s PBS to Indigenous needs a makeover | I2P: Information to Pharmacists - Archive
Publication Date 01/07/2014         Volume. 6 No. 6   
Information to Pharmacists

Editorial

From the desk of the editor

Welcome to the July 2014 homepage edition of i2P (Information to Pharmacists) E-Magazine.
At the commencement of 2014 i2P focused on the need for the entire profession of pharmacy and its associated industry supports to undergo a renewal and regeneration.
We are now half-way through this year and it is quite apparent that pharmacy leaders do not yet have a cohesive and clear sense of direction.
Maybe the new initiative by Woolworths to deliver clinical service through young pharmacists and nurses may sharpen their focus.
If not, community pharmacy can look forward to losing a substantial and profitable market share of the clinical services market.
Who would you blame when that happens?
But I have to admit there is some effort, even though the results are but meagre.
In this edition of i2P we focus on the need for research about community pharmacy, the lack of activity from practicing pharmacists and when some research is delivered, a disconnect appears in its interpretation and implementation.

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News Flash

Newsflash Updates for July 2014

Newsflash Updates

Regular weekly updates that supplement the regular monthly homepage edition of i2P. 
Access and click on the title links that are illustrated

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Feature Contribution

Woolworths Pharmacy - Getting One Stage Closer

Neil Johnston

It started with “tablet” computers deployed on shelves inside the retailer Coles, specifically to provide information to consumers relating to pain management and the sale of strong analgesics.
This development was reported in i2P under the title Coles Pharmacy Expansion and the Arid PGA Landscape”
In that article we reported that qualified information was a missing link that had come out of Coles market research as the reason to why it had not succeeded in dominating the pain market.
Of course, Woolworths was working on the same problem at the same time and had come up with a better solution - real people with good information.

Comments: 5

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Intensive Exposition without crossing over with a supermarket

Fiona Sartoretto Verna AIAPP

Editor's Note: The understanding of a pharmacy's presentation through the research that goes into the design of fixtures and fittings that highlight displays, is a never-ending component of pharmacy marketing.
Over the past decade, Australian pharmacy shop presentations have fallen behind in standards of excellence.
It does not take rocket science - you just have to open your eyes.
Recently, our two major supermarkets, Woolworths and Coles, have entered into the field of drug and condition information provision - right into the heartland of Australian Pharmacy.

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The sure way to drive business away

Gerald Quigley

I attended the Pregnancy, Baby and Children’s Expo in Brisbane recently.
What an eye and ear opening event that was!
Young Mums, mature Mums, partners of all ages, grandparents and friends……...many asking about health issues and seeking reassurances that they were doing the right thing.

Comments: 1

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‘Marketing Based Medicine’ – how bad is it?

Baz Bardoe

It should be the scandal of the century.
It potentially affects the health of almost everyone.
Healthcare providers and consumers alike should be up in arms. But apart from coverage in a few credible news sources the problem of ‘Marketing Based Medicine,’ as psychiatrist Dr Peter Parry terms it, hasn’t as yet generated the kind of universal outrage one might expect.

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Community Pharmacy Research - Are You Involved?

Mark Coleman

Government funding is always scarce and restricted.
If you are ever going to be a recipient of government funds you will need to fortify any application with evidence.
From a government perspective, this minimises risk.
I must admit that while I see evidence of research projects being managed by the PGA, I rarely see community pharmacists individually and actively engaged in the type of research that would further their own aims and objectives (and survival).

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Organisational Amnesia and the Lack of a Curator Inhibits Cultural Progress

Neil Johnston

Most of us leave a tremendous impact on pharmacies we work for (as proprietors, managers, contractors or employees)—in ways we’re not even aware of.
But organisational memories are often all too short, and without a central way to record that impact and capture the knowledge and individual contributions, they become lost to time.
It is ironic that technology has provided us with phenomenal tools for communication and connection, but much of it has also sped up our work lives and made knowledge and memory at work much more ephemeral.

