Chief Minister supports pharmacies in the bush

TRANSCRIPT

ABC RADIO ALICE SPRINGS

Thursday 6^th September 2012

Listen to sound file

CALLER:

An interview today with Rollo Manning encouraged the Government to provide pharmacies in remote communities …. what is your notion on that to get pharmacies in communities ….so there is the provision of quality use of medicines….

COMPERE:

This is a story that has been around today …. about establishing pharmacies in remote communities that could lead to some employment by taking services out bush…is that something you would consider encouraging?

TERRY MILLS MLA, Chief Minister of the NT
Yes certainly – I have been at Ampilatwatja today …and had a very sobering briefing on the health issues …I heard this report from Rollo Manning and it does make a lot of sense. I will be talking to my new Health Minister to pursue this. Our core philosophy is to make sure wherever possible we put the decision making closer to the people that are affected by that decision. It does fit with my philosophy of allowing local people to be involved in solutions to their own problems in this case administering health and medicines to local people.

Pharmacies should be built in communities says consultant - Northern Territory Country Hour - ABC Rural Australian Broadcasting Corporation)

Go to ABC Rural website for story and sound file

Pharmacy businesses in remote Aboriginal communities are a “natural” and must be supported to provide income to the local economy, real jobs, and career prospects for local people, a Consultant in pharmacy services to Aboriginal health facilities is telling the new CLP  Government in the Northern Territory.

Rollo Manning, a pharmacist, and the architect of the Tiwi Health Board pharmacy business in 2001, has been trying for ten years to repeat the effort in other towns but says he has received no support from the Government.

“To read the publicity blurb behind the ‘Growth Town’ future program of the Henderson Government it appeared that here was the answer. At last something would be done to create real jobs in communities through local entrepreneur opportunities” he said. “But alas nothing happened except an army of bureaucrats hide behind the glossy websites and colourful brochures”.

The NT has one pharmacy to every 7.900 persons compared to the National figure of one pharmacy to every 4,200 people. The reason for this according to Rollo Manning is that the 53,000 persons living in remote   communities are not serviced by a “local” pharmacy.

“There is the is business out there due to the people having a health status recognised as four time worse than non Indigenous Australians. A population of 1000 remote living Aboriginals need the same amount of medicines under the Pharmaceutical Benefits Scheme as 4,000   people in mainstream.” according to Rollo Manning.

“Towns like Maningrida, Wadeye, Galiwin’ku and Jabiru should be able to support their own pharmacy business and I can assure anyone that there are the pharmacists ready and   willing to be a part of such a movement.” he added.

The inclusion of a pharmacist to the primary health effort is likely to be welcomed by all practitioners and a “point of sale” for all things towards “good health” would be the location of the pharmacy business.

“A whole of Government approach is needed and this  includes the Department of Health”, he added.

NT election outcome signals new era

Follow @rollom38 
A new approach is likely to economic development in remote Aboriginal communities as a result of the resounding victory of the Country Liberal Party (CLP) election held last weekend.
It now looks as though the CLP have won 16 seats in the 25 seat Parliament with one seat held by the Independent Gerry Wood and the balance by the outgoing Labor Party with eights seats – down from the previous 12 seats.

Picture courtesy NT News

The significant element to the result was the success “in the bush” – all those seats outside of Darwin and Alice Springs – now held by CLP members of Parliament and which were previously Labor held seats.
The gains have seen the following significance Aboriginal people being elected to the Parliament:
Alison Anderson – Seat of Namatjiraa - previous Labour Minister under leader and Chief Minister Paul Henderson who defected to the cross benches in 2009 and then joined the CLP. Ms Anderson has been outspoken in her views on the Federal Intervention, that 12 maxi Shires replaced some 80 Community Government Councils and the new Stronger Futures legislation for the next ten years from Canberra.

