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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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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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From this page you can share Pharmacy Funding Governance Lacking to a social bookmarking site or email a link to the page.
Social Web

Pharmacy Funding Governance Lacking

Staff Writer

articles by this author...

Editing and Researching news and stories about global and local Pharmacy Issues

Editor's Note: "Pharmacy Funding Governance Lacking" is the title of an article written by Carol Bennet, the CEO of the Consumer Health Forum.
It was first published in Public Administration Today, edition 34, April-June 2013.
The voice of consumers is not heard very loudly in pharmacy media, but i2P thought that this article was important for pharmacists to be aware of.
Consumer representatives are not always engaged in health decisions- but they should be.
If pharmacists wish to expand into health services, or improve their health offering, who better to talk with at all development stages than the Consumer Health Forum.
After all, they do represent the patients that we wish to develop a dialogue with.

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Carol Bennett said:

The Australasian Council of Auditors General suggests four basic elements of good governance:  accountability, participation, predictability and transparency.

The Consumers Health Forum of Australia (CHF) argues that these are lacking in the Fifth Community Pharmacy Agreement, a major health program that involves Government expenditure of $15.4 billion over five years.

Few Australians would doubt the worth of our taxpayer-funded pharmacy scheme. In any publicly funded program, taxpayers have a right to expect the principles of good governance to be applied. Do they realise pharmacies receive such enormous government funding through a scheme lacking governance standards taken for granted elsewhere?

Since 1990, the Commonwealth Government and the Pharmacy Guild of Australia have entered into Community Pharmacy Agreements. These set out the level of remuneration that pharmacists will receive for dispensing medicines covered by the Pharmaceutical Benefits Scheme (PBS) and the arrangements regulating the location of pharmacists approved to supply these medicines. More recent Agreements have increased in scope to also include provision for professional pharmacy programs and services.

These programs and services are a major feature of the Fifth Community Pharmacy Agreement, which commenced on 1 July 2010. They include medication management programs, research and development, rural programs and Aboriginal and Torres Strait Islander programs. There is also funding to support Pharmacy Practice Incentives, including incentives to provide identified services to consumers. 

Community pharmacy plays an essential role in the Australian healthcare system, and health consumers rely on pharmacy services. This is why it’s so important that consumers can have confidence in how pharmacy services are funded – and why we need to see accountability, participation, predictability and transparency as key elements of future funding arrangements for pharmacy. Each is discussed in more detail below.

Accountability

Accountability for the delivery of programs under the Agreement could be addressed through a rigorous evaluation program, with the results made public. An Evaluation Framework is publicly available, which is a good step towards delivering this accountability, but review of it raises questions about whether the evaluation will provide evidence of whether the Agreement is delivering safe and high quality healthcare and improved health outcomes to consumers. CHF and a number of other organisations have raised significant concerns about the Evaluation Framework, based on the information currently available:

 
There appears to be a lack of engagement planned with key stakeholders in the evaluation of certain elements of the Agreement, particularly in the evaluation of governance arrangements. For example, the list of stakeholders identified for consultation in the evaluation of one of the key governance structures, the Agreement Consultative Committee (ACC), is limited to the Minister for Health and the Government, Department of Health and Ageing executive, the ACC itself and the Guild National Council. All of these are directly involved or have direct links to the ACC. If it is to be meaningful, evaluation must take the views of other stakeholders into account.

,
Timeframes for the evaluation of different components of the Agreement are often unclear. For some areas of the evaluation, there are clear statements around when activities will take place. For others, there is no information regarding when data will be collected, or only vague information that data collection will be ‘ongoing’ with no indication of when collection will commence or end. Others refer to processes that should have been completed prior to the publication of the Evaluation Framework in December 2011 – for example

‘Public consultation process March/April 2011’; ‘Identification of data needs

2011’ – but there is no indication of whether these processes have actually been completed.

Also, the Evaluation Framework was not released until a year and a half after the Fifth Community Pharmacy Agreement was signed, well after the implementation of some programs had commenced.

* The scope of many of the evaluation questions outlined in the Framework is too narrow to deliver meaningful outcomes. Vague questions such as ‘To what extent have Fifth Agreement investments delivered the results expected of them?’ are unclear in scope, particularly when the ‘results expected’ are not listed.

* Health and quality use of medicines outcomes are not included as a key indicators for evaluation of patient services. Given the significant investment in Community Pharmacy Agreements, there should be a measurable improvement in these areas, and this needs to be addressed in the evaluation.

* There is a lack of consideration of how the Agreement is facilitating communitypharmacy’s integration with broader health reform processes.

CHF has been told that the Evaluation Framework is intended to be a ‘living document’, and that it is a high level Framework, with additional detail sitting below it. In the absence of the public availability of that detail, it is difficult to see how the current Framework supports accountability – particularly when there is no indication of whether the evaluation results will be made public.

Participation

With a $15.4 billion agreement, it would be reasonable to expect key stakeholder participation in developing it. But that is not the case. Community Pharmacy Agreements are negotiated solely between the Government and the Pharmacy Guild. No other stakeholders are invited to the table. This arrangement is written into the legislation under the National Health Act 1953.

