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22 May 2010

Is the PBS playing its part in “Closing the Gap” in Indigenous Health?

7th Annual Future of the Pharmaceutical Benefits Scheme Forum, Sydney, organised by Informa Australia, 22-23 April 2010

The Pharmaceutical Benefits Scheme and Aboriginal Australians

The future sustainability of the PBS centres on whether it is achieving the objectives that were set out for it when it was introduced in 1949 – to provide a range of medicines to Australians that are essential to achieve better health. We must not lose sight in all the discussions that in the end there is a patient and so long as that consumer of the PBS is getting healthier as a result of it is achieving its objective. At times there is too much emphasis on the process rather than the patient.

The PBS is a small part of a big effort to try and maintain good health so we should not get carried away with the importance of the PBS in an overall sense.

This presentation will look at
• The background to Aboriginal health and the overall picture of the problems that exist and how these have arisen.
• The infrastructure that supplies the PBS to Australians with the retail pharmacy sector still being dominant in that supply chain.
• Evaluate the PBS against the four pillars of the National Medicines Policy to comment on its effectiveness in Closing the Gap – that difference in life expectancy between an Aboriginal person and mainstream Australians.

Working in this field of endeavour is a constant learning process. In my first venture into Aboriginal health I was amazed at how badly pharmacy was practiced in the remote communities in the Katherine region through the 23 remote community health centres being supplied medications from the Katherine Hospital. There was little quality in the way medicines were being used - few records were kept of outgoing supplies, no labelling was being done and the consumer had very little idea of what their medicines were all about. There was little emphasis on dispensing and indeed no payment was received for the cost of dispensing and even now – 13 years further on – there is a discrepancy of $3.73 between what the PBS pays for dispensing PBS medicines to people from retail pharmacies and what is paid to pharmacies to supply PBS to remote Aboriginal health centres. $6.42 is the price paid to dispense a PBS item from a retail pharmacy and only $2.69 when that same item is supplied to a remote living Aboriginal person. The result of this that the Aboriginal health service – be it either government owned and operated or an Aboriginal community controlled health organisation (ACCHO) has to pay for the cost of dispensing.
In a question to the Senate Estimates Committee in June last year Senator Rachel Siewert asked why the difference and was told by the DoHA officers that the “function is not as intensive”. One has to ask why is it not so “intensive”. Are you saying the Aboriginal people do not need the same rigour in the supply of medicines as other Australians?” Of course they do and it is a cop out to say otherwise.
The Wurli pharmacy upgrade project in Katherine is asking for the $3.73 per item supplied to go towards the cost of employing a pharmacist for 12 months – that based on 12 month usage of PBS will amount to $70,000.

Let’s look at the situation in a remote Aboriginal community - Galiwin’ku in north east Arnhem Land. It has a population of 2000 people – they live in 152 houses - 90% of children under one year old have been diagnosed with scabies; dosette boxes are still used as they say they cannot afford Websterpaks; 10,000 cigarettes are smoked a day; there are five retail outlets. One store, three takeaway outlets, and the place where they buy petrol. What is it about us that we think these 2,000 people only need one store as a retail outlet?
A comparison between Galiwin’ku and Boorowa (NSW) shows a stark contrast. Boorowa has 15 retail outlets and the people live in 850 houses. Straight away it shows up the over crowded housing and lack of employment opportunities. This is the sort of community that I feel for with their level of health far below the average Australian.
The median age of death for these people is 43 years for males and 53 years for females. This is showing that the Australian average of a life expectancy gap of 17 years is not a true picture when remote living Aboriginals are included. It means young children left without a parent (or both) and their upbringing left to the grandparents who are still around with their education from the mission days. These young children are destined for a life of alcohol and drug taking simply because they have nothing better to do and through a lack of quality education. We cannot blame children who at age 10 wonder why they need an education when they see so many adults sitting around doing nothing. Jobs are a must to stimulate the need for an education. Sadly we have young adults leaving school with a Year 12 Certificate but they cannot read and write. This is sad for them and a bad reflection on our ability to help them raise their living standards.