Francis Xavier Maralampuwi – Seat of Arafura – a local Traditional Aboriginal man from Nguiu, Bathurst Island where he has lived all his life with distinction as a leader in the Community Government Council, Land Council and more recently the Shires. Maralampuwi has a good record in sport as a footballer and in charity work helping people with alcohol and drug problems for the past 30 years. He has won the Seat of Arafura by a 58 seat margin – a seat formerly held for 11 years by popular ALP member Marion Scrymgour who also had a strong local following. It was the people of Nguiu that have put Maralampuwi into Parliament with an 80% support from that polling booth.
Bess Price – Seat of Stuart- has ousted former Henderson Government Minister Karl Hampton. Ms Price has developed her own strong personal profile as a person who will say it as it is and not resort to politically correct verbage when describing how she sees the major issues confronting Aboriginal people in the “bush”. Her views are well known in the National sphere through appearances in shows such as ABC Q & A and SBS Insight. Her margin was a mere 187 votes in an electorate that is larger that most countries in Europe and spans from the centre around Alice Springs through the Tanami Desert to places like Timber Creek on the main highway to WA.
Larissa Lee – Seat of Arnhem – has won from popular Government Minister for Indigenous Affairs Malandari McCarthy – a former ABC journalist in Darwin and well known traditional Aboriginal person from Borroloola. The seat had been uncontested in 2008 and the selection of Larissa as the candidate was a stroke of brilliance by the CLP given her powerful family background being the daughter of the late Jawoyn Aboriginal Elder Robert Lee. An Aboriginal Health Worker from Barunga, Larissa won the seat with a 10.6% margin.

The above four persons have brought about the change in Government and the strength of the effort means that a 100% commitment has been made for doing things better for the “bush”.
One of the key elements of any improvement program will be more jobs and developing real economies in places (towns) that have up until now relied on no competition, welfare handouts and a static work environment with unemployment being the main occupation.

And this is where pharmacy comes in on two fronts.
The first is bringing into the community money that is currently going to the main centres of Alice Springs and Darwin by way of surpluses made on trading with Medicare for the supply of Pharmaceutical Benefits Scheme medicines. This could all be going to these towns with the strategic placement of local pharmacy businesses in the Growth Towns. There are many young pharmacists keen to establish there own businesses and what better or more challenging place to do it than a remote Aboriginal community classified as a “Growth Town” and with the support of a Government committed to creating economies.
The second contribution pharmacy (or pharmacists) can make is the provision of a “point of sale” for all things that will lead to a healthy lifestyle – food, activities, exercise programs, books, DVDs, motivational programs and the many many things that are taken for granted in “mainstream” culture way but denied of these people by a governance that has seen no reason for competition or no more that one store.

A comparison between an Aboriginal Growth Town and a mainstream country town shows that there are 15 retail outlets in the mainstream town compared with five in Aboriginal land and yet a disposable income far higher with the Aboriginals than in mainstream. This is because they pay very little rent for fewer houses and are not likely to own a car. If the cost of these is taken out of a family budget it is not hard to find and extra $500 a fortnight and yet have nothing useful to spend it on. In one store there is 35% of purchases spent on tobacco products and this has increased over the past 20 years by 2%. Quite unlike the downward spiral in mainstream where tobacco products have gone down from around 60 % of the population smoking to 15% in the same period (20 years). Problem – no point of sale for health promotion – just messages through print and media.

The CLP Government comes into office with the following policy commitments:
o The creation of a commercial environment so that businesses can earn decent profits and grow.
o The creation of a strong and growing economy by allowing and encouraging private industry to thrive.
o Expanding the Small Business Advisory Service across the whole Territory will help more Indigenous people in remote communities get into real jobs and off welfare.
o Shires and Regional councils will be assisted to pursue new business opportunities to expand their service and revenue base.
o Regional Councils will give a greater say to local people on where money is spent and how services are delivered in their region.
o The Country Liberals are committed to delivering a stronger local voice, better services and a safer, more prosperous future for our regions.
No better climate could have been created for emerging pharmacy businesses but it is now for the industry to get behind and back such a progression. The present profile in the NT shows that for a population of 220,000 there are 28 pharmacies – one per 7.900 persons compared with a National figure of one per 4,200.
The difference is in the persons in remote communities NOT being served by a pharmacy meaning that the profits from their communities is going to the big stakeholders in Alice Springs and Darwin.
Now is the time to jump and a consortium started that will seize the opportunity and allow many young pharmacists to make a contribution which although not being the most rewarding financially will certainly be rewarding in health outcomes through professional satisfaction.
Ends
Comments welcome to Rollo Manning, PO Box 98 Parap NT or rollom@iinet.net.au or 0411 049 872

Follow @rollom38

Who is an “Aboriginal”? The need to distinguish between “remote” and “urban”

The averaging of indicators of disadvantage does nothing to help understand the plight of remote living Aboriginal people in Australia.

There are some 140,000 persons living “in remote” out of a total population of 520,000 claiming Aboriginal heritage – that is 26%.

