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

GET A JOB AND A LOT OF SOCIAL PROBLEMS WILL DISAPPEAR

This may be a simplistic few words but let’s think it through – how relevant is this in today’s remote communities?

One indication to the drastic social problems confronting young Indigenous Australians living in remote communities is the fact that there are two references before Parliamentary Committees in Canberra that have a direct bearing on two major social problems. They are:
1. Indigenous youth and the criminal justice system

2. Early intervention programs to prevent youth suicide

The population in jails in the Northern Territory for Aboriginal people is 82% of all inmates and over 50% of them are under the age of 30 years. There are around 900 Aboriginal people in gaol with 95% being males.

In the NT there has been a concerning increase in suicides in recent months. The NT news typifies the situation in the following Editorial on 29^th September 2010:

AT least seven Territory children have killed themselves in the past month.

That bald statistic masks unfathomable pain - the hopelessness that leads young people to give up on life, the never-ending anguish of the loved ones left behind.
As revealed in the NT News yesterday, the problem is not confined to remote Aboriginal communities, although the suicide rate among indigenous youth is far higher than among non-indigenous children.
Most young Territorians are drunk or stoned - or both - when they kill themselves, proving that alcohol and ganja (Marijuana) can turn someone who is depressed suicidal.

The unemployment rate where these young men come from is around 30%, although an exact figure is hard to know due to the various reporting processes and Centrelink definitions that include people on disability pensions as not being employable. A person may be classed as disabled for Centrelink because they are illiterate.

The social scene and degree of cohesion and strength of social capital is weak on all counts and the greatest thing missing for young people is hopes, dreams and ambitions for the future.

When life in a community is a struggle to exist from day to day due to the indicators of poverty there is no time to think about or plan for the future. The future around them is bleak, the facilities are non existent and there is no encouragement for developing personal micro economic enterprises that might create a job.

The manner in which these social problems have been dealt with in other Third World situations revolves around enterprise facilitation and that means self help and initiative.

Why can’t Aboriginal people be encouraged to do this?

There is one simple barrier–money – money from heaven for doing nothing. A tempting gift to resist.

In the meantime employment opportunities must be considered as a solution to social malaise.

A reason to get up in the morning.

A reason to be pleased to come home at the end of the day and eat a good meal satisfied that life is good.

And then a good nights sleep.

Should that be too hard? – well it is – so lets work through the barriers together with the Aboriginal people and stop blaming them, the Government or other external factors.

Get a job – give a job – make a job – it is good for your health and then you live longer.

IE CLOSE THE GAP!

Remote Aboriginals left out of inclusion agenda

“Hey – don’t forget us – we were here first!”
Remote living Aboriginals and the cycles of disadvantage which place them at the bottom of the socio economic ladder in Australia must get special treatment from a new Government in Canberra. The fact that Australia’s first people are still living in “Third World” conditions in one of the wealthiest countries of the World is a shameful situation and only special treatment will raise their standards to a point where they can be considered “included” in Australian society.

The “social inclusion agenda” of the Rudd Labor Government said that it was a means of “building a nation in which all Australians have the opportunity and support they need to participate fully in the nation’s economic and community life, develop their own potential and be treated with dignity and respect.”
These words are admirable except that there is a need for an Action Plan to ensure it is followed through in reality. The population cohort of 150,000 Aboriginal people living in remote communities across the north of the country and in the central and western desert regions – are at present living in a constant state of “exclusion”.

