s Advancing to garbage at the speed of light | I2P: Information to Pharmacists - Archive
Publication Date 01/09/2009         Volume. 1 No. 4   
Information to Pharmacists

Editorial

From the desk of the editor

Welcome to the September 2009 issue of i2P E-Magazine - Information to Pharmacists.
In this edition I would point you to the Pharmedia link where trends in US pharmacy consumers are noted and matched to the Australian counterpart.
There is a strong similarity between the two countries.
In this commentary a direction and a strategy is suggested.
Please feel free to add your comment in the panel provided at the foot of this commentary, as it is a very important issue for Australian pharmacists.

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Another Step Back?

Neil Johnston

Anyone who has followed the story of convenience clinics in the US would have come to a simple conclusion very early in their investigations.

That conclusion would have been that with a few exceptions, the market being serviced in primary care was identical to that serviced by Australian pharmacists.

What was commonly known as “counter prescribing” in Australia became known as the “Minute Clinic” or Rediclinic in the US.

Now we have a development here in Australia where nurse-led clinics are being hosted by pharmacies, with the initial players being the Revive Clinic and the Pharmacy Alliance Group, consisting of 186 franchisees, all based in Perth, Western Australia.

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Pharmacies to write prescriptions? Yet another conflict?

Neil Retallick

The divide between who writes prescriptions in Australia and who dispenses them has traditionally been seen as an important construct in minimising any conflict of interest.
Will the evolution of nurse practitioners working in pharmacies mean that this protection mechanism for the average Australian (and their taxes) is dissolved?

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Location rules, regulation rules and money rules

Chris Wright

The National Competition Policy Review of Pharmacy has surely failed to protect the industry from itself.
The objectives of the restrictions include; “ Keeping pharmacy business small enough to facilitate the close personal supervision of their professional operation by the proprietor pharmacists.”
Oh, yeah, just how does that work?
And… “Protecting pharmacy businesses from perceived “unfair competition” and market dominance from large pharmacy-owning corporations and chains and, in some jurisdictions, Friendly Societies”.

Come on, let’s be serious!

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Advancing to garbage at the speed of light

Pat Gallagher

I am going to preach to you dear reader.
So what is new with that you will say?
Plenty, because I truly do believe in this creed, which is the belief that without rigorous control of core data integrity the whole e-health plot is flawed.
This boring subject has been raised in these pages several times and there is no doubt the message has sort of got through, but ‘sort of’ is way, way too far from being acceptable. You see this mishmash problem in the pharmacy daily as you use different PDE numbers for the same product when you buy from more than one wholesaler.
You cope with different proprietary product identification and then use the GS1 barcode, on the product pack, to close the sale at the POS (you do, you do use that barcode don’t you!).
All of this means you have to use the wetware technology tool to interpret and map information from one system to another; and the minute you introduce wetware you introduce errors.

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Pharmacy women’s Congress 2009 - Opportunities for learning

Karalyn Huxhagen

All of us have that neat stack of literature either beside our bed, under the desk or overflowing off the kitchen bench. If you are like me some are half read, bookmarked for later more in depth reads or stripped of relevant articles for pharmacy assistant training modules.
I also have a system with my emails and RSS feeds that categorises them to the ‘to be read when I have time file’. On a morning not so long back when I could lay in bed and clear this email in tray I completed a competition on the Pharmacy Daily website for the Pharmacy women’s Congress 2009. To my ultimate surprise I won!!

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The finish line of the Pharmacy Melbourne Cup is in sight…who will be the winners?

Garry Boyd

Comment about the future of pharmacy has been a daily occurrence for seemingly as long as Cook plotted a course up the eastern seaboard.
He hit the rocks, as will many of the so-called “players” attempting to seek proprietorship over parts of the pharmacy puzzle will.
Whether it be fact or Chinese whispers, a number of “core”(sorry Kev) “assets” have the attention of many.