The majority of Australia’s “Aboriginal people” live in urban areas of the cities and towns with access to education, health services, employment opportunities and the lifestyle of mainstream Australians. They have been born and raised in those developed environments and so have access to facilities to improve their life. The majority have succeeded.

By contrast, the remote living Aboriginal people who make up the 140,000 that live in communities may have never seen a train or tram, caught a bus or attended a movie cinema for entertainment. Their view of the world is entirely different from their cousins in the towns and cities. To them the world is little or no education, over crowded houses, one store with a limited range of fresh food and people who come and go delivering health services. It is a “world view” that the average Australian cannot imagine.

Nearly all of the remote living Aboriginals are full blooded Aboriginal people with no mixed blood and thus with the full gene compliment of the original race of people. Western culture has added its genes to the pool that make up the remainder of the Aboriginal population thus making comparisons difficult on the basis of genotypes.

So why is it that when analysing the “gap” - disadvantage, life expectancy or disease incidence the all Aboriginal statistic is given?

Surely the Australian Bureau of Statistics knows by now who is who – it is after all since 1967 that Aboriginal Australians have been included in Census data. So long as statistics are averaged across all Aboriginal persons a skewed picture will be obtained and the contrast between the two population cohorts not appreciated by the policy makers.

A good example of this was the PBS QuMAX/s100 Forum recently held in Melbourne with pharmacists from all over Australia gathered to learn about and discuss quality use of medicine programs to Aboriginal (and Torres Strait Islander) people in Australia. Thus pharmacists dealing with these two world views were thrust together and expected to understand each others target audiences as if they were the same. It has to be recognised by the policy makers and program planners that this is not the case and it is only when it is taken into account that realistic programs can be put in place.

The statistic is given that in 2006 deaths and hospitalisations caused by cardiovascular disease for indigenous Australians were double the rates of non-indigenous Australians[1]; or that Aboriginal and Torres Strait Islander people are much more likely to develop complications (e.g. pneumonia and ear damage) from respiratory tract infections[2].

Such sweeping statements do nothing to help understand the degree of Aboriginality that makes up the cohort from which such conclusions have been drawn. It must be possible to draw a distinction between the remote living Aboriginal people and urban living persons. The Pharmaceutical Benefits Scheme for one thing is done differently and the medicine use for remote Aboriginal people is through special arrangements using Section 100 of the National Health Act to supply medicines directly to the Aboriginal Health Services. This would allow an analysis to be done on the supplies that are paid for by Medicare to the supplying Approved Pharmacies in either hospitals or the community. But alas, after three years of trying the Centre for Chronic Disease at the University of Queensland has been denied access to the Medicare data.

At the above mentioned Forum in Melbourne it was stated that the three most prescribed medicines for “Aboriginal people” were Metformin, Atorvastin and Salbutamol. This was from CTG prescriptions and should have been possible to correlate with the usage through the s100 arrangements - but no – there is no such data available even though the scheme has been operating for 12 years.

This writer knows that from the data of one Aboriginal Health Service[3] in a remote location the usage shows the top three supplied medicines are Ramipril, Atorvastin and Amoxycillin. Such a figure should be available from supplies to all AHSs.

The final piece of information that demonstrates the point of this article is life expectancy.

When averaged out across the total population of Aboriginal Australians the 17 year gap is identified. This means the Aboriginal person has a life expectancy of 62 years for males and 67 for females.

However if the age at death is looked at for Aboriginal people in the Northern Territory[4] the median age at death for males is 51 years (15 years less than non Indigenous) and females is 55 years (20 years less than non Indigenous). A stark contrast to the “average” over the total population. When remote locations are taken into account the difference is even greater.

In the words of Professor Wendy Hoy, Director of the Centre for Chronic Disease in Brisbane:

“The quickest way to “narrow the gap” is to reduce disease burden and deaths in remote areas, where rates are much higher than in Indigenous people living closer to population centres”.

Ends

---

[1] NPS at http://www.nps.org.au/news_and_media/media_releases/repository/Experiencing_the_outback_side_of_pharmacy

[2] NPS at http://www.nps.org.au/bemedicinewise/common_colds/antibiotics_dont_kill_viruses

[3] Personal communication to author

[4] ABS - Deaths of Aboriginal and Torres Strait Islander Australians. 2010

May 2012 be the year that SOCIAL INCLUSION is the commitment to inspiring a reinvigorated relief for Aboriginal disadvantage

Minister for Social Inclusion, Mark Butler MP needs to be reminded that remote living Aboriginals are in need of        recognition before being excluded even more—write and tell him c/o Parliament House, Canberra, ACT, 2600

Extract from The Australian, Monday 26th December 2011

I never stop wondering what I could do to help bring about social inclusion. There are so many examples of where it has gone wrong over the few years I have been involved, such as the following...