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Academics on the payroll: the advertising you don't see

Staff Writer

This article was first published in The Conversation and was written by Wendy Lipworth, University of Sydney and Ian Kerridge, University of Sydney
In the endless drive to get people’s attention, advertising is going ‘native’, creeping in to places formerly reserved for editorial content. In this Native Advertising series we find out what it looks like, if readers can tell the difference, and more importantly, whether they care.
i2P has republished the article as it supports our own independent and ongoing investigations on how drug companies are involved in marketing-based medicine rather than evidence-based medicine.

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I’ve been thinking about admitting wrong.

Mark Neuenschwander

Editor's Note: This is an early article by Mark Neuenschwander we have republished after the soul-searching surrounding a recent Australian dispensing error involving methotrexate.
Hmm. There’s more than one way you could take that, huh? Like Someday when I get around to it (I’m not sure) I may admit that I was wrong about something. Actually, I’ve been thinking about the concept of admitting wrong. So don’t get your hopes up. No juicy confessions this month except that I wish it were easier for me to admit when I have been wrong or made a mistake.
Brian Goldman, an ER physician from Toronto, is host of the award-winning White Coat, Black Art on CBC Radio and slated to deliver the keynote at The unSUMMIT for Bedside Barcoding in Anaheim this May. His TED lecture, entitled, “Doctors make mistakes. Can we talk about it?” had already been viewed by 386,072 others before I watched it last week.

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Dispensing errors – a ripple effect of damage

Kay Dunkley - BPharm, Grad Dip Hosp Pharm, Grad Dip Health Admin, MPS, MSHPA

Most readers will be aware of recent publicity relating to dispensing errors and in particular to deaths caused by methotrexate being incorrectly packed in dose administration aids.
The Pharmacy Board of Australia (PBA), in its Communique of 13 June 2014, described a methotrexate packing error leading to the death of a patient and noted “extra vigilance is required to be exercised by pharmacists with these drugs”.
This same case was reported by A Current Affair (ACA) in its program on Friday 20 June
http://aca.ninemsn.com.au/article/8863098/prescription-drug-warning

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Take a vacation from your vocation

Harvey Mackay

Have you ever had one of those days when all you could think was, “Gosh, do I need a vacation.”
Of course you have – because all work and no play aren’t good for anyone.
A vacation doesn’t have to be two weeks on a tropical island, or even a long weekend at the beach. 
A vacation just means taking a break from your everyday activities. 
A change of pace. 
It doesn’t matter where.
Everyone needs a vacation to rejuvenate mentally and physically. 
But did you also know that you can help boost our economy by taking some days off? 
Call it your personal stimulus package.

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Explainer: what is peer review?

Staff Writer

This article was first published in the Conversation. It caught our eye because "peer review" it is one of the standards for evidence-based medicines that has also been corrupted by global pharma.
The article is republished by i2P as part of its ongoing investigation into scientific fraud and was writtenby Andre Spicer, City University London and Thomas Roulet, University of Oxford
We’ve all heard the phrase “peer review” as giving credence to research and scholarly papers, but what does it actually mean?
How does it work?
Peer review is one of the gold standards of science. It’s a process where scientists (“peers”) evaluate the quality of other scientists' work. By doing this, they aim to ensure the work is rigorous, coherent, uses past research and adds to what we already knew.
Most scientific journals, conferences and grant applications have some sort of peer review system. In most cases it is “double blind” peer review. This means evaluators do not know the author(s), and the author(s) do not know the identity of the evaluators.
The intention behind this system is to ensure evaluation is not biased.
The more prestigious the journal, conference, or grant, the more demanding will be the review process, and the more likely the rejection. This prestige is why these papers tend to be more read and more cited.

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Dentists from the dark side?

Loretta Marron OAM BSc

While dining out with an elderly friend, I noticed that he kept his false tooth plate in his shirt pocket. He had recently had seven amalgam-filled teeth removed, because he believed that their toxins were making him sick; but his new plate was uncomfortable. He had been treated by an 'holistic dentist'. Claiming to offer a "safe and healthier alternative" to conventional dentistry, are they committed to our overall health and wellbeing or are they promoting unjustified fear, unnecessarily extracting teeth and wasting our money?