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Paracetamol Problems in New Zealand

Staff Writer

Paracetamol overdosing is emerging as a problem in New Zealand similar to other western economies around the world.
In Australia we have seen some of larger chain pharmacies encouraging the sale of high volumes of paracetamol by deep discount, 
Despite protests from a range of pharmacists, little has been done to prevent the spread of irresponsible paracetamol sales.
Pharmacy Boards state they need an official complaint backed up with evidence of adverse events resulting from inappropriate selling.
Liver damage is one adverse event, sometimes requiring a liver transplant to rectify the damage.
There is no easy solution for paracetamol is such a useful drug.
However, there is a strong argument for confining all paracetamol sales to pharmacies irrespective of the potential inconvenience.
In fact, if the general principle applied that all medicines should be sold from a pharmacy, the need to sell other types of merchandise would dissipate.
It's worth a thought 

People overdosing on paracetamol

Source Otago Times
http://www.odt.co.nz/news/national/71209/people-overdosing-paracetamol 

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Health IT Needs More Money - What's New About That?

Staff Writer

The consistent mismatch of approaches to Health IT continue to occur, even with the best efforts of Minister for Health and Ageing (Nicola Roxon) trying to uncover the best way forward.
Costs, both in the government and private sectors, have continually expanded to now stellar $ numbers.
Nicola Roxon's focus on the patient and building out from that point, will see her win the day.
Vendors (such as the Pharmacy Guild) who are canny enough to mould their systems to her view of the world, may eventually get a "nod" of some sort, provided the systems developed genuinely provide a scale of economy, saving development costs as well as delivering the specified benefits to health generally.
Commitment has been made to a National Broadband Network (NBN) and a 16-digit patient identifier so movement to shared health records is nearly possible, with the AMA making some "noises" towards a form of electronic health record (but not a full record).

Source: Australian IT

http://www.australianit.news.com.au/story/0,24897,25975393-5013040,00.html

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UK Opposed to Direct to Consumer Advertising

Staff Writer

Proposals that would allow the pharmaceutical industry to provide drug information directly to consumers has been opposed by the Royal Pharmaceutical Society.
This against a EU background to develop an informational infrastructure that could be delivered to all of the European community.
A conflict of interest clearly exists between the public's interest to receive accurate and objective information and the pharmaceutical industry's objective of building revenue and market share. 

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NZ Considers Project Stop

Staff Writer

The New Zealand Pharmacy Guild has commented on the efficiency of Project Stop in Australia and wants to introduce it to NZ pharmacists.
They would also like to extend its use for other medication tracking.
NZ interest may further stimulate a faster uptake of the system in Australia, and by comparing notes in developing the use of the software, governments may be encouraged to fund a range of extensions.

Pharmacies Fight to Stop P-Runners
Source: Stuff.co.nz
http://www.stuff.co.nz/auckland/northland/local-news/2784402/Pharmacies-fight-to-stop-P-runners

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Health Insurers to feel the cold winds of change

Staff Writer

At last there is a move to sort out the high costs and inefficiencies inherent in Australia's private health insurance system.
Not that the private funds are totally to blame.
Government policies built around the Medicare levy (an extra tax, unless you take out private insurance), the limited range of benefits payable by private funds (because of government controls) has led to a high level of dissatisfaction by people privately insured.
It appears that an entity titled Medicare Select, may be utilised to negotiate and "bulk buy" health services, including those of the state-owned hospitals.
Private health funds, including Medibank Private, would be involved in managing the services on behalf of their members.
This new system has a real potential to reduce major health costs.

Medibank backs system shake-up

Mark Metherell
Source: BrisbaneTimes.com.au
http://www.brisbanetimes.com.au/national/medibank-backs-system-shakeup-20090827-f01u.html

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QUMAX –where to from here?

Karalyn Huxhagen

In April 2010 the current program for QUMAX (Quality use of medicine in aboriginal community controlled centres) will come to an end.
This was a pilot program and work is being done to look at where to from here?
Like all pilots the program took some time to achieve its goals but achieve them it did.
The evaluation process has been ongoing and the feedback from pharmacists and patients has been excellent.

