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

The inequity of the PBS to remote Aboriginal people

When every Australian can get a Pharmaceutical Benefit prescription dispensed and have access to the advice of a pharmacist it is taken for granted. Yes every one of the 22 million people in this country has access to a pharmacist in one of the 5,000 Approved Pharmacies around the Nation every time they have a script filled. In fact the PBS pays for that pharmacist to be there through the dispensing fee of $6.42 paid on each and every prescription dispensed..
But what of the 150,000 Aboriginal and Torres Strait Islander people who live in remote places in Western Australia, Rural Queensland, the top and west of South Australia and the Northern Territory scattered across the 70 odd communities there?

Ask any of them what a pharmacist is does or hangs out and they wouldn’t have a clue. They will never have seen one. They may remember the glossy looking shop in town when they had to go there for a medical purpose but chances are they wouldn’t have noticed because they were so intent on knowing whether they were going to get back home alive.

Pharmacists do not exist in the remote Aboriginal health workforce, with a very few exceptions. The Government provides through the Section 100 Support Allowance a possible six monthly visit by a pharmacist with the grand sum of $4 million spent on this annually across 166 health services serviced by 34 community pharmacies.

We have to get real and understand that these people not only deserve an equal deal to mainstream but probably require the help 10 times more because of their poor state of health.

The PBS has to find some money to support the appointment of pharmacists located strategically around remote Australia where they can at least direct and train others towards a quality improvement process. Go to any of the 166 health services and you will find a pharmacy supply system that simply does not match current day practice standards. This is an indictment on the profession and requires urgent attention before someone goes to the UN claiming institutionalised racism.

And okay – there cannot be pharmacists everywhere of course we know that – but then it is a matter of training persons to take the pharmaceutical care message out to people in their own language and using the basis of knowledge the person is coming from in their own cultural way. This is done in Africa (Zambia) through what is called Adherence Support Workers and a similar trial in Australia is hoped to be struck in Katherine (NT) this year to test the concept. If we cannot have pharmacists everywhere we can at least try to have their agents as ASWs trained in the need for compliance and the actions and interactions of popular medicines for the chronic diseases that are killing these people at a rate unknown in the developed world.

It is all a matter of equity – and at the moment that does not exist.

Unfortunately as in many areas of endeavour towards alleviating Indigenous disadvantage we tend to rest on our laurels with the 10% of good effort and put aside the 90% that are not benefiting.
 As Noël Pearson put it recently:
“I’m sorry I can’t take my focus off the glass 90 per cent empty, rather than being thankful for the glass 10 per cent full. Because I know what that 90 per cent translates into when those beautiful children who miss out on the social justice ticket become adults. Jail. Ill health. Early death.” (The Weekend Australian 28th November 2009).

The Federal intervention into remote Aboriginal communities - Learning from children

A child’s education depends on the motivation of a parent to assist
them in going to school, help with reading and teaching basic discipline
and values in the culture in which they live.
By the same token a child can influence an adult to live a healthy and happy life with joy shared by each party as the years go by.

In the world of remote living Aboriginal people the children are left in many instances to fend for themselves as the parents pursue a lifestyle that their culture has only just discovered. The parents are still experimenting to see if it stacks up better than the traditional life of looking for food and shelter for the present and not worrying too much about the future. The pleasure of being able to have food readily available at a store or takeaway and the ready availability of alcoholic beverages make it a tempting lifestyle to pursue.
It could be said that there is no greater gift for a child than a healthy parent who lives long enough to see their grandchildren able to carry on the culture of the clan. As some say in the NT – “I want to live long enough to
watch my grandson play football”.

In mainstream Australia the life expectancy at birth is one that Third World countries will envy while the Aboriginal person is not sure what this is all about. They never knew when a birth date was to know the meaning of life expectancy. In fact the life expectancy of the remote living Aboriginal is as low as 47 years in many communities. The average that is quoted far and wide is across the entire population that claims to be Aboriginal with the majority of these people living in urban areas. The statistic is correct. It is just that the definition of Aboriginal person casts the net over a far greater cross section of the community than those Aboriginals that are being subjected to the Federal Intervention into Aboriginal Communities in the Northern Territory. In fact only 7% of the Aboriginal population in Australia lives in remote communities in the Northern Territory.

It is necessary, when taking a holistic view of the world of the remote living Aboriginal, to acknowledge that that the children hold a very special place in the demographic. It should be obvious that with such a low age at death the average age of a population will be lowered and children under the age of say 15 years will comprise a much larger proportion of the total than where the age at death is around 77 years.
Aboriginal populations are made up largely of children and therefore attention should be focused on them if the future is to improve.
The influence children can have over their parents in this scenario should not be underestimated. Just like any other culture the child is special as shown through the title of the report - “Little children are sacred”.

It is fair to suggest that if a child learns about healthy lifestyle choices there is every chance this will be passed on to the parent and other family members.

It should also assist the young child understand what choices in education, food, exercise, sleep, happiness and good companionship can have on good health.

Unfortunately the parents of the young children in communities in 2008 have lived their entire life in a community with health status on the decline.

To the parent it is normal for a friend to die at 40 years of age; for a grandparent to have to go on renal dialysis; for a younger brother or sister to have to go to Adelaide for a heart operation; and, for a lot of people to have to go to an alcohol and drug rehabilitation program to withdraw from an addiction.
To the parent born in the last 40 years this is normal and never having experienced good health – bad health becomes normal.
The Federal Intervention is about stabilizing communities (Phase One) and then “normalizing” those (Phase Two) – but what is normal?

The Balanda (white person) view of a normal community is not necessarily the way the Aboriginal person living in 75 locations across the Northern Territory and which are subject to the Federal Intervention wants to live.