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Planning for Profit in 2015 – Your key to Business Success

Chris Foster

We are now entering a new financial year and it’s a great time to reflect on last year and highlight those things that went well and those that may have impacted negatively in the pursuit of your goals.
It's also a great to spend some time re-evaluating your personal and business short, medium and long term goals in the light of events over the last year.
The achievement of your goals will in many cases be dependent on setting and aspiring to specific financial targets. It's important that recognise that many of your personal goals will require you to generate sufficient business profits to fund those aspirations

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ReWalk™ Personal Exoskeleton System Cleared by FDA for Home Use

Staff Writer

Exoskeleton leader ReWalk Robotics announced today that the U.S. Food and Drug Administration has cleared the company’s ReWalk Personal System for use at home and in the community.
ReWalk is a wearable robotic exoskeleton that provides powered hip and knee motion to enable individuals with Spinal Cord Injury (SCI) to stand upright and walk.
ReWalk, the only exoskeleton with FDA clearance via clinical studies and extensive performance testing for personal use, is now available throughout the United States.

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Attracting and Retaining Great People

Barry Urquhart

Welcome to the new financial year in Australia.
For many in business the past year has been described as a challenging period.
Adjectives are a key feature of the English language.  In the business lexicon their use can be, and often is evocative and stimulate creative images.  But they can also contribute to inexact, emotional perceptions.
Throughout the financial pages of newspapers and business magazines adjectives abound.
References to “hot” money draw attention and comment.  The recent wave of funds from Chinese investors, keen to remove their wealth from the jurisdiction and control of government regulations is creating a potential property bubble in Australia.

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Updating Your Values - Extending Your Culture

Neil Johnston

Pharmacy culture is dormant.
Being comprised of values, unless each value is continually addressed, updated or deleted, entire organisations can stagnate (or entire professions such as the pharmacy profession).
Good values offer a strong sense of security, knowing that if you operate within the boundaries of your values, you will succeed in your endeavours.

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Evidence-based medicine is broken. Why we need data and technology to fix it

Staff Writer

The following article is reprinted from The Conversation and forms up part of our library collection on evidence-based medicines.
At i2P we also believe that the current model of evidence is so fractured it will never be able to be repaired.
All that can happen is that health professionals should independently test and verify through their own investigations what evidence exists to prescribe a medicine of any potency.
Health professionals that have patients (such as pharmacists) are ideally placed to observe and record the efficacy for medicines.
All else should confine their criticisms to their evidence of the actual evidence published.
If there are holes in it then share that evidence with the rest of the world.
Otherwise, do not be in such a hurry to criticise professions that have good experience and judgement to make a good choice on behalf of their patients, simply because good evidence has not caught up with reality.

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Laropiprant is the Bad One; Niacin is/was/will always be the Good One

Staff Writer

Orthomolecular Medicine News Service, July 25, 2014
Laropiprant is the Bad One; Niacin is/was/will always be the Good One
by W. Todd Penberthy, PhD

(OMNS July 25, 2014) Niacin has been used for over 60 years in tens of thousands of patients with tremendously favorable therapeutic benefit (Carlson 2005).
In the first-person NY Times best seller, "8 Weeks to a Cure for Cholesterol," the author describes his journey from being a walking heart attack time bomb to a becoming a healthy individual.
He hails high-dose niacin as the one treatment that did more to correct his poor lipid profile than any other (Kowalski 2001).

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Culture Drive & Pharmacy Renewal

Neil Johnston

Deep within all of us we have a core set of values and beliefs that create the standards of behaviour that we align with when we set a particular direction in life.
Directions may change many times over a lifetime, but with life experiences and maturity values may increase in number or gain greater depth.
All of this is embraced under one word – “culture”.
When a business is born it will only develop if it has a sound culture, and the values that comprise that culture are initially inherent in the business founder.
A sound business culture equates to a successful business and that success is often expressed in the term “goodwill” which can be eventually translated to a dollar value.