The National Social Inclusion Board has been asked to take immediate steps to arrest the slide that has been happening since the introduction of “self government” and welfare dependency in 1970s. These are:

1. A “Third World” classification is given by Government to remote communities that are home to Aboriginal people across the north of Australia and in the central and western desert. This is said to be essential for the rebuilding of social capital and economic prosperity to a standard required by the inhabitants to contribute to the Australian Society.
2. The Aboriginal people themselves must be involved in identifying their own social priorities of need and establishing measures to alleviate these with funding available to initiate micro economic enterprises that will provide the incentive to work and shake off welfare dependence.
3. The payment of money to individuals should cease on a universal basis when a clan or tribe group present a solid business plan for social and economic reform. Universal welfare payments have failed and worked against social inclusion. “Cashed out” Centrelink payments should be possible to put the same amount of money into targeted assistance packages and economic development.
4. The life expectancy of remote living Aboriginal Australians should be expressed separately in order to show the difference between urban and remote.
5. An acceptance of the fact that to educate young women between the age of 16 to 24 years will assist them and enable them to pass down to their children the need for an education and work ethic. Without this another generation will be lost to welfare dependency.

Remote living Aboriginals are a unique cohort whose life style and life outcomes are clearly delineated through statistical measurements. Nowhere near is enough use made of this information in planning change.  This is “Third World” country and has to be recognised as such. Some input from AusAid might be more useful for framing policy than bureaucrats used to dealing with mainstream populations living in communities with a wide range of services available in settings with already strong social capital. The remote living Aboriginal has none of these “luxuries”.
 

The cycles of disadvantage
The numerous cycles of disadvantage in remote Aboriginal communities are interrelated and synergistic in their effect on the individual. More research needs to be done to identify the priorities of need (as seen by the community) in attacking each one. Too often the cry goes out that it is “too hard” and nothing is done. The people themselves must be drawn into a conversation on the social priorities and needs for their communities. In this way moves towards building social capital can be commenced through social and economic development.
The main cycles are:

o        A denial of the human rights of the child such that abuse of those rights becomes the norm and is accepted by new generations. Housing, nutrition, education and leisure opportunities are lacking and this leads to a child frustrated from inactivity, opportunities to show creativity and exercise initiative. The overcrowded house is under estimated in the minds of government policy makers as a prime influence on this fact and each of those following. The overcrowded house brings with it immense unsafety, insecurity, a lack of food security, own space to reflect, household facilities that do not work because they were never built for so many persons living in the house. This absolutely hopeless situation is still evident with no real action to make an immediate response to this devastating influence on the ability to feel included in a social setting filled with joy and harmony. It is disgraceful that the policy makers allow a town of 2,200 people (Galiwin’ku) to have 152 houses while another in the white man’s world (Boorowa NSW) to have 857 for the same population. Galiwin’ku has five retail outlets against 15 in Boorowa – how much more serious can a lack of social inclusion get when people are denied choices, job opportunities but receive money for doing nothing and have little choices of what to spend it on.

o        Poor literacy and numeracy stems from an inability of children to understand why this is needed when all they see is adults sitting around doing nothing and no role models from their parents or carers who do not work. Creating work opportunities should be an essential part of the mix and is not receiving nearly enough attention at the local level. Unemployment is the norm and this becomes the key in removing welfare dependence. Much bolder mechanisms must be tried at the local level to encourage economic activities and employment opportunities such as “cashing out” Centrelink payments within a community or Clan group in a community. The writer is in the process of obtaining from Centrelink the stats on the quantum of money going into communities to ascertain how much would be available if people decided to “cash out”. The principle involved here relates to the social justice in paying money to individuals rather than to communities for economic and social development.

o        Substance abuse leads to violence and both are symptoms of a community without direction. The fact that substance abuse (alcohol and Marijuana or Gunja) is so widespread means that children are exposed to it at an early age and peer pressure may result in consuming drugs (marijuana) by age 10 years. This rules against any possible development of social dreams, hopes and ambitions. Future planning is absent and few children have any idea of what they want to do in a future life apart from nothing which carries with it distinct boredom and further substance abuse. The flow on is arguments, fighting, stealing for money to sustain the habit and prosecution. It is well recognised that recidivism for Aboriginal prison inmates is high following its acceptance as being “part of life”. The cyclical nature of family violence is strong, despite the resource of domestic violence orders which seem useless in alcohol and drug charged family disputes. Men and women seem to ignore the rights of the individual to lead a peaceful life free of torment, danger, uncertainty and stress. Mental health problems surge to the front of “health” problems and the resulting stress is a dampener on many a discussion regarding future hope. It is the survival of “today” that is the prime motivator not consideration of a peaceful future and how that can be attained. The definition of poverty given by Muhammad Yunus in an Interview with Andrew Denton describes the situation admirably:

“Poverty, is almost, you can describe is a living in a box, all with the thick wall, no window, no door, no light, so you don't know what's coming next, you have no idea of new day starting in different way, you repeat the same thing over and over again. No hope, basically. So you try to survive the day in very uncertain conditions. So that's poverty, you have no control over your life, that's total, that's it.” (ABC-TV 07/12/09)

o        Health, nutrition and physical activity – the cycle of poor nutrition and reduced physical activity leading to poor health has been gaining momentum since 1975. This has lead to a situation where all people born after 1975 have lived their entire life in a community with the health status on the decline. The child fed a breakfast of black tea with noodles thinks that is normal.  The two takeaway shops in town (two of the five retail outlets at Galiwin’ku) selling death through cigarettes, high fat content foods and sugar loaded soft drinks are making huge profits by selling sickness. The businesses of the two takeaways are owned by Darwin based syndicates and staffed by Asian workers on “457” Visas. And we allow this to happen to the most under privileged Australians who were here for 40,000 years before colonial British settlement. Social justice? Hardly. Social inclusion? No attempt. Only recently has there been evidence of organised sport for young people with the major emphasis having been on adult age football and basketball. The scope for athletics, swimming sports, junior football and basketball is immense and such activities could include the entire family.
The end result is the early death – and at a much earlier age than the National average depicts – let’s get real and respect the huge differences where the median age at death for men is 43 years and for women 53 years. That is a lot of adults taken out of a community at a young age and this then becomes the norm in people’s minds as if this is the way it has to be.

 It does not have to be this way and a concerted effort under the banner of social inclusion which has with it a “bottoms up” approach to a social revolution might help to reduce the intensity of these cycles.
Better health is not about building better health clinics and employing more clinical staff – it is about the relationship the dominant culture has with the people to enhance their understanding of the risks associated with lifestyle choices and the opportunities they create to reduce stress and lead a useful life. This was well expressed by Professor Fiona Stanley who said:

“..the real gains in reducing disease and improving health will come from the social and economic circumstances operating in families, communities and the wider society. That is that the most effective preventive strategies lie OUTSIDE the traditional areas of the health professions.” (National Press Club. August 2003.)

The entrapment of cycles of disadvantage
 People are born into these communities and have no option when their families have lived there for generations and their ancestors respected and owned the land for thousands of years. There is an affinity to the land which is unique. It is the heritage a child takes on from its predecessors.
It is very important that when there are people who want to break out of the cycle of disadvantage that they are helped 100% in a quest to do so. If someone puts up there hand and says “I want to lead a better life” there must be the facility to make that happen. To follow the lead of overseas efforts in Third World countries it will be the young women who are targeted for improvement. Educate a girl and you educate a future family. We must put sexist attitudes aside and decide to concentrate on young women between the ages of (say) 16-24 years old. If nothing is done to help these young women there will be no role models coming forward to show the younger ones that good is a better choice in life than bad. Is it any wonder there are no persons from remote communities attending university? – there is simply not enough done to make it happen. The fault is not with the person but with the system that seems intent on having these people continue a life of poverty.

Mutual obligation has to work both ways
An example can be given of a 21 year old woman from a remote community who came to Darwin to “make good” and was shuffled between Centrelink and Job Services Australia (JSA) agencies for three months. All she got was appointments or on three occasions cancelled appointments that did not suit the JSA agent. So much for mutual obligation! The Prime Minister during the recent election campaign claimed a get tough policy on the unemployed who did not turn up for appointments. The same should apply to JSA agents who fail to meet appointments and more importantly fail to provide a training program. Sure excuses will be made as to how hard this is but regrettably no excuses should be accepted. It is imperative we return the obligation for to leave a person in a city like Darwin with all the distractions for three months with no work, no training and no future is just asking them to continue the exclusion.