Comments: 1

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UK Media Shutdown on Complementary and Alternate Medicine Information

Staff Writer

Will the issues revolving around complementary and alternate medicine (CAM) use ever be resolved?
Outcries from some respected science authorities deride all CAM as "witchcraft", yet most pharmacists would know of at least one good outcome from CAM.
For example, recent research into Traditional Chinese Medicine has uncovered the fact that some herbal remedies for the treatment of heart conditions, help to restore the nitrous oxide (NO) balance in the body, in part by converting nitrites and nitrates absorbed from foods, to beneficial NO (allowing proper dilation of blood vessels, subsequent reduction in blood pressure and gradual depletion of arterial plaque).
This information is now evidence-based, but will you see it appearing in mainstream medical publications?
It is my belief that while many critics of CAM definitely have a valid case for some complaint (particularly when patients are financially exploited), there are many "experts" that have been blind to information that could prove useful (and cheaper) for their patients, simply because they were unaware of the evidence available.
It is simply hidden from view under the sheer volume of total information that is being published and disseminated to health profesionals.
In February 2008 the respected BBC came under fire for providing information on CAM's and withdrew this popular service. I was unaware of this happening and have provided one of the media stories reporting the incident, for others who may have been unaware.
The BBC is a public broadcaster (like Australia's ABC) and serves the interests of the general population free from commercial pressure.
As 41% of people in the UK use CAM the decision to close down the service was certainly a controversial one.
A recent visit to the BBC site demonstrated some CAM news stories, mostly geared towards the potential problems that may be associated with its use.
This is a shame because the BBC are well placed to research evidence surrounding CAM's and provide a much needed and unbiased site for solid information.

Source: NaturalNews.com

http://www.naturalnews.com/022734_BBC_medicine_complementary_medicine.html

The BBC Abandons Its Complementary Medicine Website Due to Pressure

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Software Licences Trigger Software Investment Review

Staff Writer

Many firms that licence key software programs are tightening up licencing conditions such as who is entitled to received free licences and what scale of charges apply.
Clients are reluctant to pay fee increases for basically the same software each year, but charitable and aged care organisations will be hit hard for licences that formerly were available to them free of charge.
Obviously there will be some hard negotiating coupled with a review of the actual software required.
One alternative may be to replace Microsoft with the Sun Open Office suite of programs that virtually duplicates the entire range of programs contained in Microsoft Office and comes entirely free of any cost. Open Office can also convert to any of the Microsoft formats.
Pharmacists may like to consider the change as well.

Source: Aged Care Guide

http://www.agedcareguide.com.au/news.asp?newsid=3869

Aged Care IT Investment Put on Hold

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Supporting the Carers

Staff Writer

With the Baby Boomer retirement revolution due to start in 2010, one of the key needs will be an army of carers to provide home support needs.
Traditionally, this has fallen to family members, usually female.
And with a considerable number of carers being elderly themselves, there will be a human resource shortfall in this area.
One obvious solution is to elevate this activity to that of a career and the necessity to put training processes in place coupled with appropriate remuneration.
Government has made some moves in this regard, but not nearly enough nor in a timely fashion.
There is an opportunity for pharmacy to provide a support service in the form of "Pharmacy in the Home" services.
Creating the outreach is the difficult part, but pharmacies that do not try and participate will lose market share to those who do provide the service.

Carer at home issues raised by NHHRC reform proposals

Source: Aged Care Guide
http://www.agedcareguide.com.au/news.asp?newsid=3866

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The Importance of Vitamin D3 in Aged Care

Staff Writer

A walk in the sun to generate a reasonable level of vitamin D3 is said to delay the need for a knee replacement.
But this vitamin is also implicated in heart health, cancer prevention, osteoporosis, arthritis and immune modulation, as in multiple sclerosis.
In fact, it is said that vitamin D3 is involved with over 1100 individual genes in an average person.

Even if you get sun exposure, if you utilise sunscreen preparations the conversion reaction in the skin is virtually negated, or if you have a shower 15 minutes after exposure, the vitamin washes away before being absorbed through the skin.
Old skin is also inefficient as a medium for generating and absorbing the vitamin.
While sun exposure is the cheapest and most optimal way of getting a daily dose of vitamin D3, a back up through oral supplementation is also recommended. 