Deleece was let down by a system that thrives on mediocrity.
Centrelink, Job Services Australia and the entire “job ready” effort is organised by an army of bureaucrats gobbling up endless amounts of money and losing sight of what they are really there for – the people, and yes... there are people at the end of the line that need help.
SOCIAL INCLUSION should mean the provision of the tools for everyone, regardless of location, to education and training to join in their share of the Nation’s wealth.

 Zoe and Lucinda are from a remote community with a population of 1200 people 500 Kms north east of Darwin. There are few employment opportunities apart from services and little attention is given to starting entrepreneurial businesses. Without this to observe, the growing child has little opportunity to view scope, dreams or vision for the future. Their future is in our hands.

SOCIAL INCLUSION should give all children the chance to dream and aspire to future successes - at present they complete their schooling and have no idea what they want to do with the rest of their life. Hundreds of young Aboriginal children who finish their schooling are lost every year to another generation of welfare recipients simply because they know of nothing better to do.

Bob Beadman asked...
"WHAT HAPPENED TO THE DREAMS?"
(Do Indigenous youth have a dream– Menzies Research Centre 2004)

“I am looking at human detritus right here in Darwin, and wonder what dreams they might have once had for themselves?

What dreams they might have had for their children? What dreams their children might have had for themselves?

I wonder if people have abandoned those dreams, what caused them to give up, what is it about the world that surrounds us all that makes them think that their dreams are  unachievable.”

We must strive to assist the young ones to develop those dreams they once had but now seem forgotten.

SOCIAL INCLUSION should not be hard to grasp - it does what it says - includes people in a social context as well as economic and environmental settings in communities. Where social capital is the glue that holds a community together - social inclusion is the philosophy under which all else happens.

SOCIAL INCLUSION must be the focus of a renewed reconciliation for all young Aboriginal children and youth no matter where they are from BUT particularly those from remote commuinities where an understanding of the dominant culture's world view is somewhat lacking. The youth of Australia must be made to know they are wanted and loved and be inspired to enjoy the Nation's opportunities just like their urban counterparts attending the plush private schools in the capital cities.

Ends

INTEREST HIGH WITH STUDENTS IN ABORIGINAL HEALTH

The future supply of pharmacists to work in Aboriginal health is healthy if the outcome of a National Australian Pharmacy Students’ Association survey is anything to go by.

While 83% of respondents felt it is important to be taught about Aboriginal and Torres Strait Islander health issues as part of their pharmacy course curriculum, only 60% have access to such education. Furthermore, only half of those respondents feel they are taught enough about this topic.

Students believed that the present level of awareness was good with 60% saying they had exposure to Aboriginal health learning during their course.

Only 9% of respondents had Aboriginal health as an integral part of the core curriculum while 50% had the information delivered in just one or two lectures.

A minority of respondents (25%) felt they were trained to competently practice in a culturally acceptable manner while 35% felt they could not.

The favoured method of learning about cultural awareness in Aboriginal health was a half day or one day training course (45%) while practical experience was mentioned as the best way of learning the subject.

The recommendations of the survey outcomes should see an increase in the component of Aboriginal health training in pharmacy curriculum with an emphasis on cultural awareness.

With a workforce planning study being commenced on the supply and demand for pharmacists in rural and remote areas it is to be hoped that staff establishments for primary health care in communities will include the position of a pharmacist.

It is only by participating that pharmacists will be able to show how they can contribute beyond the “pick and lick” image that is currently held on their role.

Ends

Comment to Rollo Manning at rollom@iinet.net.au or call on 0411 049 872

  

Senate inquiry agreed to in Parliament— PBS to remote living Aboriginals to be examined

 

On 24th March 2011 the Senate agreed to a motion from Senator Rachel Siewert (Greens, WA) that the supply of Pharmaceutical Benefits Scheme medicines to remote area Aboriginal Health Services be referred to the Senate Community Affairs Reference Committee. The special  arrangements under Section 100 of the National Health Act have provided a bulk supply scheme with no value added component from a pharmacist.