What do the authorities planning this transition from welfare to work expect people to do with their idle time? Or are they so used to people that do not want anything to happen (like find a job) that when a person wanting to do better comes along they cannot handle the positive nature of the inquiry. It appears that the entire system is geared to mediocrity and the Centrelink and job finding agencies are so used to people that don’t want to work that they have no strategy to help those few that want to make good. There could be no bigger turn off for anyone than to be left in front of a TV all day waiting for the next appointment when what they really want is to learn and find work that suits their ambitions.

The problem of “disengaged youth” is attracting a lot of attention from Government programs and in the work of Non Government Organisations (NGOs). And yet little is being done to prevent young people from becoming “disengaged” when they really want to be more engaged. There are youths (aged 16-24yo) who want to be included in the world—not excluded like so many of their peers that end up in prison or on diversion programs.

In Darwin there is an 800 bed prison, Berrimah Gaol, costing $80 million a year for people who have chosen to be bad. The young Aboriginal inmate – and that is 90% of the prison population – is probably in there for some anti social behavior fuelled by alcohol and Gunja – will receive tuition in literacy and numeracy and computer skills.

Upon release they will be remanded to a formal rehabilitation program in a beautiful garden setting hostel style accommodation with all meals and training provided for a further 12 weeks.

Oh for such a facility for those those who want to do “good” – and not just for those who choose to do “bad”.

Government programs exist—the Job Services Australia network; Language, Literacy and Numeric Program; Step-Up; WELL; Youth Connect; the  Indigenous Youth Mobility Program; Youth in Communities and the exalted Youth Attainment and Transitions program - BUT there is no co-ordination and each program is delivered by a contracted provider that once having gained the  contract has little competition leaving mediocrity to reign.
Glossy websites and publications mean nothing if the product is not being delivered. The so-called “mutual       obligation” means equal commitment from all parties and yet Governments seem to think their obligation is finished with the appointment of an agency to deliver programs. If the government funded agency fails to perform there seems to be no obligation but if the client does not arrive at an appointment the welfare payment can be stopped. This begs the question of why it is so hard to co-ordinate the efforts of these similar government funded programs with the same goals so that the clients get what they want. An element of “discretionary funding” must be made available for use at the local level to stimulate initiatives and help to fund the work needed to build plans to a point of applying for funding.                                                                                                                   

Breaking out of cycles of disadvantage
Control of ones own life is an important element in building social capital. The principles that were espoused in the Australian Assistance Plan of the Labor Government in 1972-75 were said to be ahead of their times but maybe the time is NOW for Aboriginal communities to receive an Aboriginal Assistance Plan along the same lines that could involve the people in determining their social needs and priorities. This would also make micro loans available to seed new ventures that would create training, employment, independence from welfare and a purpose for rising every morning and getting the children to school.
The time is now when it comes to building stronger social capital in remote Aboriginal communities and this is well reflected in the words of Nobel Laureate Chilean born Gabriel Mistral who said of the needs of children:

Many things we need can wait, the child cannot. Now is the time his bones are being formed, his blood is being made, his mind is being developed. To him we cannot say tomorrow, his name is today.