Knee replacements delayed by sun

Source: Aged Care Guide

http://www.agedcareguide.com.au/news.asp?newsid=3854

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Pharmacy in the Home Opportunity emerging

Neil Johnston

The following story published by Drug Topics mirrors a trend that has already commenced in Australia.
A more conservative customer/patient is emerging, in part driven by government attempts to convert branded drugs on the PBS to a cheaper generic version.
Harsher economic conditions have also played a major part.
As we all know, not all customer/patients are convinced of the value involved in changing from long established brands, no matter what arguments are offered.
That means two distinct classes of health consumers are forming up within Australian pharmacies.
Note also that the value-conscious health consumer illustrated in the article is less impulse driven and creates a shopping list before leaving home.
And in the background, high levels of government stimulus spending means that the ability for government to fund existing and future services is at risk, and resources will have to be rationed even more than they are currently.
But this trend opens up a range of opportunities for pharmacists to develop a range of services targeted for customers/patients within their homes.
Mark Coleman discusses a "Pharmacy in the Home" concept further along this article.

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Advancing to garbage at the speed of light

Pat Gallagher

articles by this author...

Patrick Gallagher is well known in Information Technology circles. He has a vital interest in e-health, particularly in the area of shared records and e-prescriptions, also supply chain issues. He maintains a very clear vision of what ought to be, but he and many others in the IT field, are frustrated by government agencies full of experts who have never actually worked in a professional health setting. So we see ongoing wastage, astronomical spends and "top down" systems that are never going to work. Patrick needs to be listened to.

I am going to preach to you dear reader.
So what is new with that you will say?
Plenty, because I truly do believe in this creed, which is the belief that without rigorous control of core data integrity the whole e-health plot is flawed.
This boring subject has been raised in these pages several times and there is no doubt the message has sort of got through, but ‘sort of’ is way, way too far from being acceptable. You see this mishmash problem in the pharmacy daily as you use different PDE numbers for the same product when you buy from more than one wholesaler.
You cope with different proprietary product identification and then use the GS1 barcode, on the product pack, to close the sale at the POS (you do, you do use that barcode don’t you!).
All of this means you have to use the wetware technology tool to interpret and map information from one system to another; and the minute you introduce wetware you introduce errors.

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As I have said here before, using more than one single, unique product identifier defeats the upside of the technology’s ability to automatically reticulate common, error free transactions. All the hardware, middleware, software and broadbandware come to grief holistically when wetware gets involved.

You do understand this?

No - well, wetware is a euphemism for people – you, your staff, catalogue managers, anyone who is going to enter or use multiple systems (interoperability) and multiple identifications to manually exchange information about the same things. Wetware basically dilutes the value of the technology mix enormously.

The two technologies that combine to deliver a level of garbage data are wetware and paper – put them together and errors are assured.

The elementary discipline of a data alignment and integrity practice 101 is to ensure one accurate identification number for any one data item is the rule that rules the world of automatic data exchange.

Yet, there is always a yet, and that normally comes before the but, in Australia we still do not have a single source of product data electronically feeding and linking the working catalogues and data files. Files that today are being used by prescribers, dispensers, suppliers and hospitals to exchange common product data electronically. All based on the belief that it will all be without risk.

This is not referring to a financial risk; this is referring to a clinical risk. As in unintentionally substituting 50mg for 0.5 mg, because that is what the ‘computer’ said ‘to do’. The descriptor that best fits this linking of clinical and product data is: “every clinical decision is a procurement decision”

Is there truly a risk that we can introduce harm faster and more ‘efficiently’?

Surely not?

Sorry, the answer is - yes we can and yes we will

Driving to work this week I caught a garbled snatch on the radio along the lines of: “electronic prescriptions threaten safety due to an increase in errors” (sic).

C’mon! How crazy is that?
The act of replacing handwritten scripts with clearly printed forms must be a huge improvement.

And, of course that is certainly, to a degree, the case.

