the arrangement for fear that going without proper government guidelines in place, the project would become cost prohibitive,
Why then is the PGA putting its member’s money at risk in an area that has its landscape littered with failures that the PGA has been right in the centre of?
And why does it plan to utilise a model (charge per script) that adds to the overall cost of patient health considerably. This is an area that government should seriously take a lead responsibility in.

This has all the makings of another PGA loss at member and taxpayer expense,
All ministerial statements relating to a new primary health initiative have so far not mentioned pharmacy definitively, and pharmacy now finds itself politically lumped in as part of “allied health” rather than its separate identity (along with medicine and nursing) that used to form the traditional triad of professions collectively forming Primary Health Care Delivery.
The only plus so far is that one of the PGA national councillors (Judy Liauw) has been appointed to the reference group to advise Nicola Roxon on National Primary Health Care strategy.

Whether a PGA appointee to this committee is the right decision will only be known as the plot unfolds. Technically, it should have been a PSA appointee.
Pharmacy’s stakeholding in Primary Care is viewed politically, and also by doctors and nurses, as being tenuous at best. Given that in past years pharmacy has excelled in the Primary Care area, it has a lot of ground to make up.

It is obvious to most observers (as well as Nicola Roxon) that the group she should be dealing with in terms of Primary Health is the Pharmaceutical Society of Australia, the now poor relative (in reality) because of an earlier decision by government, to appoint the PGA as the sole negotiator for all things pharmacy and be the distributor of government grant monies for all pharmacy organisations.
This decision was criticised by a range of observers (including i2P) at the time it was announced, and has been the single most damaging decision that has affected the entire profession detrimentally, since that fateful decision.
With PGA stewardship, government funds have been channelled into projects that could be referred to as being for “the anointed few”, stifling innovation and initiative for pharmacy practice and research on one hand, while simultaneously creating a single, most powerful and very wealthy pharmacy organisation on the other hand.
The process has generated a range of expensive “top down” projects that all look good on the surface, but never seem to reach down deep enough to deliver for the benefit of all pharmacists and their consumers – because development must be adequately shared and built from the bottom up.
This was the lesson not yet fully learned by government and the PGA, and the single major reason for the loss of $’s multi-million spread over the sad history of health IT, an area in which Nicola Roxon has been silent to date as to her own plans.

A few months back saw the PSA suggest a new model for pharmacy utilising pharmacist practitioners within the new GP superclinics and being funded from the MBS pool rather than the PBS pool of funds.
Well, did that stir the pool and some very insulting remarks from senior PGA officials towards their PSA counterparts, all in the cause of promoting “solidarity”.
Why did the PGA feel threatened?
Simply put it meant that PSA would be able to wrest the leadership of the profession from the PGA- because it would provide leadership to the silent 65% majority.
Giving that group of pharmacists a voice would have created a strong but separate income stream from that of community pharmacy.
The silent majority have no real need of the PGA to represent them when the various Guild/Government agreements are being negotiated because that pool of money is tied to distribution and will never be sufficient to develop and fund a range of clinical services.
There will always be pressure on PBS prices and little opportunity for community pharmacy to value add to that sector.
There must be a clear boundary between distributive services in pharmacy to be totally distinct from clinical services.
They will have a need to coexist, but both have different parameters for development, management and marketing strategies.
And they will, and should, be supportive of each other because the distributive side has the capacity to provide infrastructure services, and the clinical side will create a rental market plus indirect sales generation for their distributive alliance partners.

At the height of the insult-trading Professor Charlie Benrimoj was moved to say:
"The Guild is a big gorilla that wants to control everything. It negotiates the head contracts and does not let anybody else near those negotiations."
He also stated the Society was underrepresented on Fourth Community Pharmacy Agreement committees, a situation he called "unsustainable".

"I don't believe that position is sustainable; the agreements are moving to the service delivery area. If service delivery is going to be a big issue, you would expect the professional organisation to be much more proactive, given at least an equal say in negotiations with the government," he said.

Prof Benrimoj also criticised a lack of planning in joint pharmacy research needs and outcomes, saying the Guild and PSA needed to create a joint strategic vision for the profession, from both economic and professional perspectives.

"We don't have that at the moment. We have a very ad hoc way and a very unsystematic way of doing things. What we do is fight fires all the time, within and between our organisations. We're very reactive. We need a blueprint for the future that takes into account both the economic and the professional perspectives -- otherwise it is doomed to failure."


Pharmacy Guild of Australia president, Kos Sclavos, dismissed Prof Benrimoj's statements as a "stunt".
He is reported as saying:

"Talk is cheap, Charlie; resourcing is what matters. In this coming agreement the Guild will invest some $5 million in background papers, research and resourcing. The Guild is happy to have assistance, but that is the level of funding and expertise that is needed to ensure the best possible outcome for pharmacy. That has been the secret of success in the Guild's negotiations over the years.”

A perfect example of the current imbalance of power in pharmacy.