The Pharmacy Guild represents pharmacy owners. It does not represent employee pharmacists, who are often the people involved in rolling out programs funded under the Agreement. It does not represent the consumers who ultimately fund the Agreement through their taxes, and will be the beneficiaries if programs are delivered well. There are many other stakeholder organisations that are directly impacted by the Guild-Government Agreement, but nor do they have a seat at the table.

Other stakeholders are also absent from the high-level governance of the Agreement. The Agreement Consultative Committee oversees programs funded under the Agreement, including, but not limited to, their design, business rules, timelines, outcomes and expenditure. These are areas where external stakeholders could add significant value. But the ACC membership is limited to membership from the Pharmacy Guild and the Department of Health and Ageing.

Other stakeholders do get a look-in on the Programs Reference Group. But this is only an advisory body – it does not have any authority to make decisions about program delivery. Also its terms of reference do not provide any scope for it to provide advice proactively – advice is to be provided ‘when requested’.

Predictability

Until recently, predictability was one area in which the Fifth Community Pharmacy Agreement was doing well. Five-year agreements clearly set out the funding to be provided by government and the programs that would be delivered through community pharmacy. The government has indicated its commitment to maintaining the Fifth Community Pharmacy Agreement for the full five years, in spite of concerns expressed by some stakeholders.

In January 2013, however, the Guild called for a moratorium on the provision of one of the key programs delivered under the latest Agreement – Home Medicines Reviews (HMRs). This call was based on a higher than projected uptake of the HMR Program in the latter months of 2012, resulting in a projected overspend in the program for the 2012-13 financial year. The Guild also raised concerns about short timeframes for HMRs and careless behaviour by providers.

Australian research, including reviews of the HMR Program itself, clearly indicate that the groups at the highest risk of medication errors and adverse medicine events after discharge from hospital are older people, those taking multiple medications and those taking high-risk medications. HMRs are intended to reduce the risk of these adverse medicine events and errors.

Although the HMR Program is a free consumer service, research has consistently indicated that the community initiated HMRs uptake has remained below the projected use. This is despite the fact that the program has been shown to successfully identify medication-related problems and improve the knowledge and adherence of the consumer to a medication regime.

Previous evaluations of the pharmacy component of the HMR Program commissioned by the Guild have cited a lack of awareness of HMRs among consumers as a key barrier to participation. More recently, the Guild commissioned Increasing Patient Demand for HMR: A Marketing Plan, outlining a number of detailed strategies to increase patient demand for HMRs. As recently as 2012, the Guild indicated it hoped to see the number of HMRs delivered under the 5CPA grow substantially.

To date, HMR Program overspend has amounted to $4.2 million, largely as a result of a recent spike in demand. CHF notes that $52.11 million has been allocated for the provision of the HMR Program, much of which has not yet been spent, and argues that it should be considered within the broader context of the $15.4 billion provided to community pharmacists under the 5PCA.

The Fifth Community Pharmacy Agreement provides community pharmacies and pharmacists with $386.14 million in funding for the provision of professional services, with an additional $277 million for programs to support and deliver patient services. This amounts to total funding for programs to deliver professional services over the life of the Agreement of around $663 million.

CHF also notes that the Pharmaceutical Society of Australia (the peak national professional pharmacy organisation representing Australia’s 25,000 pharmacists – which is excluded from the negotiation of the Agreement) has initiated moves to improve the business rules associated with the HMR Program in 2012, and has described the proposed moratorium as unnecessary.

CHF has argued that the HMR Program is not unsustainable. No evidence has been provided to suggest that the program could not be cross-subsidised within the existing parameters of the Fifth Community Pharmacy Agreement. Ongoing delivery of a program that delivers value to consumers – and potentially reduces other health system costs through reductions in adverse medicines events and errors – is the kind of predictability that the Agreement should provide.

Transparency

With all the issues outlined above, it is hardly surprising that transparency is not one of the key strengths of the Agreement. Details are only available at the very highest level about how the $15.4 billion is being spent, and how spending and outcomes are being monitored. The gaps in the Evaluation Framework outlined above, combined with very little publicly available evaluation data on program delivery under past

Agreements, means that Australians can have little confidence this major investment is delivering results. Health consumers have questioned the lack of data on the quality and consistency of health information and services provided by pharmacists through 5CPA programs. They deserve to know whether the substantial funding that goes into these programs is delivering improvements in healthcare and health outcomes.

Conclusion

The importance of community pharmacy in the Australian health system cannot be questioned. Australians value the central role played by pharmacists in the delivery of primary health services and the provision of health information. CHF does not question the role that pharmacists play or the value that they provide.

But when we are talking about $15.4 billion of public money over five years, it’s reasonable for Australian taxpayers to expect that the basic elements of good governance will be met – accountability, participation, predictability and transparency. The current Community Pharmacy Agreement ends in 2015. It’s time for Government to consider a fundamental shift in how pharmacy services are funded – with substantial changes to how future agreements are negotiated, delivered and evaluated, or ideally through a new model which involves all the key stakeholders.

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