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ReWalk™ Personal Exoskeleton System Cleared by FDA for Home Use

Staff Writer

Exoskeleton leader ReWalk Robotics announced today that the U.S. Food and Drug Administration has cleared the company’s ReWalk Personal System for use at home and in the community.
ReWalk is a wearable robotic exoskeleton that provides powered hip and knee motion to enable individuals with Spinal Cord Injury (SCI) to stand upright and walk.
ReWalk, the only exoskeleton with FDA clearance via clinical studies and extensive performance testing for personal use, is now available throughout the United States.

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Pharmacy 2014 - Pharmacy Management Conference

Neil Johnston

The brave new world of health and wellness is not the enemy of Pharmacy, it is its champion.
Australian futurist, Morris Miselowski, one of the world's leading business visionaries, will present the Opening Keynote address on Pharmacy's Future in the new Health and Wellness Landscape at 2.00pm on Wednesday July 30.
Morris believes the key to better health care could already be in your pocket, with doctors soon set to prescribe iPhone apps, instead of pills.
Technology will revolutionise the health industry - a paradigm shift from healthcare to personal wellness.
Health and wellness applications on smartphones are already big news, and are dramatically changing the way we manage our personal health and everyday wellness.

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Generation and Application of Community Pharmacy Research

Neil Johnston

Editor’s Note: We have had a number of articles in this issue relating to pharmacy research.
The PGA has conducted a number of research initiatives over the years, including one recently reported in Pharmacy News that resulted from an analysis of the QCPP Patient Questionnaire.
Pharmacy Guild president, George Tambassis, appears to have authored the article following, and there also appears to be a disconnect between the survey report and its target audience illustrated by one of the respondent comments published.
I have asked Mark Coleman to follow through, elaborate and comment:

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PBS to Indigenous needs a makeover

Rollo Manning

articles by this author...

Rollo Manning has experienced pharmacy practice from all sectors of the industry – retail, administrative, policy and remote Aboriginal practice. He spent 10 years with Glaxo Australia and was the first Director of Public Relations at the Pharmacy Guild National Secretariat in Canberra.
He has also held the position of Pharmacy Policy Officer for Territory Health Services in Darwin.
Rollo is currently a Consultant working in his own practice with remote Aboriginal communities, in Northern Australia.

The current situation for Aboriginal and Torres Strait Islander people accessing the Pharmaceutical Benefits Scheme presents a complicated mix of mainstream programs and tailored measures to suit particular needs.
The result is mini bureaucracies established in key stakeholder organisations to deliver programs that do little to help the Indigenous person understand what their medicines are for and why they should take them.
The following summarises the current situation and offers suggestions for improvement.

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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:

* Special PBS listing of medicines specifically for Indigenous Australians
* Section 100 arrangements for supply to remote living Indigenous Australians
* Special allowance for pharmacists supplying remote health services under s100 to implement quality use of medicine measures
* National Prescribing Service program for “outreach pharmacists” to remote Aboriginal health services (OPRAH)
* QuMAX program for cost of DAAs to Indigenous patients attending eligible community controlled health services.
* 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.

 

 Questions or comments to the author at rollom@iinet.net.au

PO Box 98 Parap NT 0804 or 0411 049 872

 

 


[1] Pharmacy Guild of Australia at http://www.guild.org.au/uploadedfiles/National/Public/Programs/QUMAX%20Business%20Rules%20and%20Guidelines.pdf  (accessed 18 January 2011)

[2] Kellaher M, Taylor-Thompson D, Harrison N, O’Donoghue L, Dunt D, Barnes T et al. Evaluation of PBS medicine supply arrangements for remote area Aboriginal health services under S100 of the National Health Act. Melbourne, VIC: Co-operative Research Centre for Aboriginal Health and Program Evaluation Unit, 2004.

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