When a script is printed it is easier to read, as the ink on *paper is clearly readable. The question is all about how reliable is the information and how much work is required to routinely interpret that description, on the paper form, and ‘get it right’ for the patient.

(* Paper! Of course the whole e-health framework is based on saying bye-bye to paper in all its inefficient, time consuming, error inducing and costly, pun intended, printed forms. Easy to say, very hard to do and a subject too big to digress with here today)

Imagine this scenario if (and when) the process is totally electronic.

That is, all data is exchanged by machine-to-machine transactions whereby, over time, the inclination is to rely more on the middleware than the wetware and then discover that mistakes occurred due to the source of the data being less that 100% accurate.

The prescriber used a faulty file and the dispenser’s file didn’t mismatch and the process was concluded, in error.

It can, will and does happen.

This was all researched exhaustively in 2001/2002 by a committee of over thirty stakeholders and the report urging total compliance for the Australian e-health industry of a single data repository, was tabled to the then Health Minister.

Yet, here we are in mid-2009 and (and no buts) it still has not been put in place.
It is useful to have a snapshot of what this model is designed to look like without soaring to nosebleed country of complex mind maps and PowerPoint jargon.

 1. First we should have the small core repository or database with only static identification data in it:

• Only the manufacturer or supplier (as is the TGA requirement) can add, delete or alter any product data centrally;

• Because they own the identification (GS1/GTIN barcode) data and as such must take responsibility for its accuracy - ‘relying’ on second hand or third parties to do this work will introduce errors;

• Even worse, introducing proprietary numbers, not used by the manufacturer or supplier, as a high order ‘number plate’ to link to product information, is sacrilegious;

• Like we do for the TGA, and to limit the workload and maintain enthusiasm and cooperation, the data fields for this central repository should be the minimum required to ensure total, risk free, accuracy of the information, to be electronically shared between users;

• In Europe and the USA, in respecting this barrier of potential and real non-cooperation, the rule is that a supplier can start to become compliant by entering a mere seven (7) fields – the maximum being forty (40) fields of commonly required information;

• The obvious benefit to a manufacturer/supplier is that they are only doing this information task once for thousands to share, and not a thousand times for one user to be reached; and

• This asset would be administered and operated, in terms of QA and service delivery , by an accredited agency who would triple check the data before releasing it to ‘working’ catalogues

2. What is a working catalogue?
It is the business level where different disciplines and professions use the core data seamlessly and then add the dynamic fields of data they require (and by definition) are not required by other users.
One such group is the clinical users:

• Prescribing software vendors and their clients;

• Dispensing software vendors and their clients;

• Hospital clinical software vendors and their clients;

• Clinical service software vendors and their clients; and

• Clinical date exchange hubs and gateways

Whereby these accredited users then add their ten (10), twenty (20), thirty (30), or whatever, fields of data that only they use and need for their catalogue

3 And then we have the supply chain community as a second group of catalogue users:

• Pharmacy, hospital and other health sector procurement and other buying entities;

• Wholesalers - that by association will feed into your computer inventory files that, ergo, will be identical to your dispensing files that came from the clinical group;

• Please think carefully about the future consequences of having or not having your POS and Dispensing system aligned; and

• Transport, logistics and other support service providers

These wholesale enablers and other users would add their ten (10), twenty (20), thirty (30) odd fields of supply and packaging data; such as: a) packs in a carton; b) cartons an a pallet, c) weight and dimension; d) pricing and all that good stuff for the guys in supply that no clinician ever wants to see, needs to see or should see.

4. And then there would be and are ‘other’ types of combined users, like accounts, record keepers, researchers and academics - which we will call group 3.
And they too can happily add their unique data field requirements that the supply tribe do not need nor do the group 1 clinical people as a general rule.