Three reviews of the scheme in 2004 (Kelaher) 2006 (Urbis) and 2010 (Nova Policy) have failed to produce any significant improvement in the quality use of medicines by Aboriginal clients of health services. 

A matter of equity

The matter to be reviewed by the Senate Committee is a matter of justice, fairness and   equity particularly relevant at a time when Closing the Gap is so much in the headlines and remote living Aboriginal people are dying at such a young age.

After three reviews of the Section 100 supply arrangements little change has occurred. The Senate Inquiry should be able to identify what needs to be   improved and which agency should be responsible for making it happen. The involvement of pharmacists in this process should be a leading principle.

Inequities for remote Aboriginal Health Services (AHS) and the Pharmaceutical Benefits Scheme (PBS) include:

• Over the ten years the scheme has been in place there has been no money made available to the Aboriginal Health Services to develop their own pharmaceutical care program.
• Recording of outgoing supplies (dispensing) by any electronic process incorporating scanning is absent and hand written labels are the norm.
• While the PBS pays a dispensing fee ($6.42) to pharmacies in all situations under Section 85 (mainstream) there is no fee paid for the dispensing  carried out at Aboriginal Health Services.
• The PBS saves $3.68 every time a PBS medicine is dispensed to a remote living Aboriginal person. A handling fee of $2.74 is paid to the supplying Approved Pharmacy for the bulk supply but no dispensing fee is paid to the AHS.
• Mainstream Australians have access to a pharmacist (by law) in every pharmacy in Australia when a PBS prescription is dispensed. No such facility is available to an Aboriginal patient of an AHS or to a  
  person trained by a pharmacist to inform them of the nature of the medicine prescribed.
• No data is analysed to assist in decision making towards improved medicine utilisation across States and regional boundaries. 

Go to the following link for details on the Inquiry and the making of a submission:
http://www.aph.gov.au/Senate/committee/clac_ctte/pbs_medicines/index.htm

Closing date for Submissions is 30th June 2011.

The Terms of Reference seek comment on a  range of issues. The full text of the Motion agreed to by the   Senate follows:

The effectiveness of the special arrangements established in 1999 under section 100 of the National Health Act 1953, for the supply of Pharmaceutical Benefits Scheme (PBS) medicines to remote area Aboriginal Health Services, with particular reference to:

(a) whether these arrangements adequately address barriers experienced by Aboriginal and Torres Strait Islander people living in remote areas of Australia in accessing essential medicines through the PBS;

(b) the clinical outcomes achieved from the measure, in particular to improvements in patient understanding of, and adherence to, prescribed treatment as a  result of the improved access to PBS medicines;

(c) the degree to which the ‘quality use of medicines’ has been achieved including the amount of contact with a pharmacist available to these  patients compared to urban Australians;

(d) the degree to which state/territory legislation has been complied with in respect to the   recording, labelling and monitoring of PBS medicines;

(e) 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;

(f) 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;

(g) the degree to which recommendations from previous reviews have been implemented and any consultation which has occurred with the community controlled Aboriginal health sector about any changes to the program;

(h) access to PBS generally in remote communities; and

(i) any other related matters.

Question agreed to.

Any person or organisation requiring further background to the Inquiry or assistance with the writing of a submission can contact Rollo Manning at rollom@iinet.net.au or 0411 049 872.

Take medicines - seriously, and help Close the Gap

The life expectancy gap for Indigenous Australians could be significantly closed if the same level of pharmaceutical care was applied to those living in remote communities as it is for the rest of the Australian population. The management of chronic diseases requires urgent attention in the provision of prescription medicines - in both monitoring adherence and follow up adjustment of dosing.

Patients attending Aboriginal health services in remote communities are being dispensed medicines with little recording, probably no label and scant advice on what to expect of it.  This is the outcome of ten years of bulk supply of Pharmaceutical Benefits Scheme (PBS) medicines from an Approved Pharmacy with no involvement of a pharmacist in the dispensing process. The scheme is costing the Australian taxpayer $40 million a year yet even the Department of Health and Ageing admit there is wastage and an analysis of the Medicare records of payment would not be an accurate evaluation of what is being supplied to patients.

Whilst it will take years for medicine taking to impact on the life expectancy gap between Indigenous and non-Indigenous Australians this discreet group of patients with only one supply route should be an ideal target for some primary practice research.

But no!