Charlie Benrimoj is an academic who has had a long and distinguished career in Australian Pharmacy. He has been very proactive in pharmacy practice development.
His comments should be heeded.
i2P has often warned that the PGA is, and will, lose its power base progressively by pusuing policies that are not inclusive.
That will damage everyone given the level of arrogance and greed involved.

And now the stage is set for a new project in the form of Mirixa.
From the Mirixa website we quote:

”Mirixa Corporation is a leading developer of innovative clinical solutions that facilitate pharmacist-based patient care services and a leader in Medication Therapy Management (MTM) technology solutions. Founded by the National Community Pharmacists Association (NCPA), Mirixa has assembled the largest pharmacy services network of its kind with over 40,000 contracted community pharmacies – including both independents and chains. Mirixa’s technology portfolio empowers the delivery of highly targeted medication management programs, patient education, recruitment campaigns and patient medication records. The company’s leadership team shares a vision and passion for improving patient care, reducing overall health costs and expanding consumer access to accurate medication information.

Mirixa Corporation, the leader in pharmacy-based patient care services and healthlinks.net, a subsidiary of the Pharmacy Guild of Australia, announced today that they have signed a definitive technology licensing and business consulting agreement, paving the way for the use of MirixaPro in Australia's pharmacies nationwide.  Mirixa Australia, a newly formed business venture, will be operated by the Guild's healthlinks.net subsidiary. 

Under the agreement, Mirixa, which is sponsored by the National Community Pharmacists Association (NCPA), will adapt and license its widely used web-based software, MirixaPro, for use by pharmacies in Australia.   Additionally, Mirixa's success and leadership in enabling patient care services, through its U.S. network of 46,000 contracted pharmacies, will be leveraged by the Guild as it builds its Australian national program.  The Guild will initially deploy Mirixa technology and services to facilitate improved medication adherence and outcomes via programs that harness the power of the pharmacist-patient relationship. 

"Medication non-adherence is a challenging and complex global problem that results in poor health and increased health care costs," said Kos Sclavos, National President of the Pharmacy Guild of Australia. "After investigating several options, it became clear that Mirixa's experience and advanced technology provide us with the ability to quickly introduce programs that improve medication adherence and healthcare outcomes in Australia.  We are looking forward to working with the Mirixa team to bring technology-enabled services to pharmacists and their patients across Australia," added Mr. Sclavos. 

"The partnership between Mirixa and the Pharmacy Guild of Australia is a culmination of years of conversations with our international pharmacy partners.  The endorsement of Mirixa and MirixaPro is a testament to our emphasis on the pharmacy and patient care relationship, and the realization of that focus by our partners in Australia," said Bruce T. Roberts, Chief Executive Officer and Executive Vice President, NCPA. 

"The Pharmacy Guild of Australia has a widely recognized track record of innovation in technology and services at pharmacy, and we're honoured to have them as a business partner," expressed Rick Solano, Mirixa's Chief Executive Officer.  "We foresee a bright future of collaboration with the Guild, and look forward to demonstrating the clear value that community pharmacy brings to improving the safety, quality and effectiveness of patient care worldwide," added Mr. Solano.”

There is no doubt that Mirixa is a fine organisation with a great track record in the US.
i2P makes the following comment:

1. This is another case of a major system being introduced in a “top down” fashion, mainly as window dressing for Nicola Roxon to head off attempts to form a separate model of pharmacy in a range of GP superclinics.
Being “top down” it will substantially fail.

2. The cost of bringing this program to Australia is horribly expensive.
This is a project that the PSA could have developed, given proper financial resources and backing from government and the PGA.
Think of this in terms of lost opportunity for Australian pharmacists to be employed in developing a similar project and the future pharmacy practice research opportunities that will be lost.
Australia has a wealth of talent in IT and clinical service development…it is being denied the opportunity to make a valuable contribution towards a sustainable “oz” pharmacy future.

3. There has been a regsitration on the ASIC database for “Mirixa Australia”, the word Mirixa does not seem to be registered in Australia as a trademark, and there are two separate domain registrations – mirixa.com.au registered by PCA Nu Systems and mirixa.net.au registered by Healthlinks Net Pty Ltd.
It is curious that Mirixa has allowed part of its intellectual property to escape in the form of a domain name to be registered under the control of the PGA.
Also given that an e-script program (Surescripts) is an alliance association with Mirixa, is there a future potential here for friction with the PCA Nu Systems model about to be trialled?

4. With the PGA going down the pathway it has chosen it has already sown the seeds of division that will further simmer at the edges until the next “blow-out”.
Minister Roxon must be under some considerable private pressure, given that her parents are pharmacists and that the dinner conversation at home must occasionally work towards “what to do?”
Nicola Roxon is committed to the GP superclinic model that should include pharmacist practitioners. The PSA endorses that model.
The Minister must eventually come to a decision that will be a compromise between the PSA and the PGA.
If she wishes to see pharmacy flourish in the delivery of Primary Health Care, she must not only endorse a PSA initiative, but must also separate the funding.
That will be divisive, but the silent majority will be vociferously cheering on the sidelines and will finally be heard.

At last, an opportunity to provide creative and meaningful professional services.








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