Summary: this model will suit all users, who are disparate in their own requirements, but share a common need for the same core, static data. In doing so they will never make a mistake with the core data and thereby never endanger any patient due to human induced of otherwise undetected, errors

If a price is wrong, or a weight is wrong, or a delivery instruction is wrong, then the cost is financial or inconvenient; but the error will not kill or harm anyone

Secondly, the other big point is they should only receive, store and use the minimum data set required to do their job. Only store and pay for transacting ‘X megabytes’ of data and not the unnecessary total set of ‘Y megabytes of data.
So compellingly, so sensible, logical and usable that even an Einstein could understand and accept it.

To the background tune of ‘Advance Australia Fair” let us review what has happened, more or less, in the lucky country since 2002.

We have the NPC (National Product Catalogue) and the NBN (National Broadband Network). Yippee?

Nope – neither is in place.

The latter is not that critical because most of us have reasonable access to reasonable broadband; so the people most likely to benefit from the rainmaking, of such a huge investment, is the ICT sector. While they might be panting in lustful anticipation, I for one am a sceptic.

I do not believe the NBN financial numbers will pan out so that investors will get a return on their money; of course if the comrades decide that we the taxpayer noddys will pay, then we will see the NBN roll on to a MFP (Multi Function Polis) result.
If you don’t compute the MFP thing, just think of a black, failed, wet dream.

I think we can forget about advancing society of ‘girt by broadband’ being in place anytime soon. For example, last weekend the press reported that the Tasmanian effort seems likely to deliver a whimpish 22% take up at $20,000 per household. Gee, isn’t that just grand. I think I will put my dough into pork belly futures.

What about the NPC?

Deep, mournful sigh and silent gnashing of teeth.

I said above - ‘sort of’. The powers to be, or not to be, or not yet seen to be, as whatever is the case, took the concept mentioned above and decided to improve it (I am being unusually polite).

How can they improve it? Well make it uncomplicated. Dissolve the four tier model, briefly outlined above, and just have one gigantic, one-size-fits-all edifice to out-do any comparable effort anywhere in the entire world. Advance Australia – where?

Breathtaking isn’t it?
I can’t help but say we’ll be ‘girt by data’ and loving it all, I’m sure (not).

In advancing Australia’s e-health capability this means that the manufacturers/suppliers will be asked (I do agree with the ’M’ word by the way) to mandatorily enter not seven (7), not forty (40), not one hundred (100) but one hundred and fifty plus (150+) fields of data. Can you imagine the thousands of SME suppliers going - whoopee, where do I start?

Sure, the cynics out there will say that there are only 500 real important suppliers and they have the staff to manage the work load. Perhaps, and then perhaps not.

That isn’t the point.
This is healthcare.
Near enough is not good enough.
All the metaphors about ‘for the want of nail’ or the ‘weakest link’ are more than true in this context. Any gap, any error, any omission will potentially do harm, faster than we now do harm.

And then we have you the pharmacist – you the data user.
You as a buyer of products and you as a dispenser of product.
Girt by data indeed.
You will be swimming in data – 150+ bloody fields of useful and useless data.
Makes you wonder whether this brilliance came out of a gaggle of undergraduate MBAs trying to impress the Professor after happy hour.

What is certain is that the authors of this concept have not worked in all of the various and separate communities they are attempting to service with this one big bang bubble.

And, to date that is what it is – a bubble. A handful of suppliers, a few thousand products and no clinical users.
What clinical users?

Well, there are now three if not more e-script hubs up and running.
Where and how is the common data being aligned, synchronized and otherwise safely presented to a prescriber and dispenser - huh?

We can now send a script from point A to point B at warp speed. The question is - is sending data at the speed of light the benefit we are looking for, or is it merely the carrier component? Rhetorical question and you are welcome to answer it.

What if, one-in-one thousand, or one-in-a-million even, has wrong data?
Who are you going to blame?
Girt is a silly word, garbage is a nasty word, but they seem made for each other.

The lucky country is advancing fairly amateurishly to a collective oh, oh moment of - ‘how did we girt into this nasty mess’

Seeya

PS

Can’t help myself - again. In the movie ‘Kenny’ there is a wonderful gag about ‘Advance Australia Fair’. He confesses that at school he always thought the line was;

"Let us meet Joyce"

rather than

"Let us rejoice"

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