The above shows examples of the social determinants of health that are so prevalent in Aboriginal communities - poor education and lack of employment opportunities. Along with these come overcrowded housing, high crime rate, substance abuse and poor personal and domestic hygiene. These factors have to be recognised by anyone working in primary health care as they have such a huge impact on the quality of life and therefore health. To live in a constant state of poverty is a classic precursor to poor health.
As shown by Professor Fran Baum at a Chronic Disease Network conference in Darwin last September it is no use helping people to get better and then make them go back to live in the unhealthy environment that caused them to be sick in the first place – and yet that is what we are doing. There is an urgent need for a total approach to the living environment to improve health across all sectors that have a responsibility to improve housing, environmental health, employment opportunities and education.

So this is the profile of the people I concern myself with – the remote living Aboriginals across the north of Australia – and there are some 150,000 of them living in remote communities. For many of these people the developed world has only been with them for the past 50 years and that is a very short time for them to get used to our way of living.

I used to think that we should find the latest advances and rocket these people into the next generation of pharmacogenetics and the like but really we are not even doing the simple things well. I will show later what I mean in outlining the Tiwi Islands Pharmacy that was owned and operated by the Tiwi Health Board itself with an Approval Number to supply and claim the cost of PBS supplied to the Health Centre.

What is the PBS?
The PBS is a huge sum amount of money (ca $10 billion) that funds a large amount of things one of which, and the most important one, is the supply of medicine to the public. In the process of doing this it helps to fund research, manufacturing, marketing, distribution, dispensing and the provision of information to the client. It is thus money that we have to be sure is being used in an efficient manner to enable the patient at the end of the line to receive the right drug with enough information for them to understand why they need the medicine to get better.

The landscape for supplying the PBS to the Australian public is dominated by the retail sector which in turn means the Pharmacy Guild of Australia. One aspect that is often overlooked by parties criticising the Guild for its actions is that the Pharmacy Guild is the only organisation named in the National Health Act to negotiate with Government over the fees to be paid to pharmacists for their role in supplying PBS medicines to the Australian public. The criticism emanates from those, such as the PSA, saying that the Guild has overstepped the powers given to it by negotiating professional services that go beyond the scope of fees.
The five yearly Community Pharmacy Agreements sets the scene for the next five years on how pharmacy practice is going to be conducted.
The carve up of the PBS money “pie” shows that the manufacturer gets the largest share, the wholesalers a small amount and the pharmacy 26% of the total to cover the mark up on cost of goods and fees. Now there is no problem with the mark up as that is a legitimate amount to cover the cost of the inventory in a business. It is the fees component where the worry starts in terms of getting value for money. The Consumers Health Forum weighed in two weeks ago with a Discussion Paper calling for input to inform the 5th Community Pharmacy Agreement. Justifiably so in their criticisms is the lack of audit processes to see if pharmacists are delivering the services they are getting paid to provide through the dispensing fee of $6.42. If we compare the rigid audit process the wholesalers have to undertake to justify the spend of $150 million through the Community Service Obligation with its reams of paper work with the degree of audit the retail pharmacists do for their $1.2 billion the difference is stark.

When we have a look at the programs that should have been delivered by retail pharmacists following the $570 million in the 4th Agreement we see from the budget papers for 2009/10 that only half the pharmacies were participating. The rest are simply taking the dispensing fee of $6.42 and doing nothing more than a supply function. The statement by the PSA in the pharmacy press some two weeks ago that the Pharmacy Guild had overstepped its responsibility to negotiate fees is wholly justified. The Guild, to give it credit, is doing the job it has to do to maintain the viability of the 5,000 pharmacies and this it does very well. It is just that we do not need 5,000 pharmacies to do the job at hand resulting in an inefficient use of public money with it being spread across too many outlets.
At the PBS Future Forum last year I made the statement that if half the pharmacies in PhARIA One closed tomorrow nobody would really miss them – the consumers would simply go to one nearby. We do not need four pharmacies in the CBD of Darwin to dispense all the PBS prescriptions and the same happens in most urban areas. It means there is a lot of money being distributed to too many pharmacies resulting in the PBS dollar being unevenly distributed and the consumer is missing out by not being provided with the service expected. The PBS dollar is being inefficiently distributed.

I do not have a problem with the $1.2 billion paid out in fees, it is just that when spread across to entire population of retail pharmacies there is too much to too many that provide nothing but a supply function.