There must come a time when the policy makers shed the shroud of fear about matters such as “paternalism”, “stolen generations” and “separatism”. In decrying paternalism self determination was brought in and it has now been recognised that has been a failure. The basic ability and understanding is simply not there for these Aboriginal people to negotiate the machinations for moving ahead in the western world. There does need to be considerable mentoring, guidance and fostering of confidence which can still be done in a facilitative way without being labelled as paternalistic. To wait until the people are ready for change could be to wait another one or two generations – a prospect that no Australian would feel comfortable in accepting. If there is tutoring and mentoring to be done we must do it in a vigorous manner and not just pay lip service to it against a backdrop of centralist policies and program development.
With respect to the stolen generation - there is no doubt the forced removal of children from their parents in previous generations was despicable. However this was forced removal. To suggest that an Aboriginal child may be assisted by attending a boarding school in another state is not forced removal. The paranoia that surrounds suggestions of moving must be diminished by examples of well being fostered from such experiences. Research should be done to demonstrate the long term benefit in voluntary removal to allay these fears. Even the “dormitory” style living and mentoring and caring for children who are disengaged would be better than the nomadic existence so many young children have to undertake when abandoned by their natural mother or father.
Separatism was a sensitive issue in the world in the early 1970s with vivid memories of the tour of the Springbok Rugby Team in 1971 still vivid in the minds of those of us around at the time. The apartheid movement in South Africa has finished and should never be seen again. It was the forced separation of one race of people from another with harsh penalties for anyone who crossed the line. However in decrying apartheid it should be acknowledged that there will be situations where one race of people may decide that it does not want to live in the same way as another. At no time in the history of the Aboriginal survival efforts have they been given the opportunity to decide the way they want to live. The Aboriginal men from remote communities seem unable to embrace a mainstream culture and legal constraints while for the women there are those that simply see themselves as “community girls” with no intention of even trying to live the mainstream lifestyle. If we do accept that assimilation failed and that self determination has failed then we need another word that will describe a phase whereby Aboriginal people are given the resources to develop a world of their own that takes what they want from the western world and allows them to remain in their own country.

Personal choice should play a part
Choices are made on a basis of knowledge so that the costs and benefits of a situation can be weighed up critically to choose a path. In the situation under review the people involved do not have an education or awareness of a logical framework in thinking that allows to them to participate in an analysis of choices.  The educated mainstream person does not appreciate the manner in which their upbringing in a culture that has thousands of years of development through many “revolutions” that have embraced invention to move that culture ahead in a manner that is “mind boggling” to a person from a culture that subsisted in the desert for thousands of years without even knowing what a wheel could do. It was not until the arrival of ships from foreign countries such as Holland and Indonesia (Macassans) in the 16^th and 17^th century that these people learned what metal was. The power of logical thinking that comes with an ability to manage a situation, prioritise things, file away messages and thoughts in the brain to a later date are all practices that come naturally to the educated dominant culture person in Australia. This value was highlighted during a recent visit to Australia of the Somalia born women’s activist Ayaan Hirsi Ali who said:

“We can learn from you and your centuries of critical thinking. You Westerners come to Africa with your money but you can keep your money - we want to share with you your values. The most important value – the value of critical thinking – questioning authority – no matter who it is – question why things are the way they are and why they cannot be done better.” (Interview with Monica Attard – Slow TV – August 2010)

To expect Aboriginal people to think through their options for survival in a world that none of them has grown up in is a tall order and the resolution needs a lot more talk and research to find the best path ahead. In 2005 the present Co-ordinator General for Remote Service Delivery in the NT, Mr. Bob Beadman wrote a paper in which he lamented the fact that something had taken away the ability for Indigenous people to have dreams for their future. He wrote:

“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.” (Do Indigenous youth have a dream Menzies Research Centre, Canberra, 2004).

Work is needed to ascertain how many young people would like to see a better life and this needs to be carefully structured. The target population is not English speaking, does not understand concepts of space and time and is not confident in working with the dominant culture. The young people must be encouraged to question why the situation is the way it is and not to simply accept as normal or necessary for it to stay the same.

Somehow the minds of the young have to be engaged in wanting to see an improved life ahead for their children – the next generation and social inclusion could be the agenda through which to make this happen.

Ends

30^th August 2010

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

ADDRESS BY ROLLO MANNING to the
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
rollom@iinet.net.au
30th April 2010