Researchers admit that the missing element in data with respect to chronic disease management is knowing whether the patient is taking their medicine. Whilst this might apply to the bulk of Australians with chronic diseases, the clinical signs should be there to illustrate the benefits of medicine taking. Otherwise why is the taxpayer paying $8.4 billion a year on the PBS?

With no record of supply and the labelling an unknown quantity – the quality of pharmaceutical care is suspect.

Approved Pharmacies (agents for the supply of PBS medicines) are under no obligation to provide support in the supply on to the patient. That is the job of the Aboriginal health service and done by doctors, nurses and Aboriginal Health Workers with no payment from the PBS to meet the cost of dispensing.

In mainstream PBS supply the Approved Pharmacy is paid $6.42 every time a prescription is dispensed. It is recorded on an IT system that has been paid for and upgraded by the PBS. In remote “drug rooms” there is no such luxury – not even a typewriter for labelling.

Of the $40 million dollar cost to the PBS in this financial year, $10 million will go to the Approved Pharmacy through a combination of a $2.74 handling fee per item and a 15% mark up on the cost of goods. The PBS actually saves $3.68 every time a packet of pills is given to a remote living Aboriginal person. Extended across a year this amounts to $5.52 million and that would employ a lot of pharmacists at Aboriginal health services to add some quality to the supply and give the patients an understanding of what western medicine is all about.

All Australians, when given a prescription by a doctor, take it to a pharmacy for dispensing. They can then ask the pharmacist (always present by law) whatever question they want about that medicine. The salary of that pharmacist is largely contributed to by the PBS through the dispensing fee. For the remote living Aboriginal there is no such practice. There are no pharmacists employed by Aboriginal health services in the NT and only three in the whole of Australia.

This is a shameful situation and one that shows a high degree of discrimination and unacceptable level of unequal opportunity. The National Indigenous Health Equality Council is not interested in this matter claiming that it does not fall within its terms of reference. The Pharmacy Guild is interested in its members being viable entities while NACCHO (the Aboriginal health peak body) is overwhelmed by the Pharmacy Guild into thinking that “this is as good as it gets”.

The diseases killing Aboriginal people at a young age were not there 40 years ago and have been brought on by lifestyle choices. This makes it even more important that information is provided to help the patient understand what the medicine is going to do and how it will work to help them live longer.

Such is the need for a greater emphasis on the quality use of medicine for Aboriginal people in remote communities if Close the Gap is to be taken seriously.

Ends

The plethora of pharmacy programs

The purpose of this paper is to describe the current situation for Aboriginal and Torres Strait Islander people obtaining a prescription for medicine under the Pharmaceutical Benefits Scheme and dispensed by a pharmacy – be that in a hospital, the community setting or from an Aboriginal Health Service either government owned and operated or under community control.

Introduction
The past ten years has seen some effort put into improving the compliance rate and health gains by Aboriginal and Torres Strait Islander people from the use of western medicines. Emphasis has been placed on chronic disease conditions which are having a serious impact on longevity of life and forcing a wide gap in life expectancy between Indigenous Australians and non-Indigenous Australians. The average “gap” is shown to be 17 years although by region those living in remote areas of Australia have a lower life expectancy and are thus crucial to “closing the gap” on an Australia wide count.

Background
The respective stakeholders in primary health care each has a concern for the health of Indigenous Australians. The needs of the patient must be paramount over the processes that suit a mainstream population. Too often remote living Indigenous Australians have been forced to accept a mainstream model of service delivery when their needs reflect more that of a Third World country requiring a program designed to specifically meet their needs. This applies to the Section 100 PBS to remote AHS arrangements. In urban areas where possible the needs of the patient can be made to fit the mainstream model and this should be done rather than establishing new processes. The QuMAX and Close the Gap programs have failed to do this effectively.

The Federal Government, as the funder, has tried to meet the requests emanating from the prime peak bodies, the Pharmacy Guild and NACCHO. In addition the following have had some part in the lobbying process:

• ·         The Pharmaceutical Society of Australia
• ·         The Australian Medical Association
• ·         Australian Divisions of General Practice
• ·         Royal Australasian College of Physicians
• ·         Royal Australian College of GPs
• ·         Rural Doctors Association
• ·         National Rural Health Alliance
• ·         Australian Pharmacy Council
• ·         The Society of Hospital Pharmacists of Australia

The following programs have been put in place over the past ten years:

1. ·         Special PBS listing of medicines specifically for Indigenous Australians
2. ·         Section 100 arrangements for supply to remote living Indigenous Australians
3. ·         Special allowance for pharmacists supplying remote health services under s100 to implement quality use of medicine measures
4. ·         National Prescribing Service program for “outreach pharmacists” to remote Aboriginal health services (OPRAH)
5. ·         QuMAX program for cost of DAAs to Indigenous patients attending eligible community controlled health services.
6. ·         Close the Gap co-payment relief for Indigenous people attending eligible general practice centres and registered for chronic disease management.