The change planning process must come from a close evaluation of the needs as seen by the Aboriginal people themselves – and not just because some Balanda thinks it should happen or try and become a “normal” community like the suburbs of a city. This should go without saying but is being said because it is one principle that the government policy planners have failed to do over the past 40 years.

2008 is the opportunity for the Australian Government to acknowledge that this is the year to start planning with the Aboriginal people a community that meets their values and culture and thus has a distinct “look” of its own. The time has come to stop trying to put these people into little boxes in the same way as Balanda like to live. The often claimed fact that houses are overcrowded implies that the Aboriginal people are at fault because they have too many people in the one house. The real fact is that this is how they want to live as a family unit and the roof was simply not big enough in the first place.

There needs to be model programs established that test a whole host of concepts and beliefs that bring together the wisdom of the Balanda and the vision of the Aboriginal older person who can see the way the decline is affecting their culture.

To take pharmacy as an example and the role pharmacists can play in both public health and primary health care it is possible to build a curriculum that if conveyed to children could have a significant impact on the health of the adult population. It could impact on those suffering from chronic diseases and the ongoing burden of illness due to the environment in which the people are living.

In taking the example of pharmaceutical care it should be possible for children to learn some of the following principles that are inherent in achieving adherence through pharmaceutical management:

1. Understand the condition and what put it there in the first place before starting to look at management through pharmaceutical care. This involves explaining to children through interactive media the common chronic disease states in the community.

2. The use of medicines in managing chronic diseases and the fact that medicines are for sick people and if well people take drugs they might get sick.
This poster (left) was drawn by Linda Joshua from Numbulwar during a pharmacy training session for Aboriginal Health Workers at Bachelor Institute. Input to programs by Aboriginal people is essential to success.

• 3. The importance of adherence – sticking to the doctors recommendations for dosing and when to take them. This would also cover the use of Dose Administration Aids and that Websterpaks (or similar) are the lifeline to a healthy life and should not be tampered with by anyone but the person for whom they have been prescribed.
• 
  4. The dangers of chemical substances when not used correctly or stored properly.”If its poison you can’t kiss it better” should be the slogan (or similar) to bring the message of safety home to young children.
• 
  5. Substance abuse and the problems inherent in drug and alcohol abuse by learning about the effect that these substances, along with cigarettes, have on the health of the individual.

6. Misuse of medicines and the way over use of some medicines can cause serious problems. Emphasis can be given to the need to follow the directions on a pack or label. Paracetamol is the most used drug in communities and overuse of it combined with other liver damaging choices can create an insidious illness of hepatic failure that could easily be put down to simply “not feeling well”.
7. Public health programs through education on subjects such as smoking, nutrition, breast feeding, immunization, sexually transmitted diseases and healthy skin are all ones which a pharmacist can contribute to because of their understanding of the treatment processes.

It is to be hoped that in Stage Two of the Federal Intervention there will be the opportunity for pharmacists to be involved. The record of the health authorities at both State/Territory level and nationally is not great in giving pharmacy a status of much more than a supply agent. The value pharmacists can add to primary and public health education can be finally tested on an exercise such as the NT Intervention into Aboriginal communities.

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It’s a new world with new diseases – don’t expect me to understand

A novel way is needed of remembering to take medicines - seriously
It is less than 50 years since many remote living Aboriginal people were living in a traditional way; obtaining their food largely from hunting and supplementing this with the basics of western diet such as flour for making dampers. In 2008 the Australian health authorities are faced with an epidemic of chronic diseases brought on by too rapid a change to fast food, TV advertising of junk food and alcoholic beverages. During this period tobacco was first portrayed as an appropriate and smart thing to do. Then advertising was banned and the message has turned around.
Australian Aboriginal people have been abruptly confronted with a totally different world to the one in which they were raised. Their children, born in the last 30 years, are growing up in an environment where most of their elders suffer ill-health, with an epidemic of diseases such as diabetes, cardio-vascular diseases, renal failure, asthma and heart failure.
These are not diseases understood by the traditional belief systems of the Aboriginal people or their traditional healers. There are no traditional remedies for clearing hardened arteries, or reducing blood cholesterol. By the same token, the concept of lengthening the life span of a person already feeling bad may conflict with beliefs that welcome the chance to pass away and have their spirit return as a better being.
The task of introducing western concepts of ongoing medication a group of people who do not understand why they are feeling sick is made more difficult by virtue of the fact that the people have English as a second language. The younger generations have better English skills but do not have the disease and medication knowledge, the doctors do not have the skills in local languages. The present generations of Aboriginal Health Workers have not been trained to address medication adherence.
The successful use of medicines to manage chronic disease will only occur when the person understands their illness, their body and how it is affected by life style choices that oppose healthy living. So little has been achieved over the past 30 years that people who are growing up in 2008 will only experience a community that is in a constant state of ill health which then becomes perceived as normal. Children will expect to get overweight and diabetic.
Australian Aboriginals with chronic disease will be confronted with the medical jargon of the doctor or the need for exercise by the diabetic educator; and, if there is the opportunity in the mix of allied health professionals, the pharmacist or pharmacy assistant on the notion of taking medicines as directed, regularly, at the time specified and with or without food.
The mix is already confused with language meaning that understanding is poor and adherence minimised to a dangerous level that leads to avoidable complications and hospitalisation.
The consequent temptation to spend the available money on quick fixes is too great for the uneducated person. That means the purchase of fast food for an unbalanced diet and the hazards of alcoholic beverages and other drugs (especially marijuana) to take the stress out of an otherwise boredom riddled day.
Strategies to address medication use in Aboriginal people, especially those from remote areas, must be founded upon their view of the world.
Ends