Where does this having an impact on Aboriginal Health Services?
As a result of the above inefficient supply system for PBS and the insistence on the 5,000 retail pharmacies remaining the custodians of the PBS Aboriginal Health Services are forced to fit into an inefficient mainstream model that simply does not work for their client base. The time must come when Aboriginal Health Services have their own in house pharmacy operation so they have complete control over the pharmaceutical care process in the same way as they do over every other aspect of primary health care. It is only when this happens that the wealth in the PBS can be shared and put to work in the best interests of the client (consumer). Dispensing is happening now in Aboriginal Health Service but in a way that does not meet the standards that are expected in mainstream pharmacy. Examples exist where dispensing is done from a tiny room stacked full of samples from drug reps and any other source that can be found to be able to dispense to patients who are unlikely to take their prescription to an Approved Pharmacy.

Let’s look at the PBS for Aboriginal people against the principles of the National Medicines Policy. We can see that access is okay in that the facility is there to provide medicines. It is just that the client base is not comfortable in a glitzy mainstream store in a prime retailing location. The quality is there for storage however efficacy is compromised by a lack of information on the medicines supplied. As for quality use of medicine it is simply not there and largely because of the lack of access to a pharmacist to steer the process. In terms of a collaborative effort on the part of stakeholders there is a lot that could be done by manufacturers to ensure the client who receives a prescription for their product has the information needed to want to take the medicine.
The Aboriginal population is spread across the continent with only a small number in the remote regions – around 150,000. This is not a lot for a politician to take an interest in and the ability of this consumer to lobby is negligible. It behoves us all, if we have a social conscience, to make an extra effort for these people who really have had a very hard time over the past 220 years. The manner in which additional product has been made available on the PBS through the special listings for ATSI people is also an inefficient use of public money and the perfect example of how many of the problems would be overcome with an in house pharmacy business. As an example Clotrimazole Cream – Item No 1017M – can be bought by the pharmacy from the manufacturer for $1.43. The same item when listed on the PBS costs the Government $11.26 or can be bought from an Internet pharmacy for $4 - $1.50 less that the Concessional co-payment. Given its own pharmacy the AHS could be making a much more efficient use of Government money with a pharmacist on site to provide information as happens in every other Approved Pharmacy across Australia.

A solution has to be found to pay for the cost of dispensing at remote Aboriginal Health Services – the iniquitous situation that exists where there is a $3.73 shortfall between what the PBS is paying to supply a PBS item to mainstream Australia ($6.42) compared to the $2.69 for the same item to a remote Aboriginal person.

Balance cost with information for maximum adherence

The concentration on cost also has to be balanced against the need for information. There is currently a program to commence on 1 July, 2010 whereby Aboriginal people on Health Care Cards will get their benefits for no cost – and general beneficiaries will get their PBS medicines at Concessional rates. This will not solve the problem. For some people you might have to pay them to take something which they know nothing about. So reducing the co-payment will not necessarily result in patient compliance. Research conducted at the University of Newcastle has shown that there needs to be a lot more work on the impact of co-payments before any further changes are made. To me information is more important than cost – and that needs to be rectified first.

Statistics needed
Statistics are another area in Aboriginal health that needs attention. Under the Section 100 arrangements there are only 166 AHSs being supplied through 34 pharmacies but we are still not able to find out what is going where to make any regional comparisons or correlate this with health outcome information. In the NT we do not even know the value of the PBS spend even though Medicare Australia makes payments to every pharmacy supplying and dissects this by individual items.

It does not have to be this way

Pharmacy practice to Aboriginal people does not have to be this way as it is possible to do the simple things well as was shown with the pharmacy at Nguiu on Bathurst Island, which was owned by the community controlled health board. Information systems allowed us to know what was going out, who prescribed it and with a label on every supply. However their has to be the infrastructure in place and this needs a certain will on behalf of the leaders to want to see it happen. On the Tiwi Islands compliance was improved significantly in less that two years and it is hoped that this will be able to replicate a model being developed at the Wurli Wurlinjang Health Service in Katherine that will bring into play technological advancements. You don’t know what you don’t know and the people involved in Aboriginal health have not experienced a pharmacy of the quality that exists in other parts of the country. We must all contribute to improve this situation as it is all possible.

Thank you
Rollo Manning
30th April 2010

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