The above programs have solved some problems but in doing so have created problems of their own. There needs to be a “global” look at the whole scene to evaluate where this has occurred and what can be learnt from the past ten years involving operators at the coalface.

In evaluating the cost benefits of these programs it is important to keep in mind the four basic principles of the National Medicines Policy which should be the underlying guide to development of quality pharmaceutical care. These are:

1.      Timely access to the medicines that Australians need at a cost individuals and the community can afford – this has been assured across the Nation

2.      Medicines meeting appropriate standards of quality, safety and efficacy – including the correct recording and labelling of prescribed medicines in accordance wit the law – this has been assured across the Nation.

3.     Quality use of medicines with information to allow the patient to understand the medicines they are getting including effects, side effects, interactions and expectations of outcome. This is available to ALL Australians through a local retail pharmacy – but not remote living Aboriginal people.

4.     Maintaining a responsible and viable medicines industry including sustainable research, manufacturing and supply chain to the patient. The s100 to remote arrangements offer a sizeable income to retail pharmacies thus ensuring their viability. The urban programs ensure the “bill” is paid at the local pharmacy by health services and their patients.

Situation analysis
The following comments are now made on each of the above:

1.     Special PBS listing of medicines specifically for Indigenous Australians
The list is essentially medicines which can be bought over the counter at a pharmacy. The cost of such an item when added to the PBS list and supplied in accordance with a legal PBS order immediately increases the cost to taxpayer by the dispensing fee, safety net recording fee and in the instance of urban dwellers the “additional extra charge”. This result means either the PBS or the consumer is paying more because of PBS listing unless the consumer has a Health Care Card.

2.     Section 100 arrangements for supply to remote living Indigenous Australians
This has increased the availability of the full range of PBS general list of medicines to remote Aboriginal health service. However in devising the reimbursement formula to supplying pharmacies no consideration has been given to meeting the cost of dispensing at the AHS as the PBS does for every other Australian attending an Approved Pharmacy. The result has been poor quality in the standard of pharmaceutical care and no apparent indication of which party is responsible for improvements. The State/Territory governments are responsible for ensuring the legal requirements for supply are being met whilst the Commonwealth should be responsible for ensuring the remuneration is adequate to meet the principles of the National Medicines Policy.

3.     Special allowance for pharmacists supplying remote health services under s100 to implement quality use of medicine measures
This allowance has provision for two visits a year by a pharmacist to an Aboriginal Health Service to which the pharmacy is supplying medicines. This is inadequate to meet the needs of the patients attending that centre to understand and comply with the expectations of the medicine. Trust and confidence as a member of the central team is simply not possible with such infrequent visits. Reports of the major mission being to check for out dated stock do not indicate a high level of QUM activity.

4.     National Prescribing Service program for “outreach pharmacists” to remote Aboriginal health services (OPRAH)
This program has the distinct advantage of bringing together pharmacists who are involved in the supply function to remote AHSs. This could provide a forum for a wide ranging discussion on improving quality and the avenues that work but unfortunately due to the policy of the NPS it is an educational session on a topic identified though “focus groups” in mainstream Australia and does not always bear relevance to a vital subject in remote Aboriginal health. If it was more directed to the target audience it could be more relevant.
Participants should be assisted to understand the social determinants for health and where the management of medication use fits in to the overall patient care and prevention of illness process.

5.     QuMAX program for co-payment relief and cost of DAAs to Indigenous patients attending eligible community controlled health services.
This program has failed to meet a wide audience of need due to its restriction to the community controlled sector. Funding for this program will cease on 30 June 2011. Even then the bureaucratic processes that have been established have not assisted a rapid uptake of co-payment relief or provision of more DAAs. An examination of the 13 page “Business Rules and Guidelines”[1] is testament to this. The money spent on preparing, implementing and evaluating these could have been well spent in providing a pharmacist to many ACCHOs to do what they wanted in the spirit of community control.
The positive side for NMP purposes is that it assists in paying the bill at the pharmacy providing the services and thus add to its likely sustainability.
The provision of DAAs through this program will cease on 30 June 2011 while this has been seen by pharmacists as a positive aid to adherence. A scheme such as exists for Department of Veterans Affairs beneficiaries is advocated to replace the QuMAX initiative.

6.     Close the Gap co-payment relief for Indigenous people attending eligible general practice centres and registered for chronic disease management support
While the QuMAX program assisted patients of community controlled health services, the Close the Gap program assists patients attending a GP centre or an ACCHO thus replacing the QuMAX scheme. Patients eligible to register must be considered at risk of developing a chronic disease.  The notion that cheaper PBS medicine will improve adherence is suspect as at some ACCHOs patients have had “free” medicine for years. This program is simply helping to “pay the bill” at the local pharmacy and not assisting the patient to obtain the quality needed to meet principle three of the National Medicines Policy shown above.

To summarise – for the remote living Indigenous Australians there is a second class PBS that provides no help in understanding medicines and their effect on the body but provides a good income to the supplying pharmacies. The cost of dispensing is not being met by the PBS as it does for every other Australian with the Commonwealth saying that this is a State/Territory government responsibility.

For urban living Indigenous Australians there are two systems both of which provide financial advantages to the dispensing pharmacy by ensuring the cost is met by the PBS as opposed to the health service or patient. Where this is advantaging the Aboriginal health service by saving it money on patient co-payments there is no requirement for these savings to be spent on “Quality use of Medicine” improvements.
The complicated bureaucratic process to obtain the benefits is believed by some to be “not worth the effort” while the Indigenous patient has no idea of what the programs are or how best they can access them. Even pharmacists are confused as to what applies to whom.

Recommendations

1.     PBS listing – disband the current Indigenous Expert Advisory Panel due to its listings being inconsequential to improving Indigenous health in a cost effective way. Replace it with a panel including people involved in delivering pharmaceutical care services and have a scope beyond just PBS listings and include quality use of medicine measures. The most relevant factor is making product available to Indigenous Australians at the best price through a functioning pharmacy in every Aboriginal Health Service under the supervision of a registered pharmacist.

2.     Section 100 Remote – make funds available to AHSs to meet the cost of dispensing on to patients after having received product from a supplying pharmacy. This can be done by initially meeting the cost of dispensing as it applies in mainstream ($6.42 at 1 January 2011). At present 25% of government outlays (estimate $40 million in 2010-11) goes to the supplying pharmacy and nil to the dispensing AHS.
No data is available to analyse drug utilisation as happens with the mainstream PBS. Although this has been called in a review of the program[2] – Medicare Australia is still unable to make publicly available detailed statistics.

3.     Special allowance under s100 – disband this allowance and put funds into 2) above. The current arrangement provides no value add to the individual patient which is where the focus should be. Pharmacists checking stock for out of date and smoothing administrative arrangements are a waste of professional time.

4.     NPS OPRAH program – this should be directed to pharmacists working “at the coalface” and be relevant to the needs of the patients. Past programs such as pain management, stroke prevention, COPD and diabetes are well covered by primary health care specialists in patient education. An evaluation from the AHS level would be of interest.

5.     and 6. QuMAX and Close the Gap - should be disbanded and incorporated into the PBS General Scheme with Aboriginal people entitled to whatever concessions Governments of the day believe provides equity and justice. This should NOT be based on where a person attends a doctor as it is now. If all persons identifying as Indigenous and at risk of chronic disease they should be issued with a Health Care Card. If there is a need for an income/asset test then leave that to Centrelink in issuing the card as for every other Australian. There must be a universal Indigenous Pharmaceutical Care program and not one based on the governance structure of a health service. Hospital pharmacies must be included in having access to these measures. At present patients are discharged from hospital with a varying array of quantities and charges. The training provided for Medicare officers and retail pharmacy operators has also failed to meet the need with respect to the detail and cross cultural sensitivities.

Conclusion
As a general principle all benefits should be made to fit a program developed with the Indigenous patient as the beneficiary.  The PBS contains various elements that can be utilised to suit the need. There is no reason why NGOs such as the Pharmacy Guild, NACCHO or Divisions of General Practice, should be involved in delivering a program that falls within the scope of PBS capability with the elements to obtain special benefits for special groups of patient needs.
The reality is that for some patients money would have to be paid to them for them to take their medicine. Making it available at little or no cost does in no way help them to understand why they should take it.
Rollo Manning