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Faculty of Pharmacy and Pharmaceutical Sciences

Centre for Medicines Use and Safety

Submission to the

Standing Committee on legal and Social Issues

Legislation Committee

Inquiry into the roles and opportunities for community pharmacy

30th June 2014

Pharmacists are health care professionals who are sought after and valued for their expertise in medicines in working with consumers

and the healthcare team to deliver optimal health outcomes.i

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Executive summary

Under the shared Commonwealth and State / Territory regulation and funding of healthcare and health professionals, the Victorian government has an interest in and can benefit from enhanced health care services being delivered by community pharmacists from community pharmacies and in other areas of primary health care.

The ease of access to community pharmacies and the expertise of community pharmacists should be utilised to establish them as an additional entry point into the health system and as a source of referral to other health care providers. Pharmacists should be supported to provide management of minor ailments and less complex medical conditions and to undertake screening for chronic disease. Population based public health messages should be delivered via the community pharmacy network.

Specific areas of patient care that would benefit from enhanced pharmacist involvement include management of patients’ medications at time of transition within the health care system, improving medication management in patients with chronic disease such as asthma, hypertension and diabetes and the provision of immunization services from community pharmacies.

Central to the development of these and other roles and opportunities for community pharmacists is the recognition in legislation of pharmacists as providers of primary care and the establishment of both program specific and fee-for-service models of funding.

Contacts

Prof Carl Kirkpatrick Director, Centre for Medicine Use and Safety

Mr John Jackson Director, Project Pharmacist

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Recommendations

1. The State government should develop a vision statement and implementation strategy for community pharmacists and community pharmacies as part of an integrated profession-wide pharmaceutical service in Victoria.

2. Models should be established for community pharmacists to provide pre-admission and post discharge medication management and related services.

3. A cost benefit analysis of dose administration aid services to aged care should be undertaken to enable development of a sustainable model for ongoing delivery of these services.

4. A program of collaborative care between medical practitioners, pharmacists and other health care providers should be developed which ensures the expertise of pharmacists can be applied where necessary prior to and at the time of prescribing in addition to the time of dispensing.

5. Funding should be established for pharmaceutical care in relation to specific chronic diseases such as hypertension, diabetes and asthma.

6. Legislative change should be enacted to enable the implementation of community pharmacy based and pharmacists administered vaccination, initially but not limited to influenza.

7. Community pharmacists should be formally recognized and remunerated as an entry point to the health system and a source of referral to other health care providers with a standard documentary process established for referrals.

8. In locations where GP resources are inadequate, community pharmacists should be commissioned to manage less complex consultations under a shared-care model.

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9. Victorian legislation should recognise community pharmacists as primary health care providers able to be funded through establish primary care programs.

10. The State government should offer contracts for the delivery of professional pharmacy services and related programs required by local communities or by subsets of the population with funding based on performance.

11. The Victorian government should work with governments of other jurisdictions to have pharmacists funded as health care practitioners on a fee-for-service basis though both Medicare and medical insurance. The credentialed status of the pharmacists, the requirement for referral from a GP and the source of funding would be dependent on the specific pharmaceutical care being delivered.

12. Community pharmacies should be commissioned to deliver a program of community focused health messages.

13. Community pharmacists should be supported to implement public health programs in response to and tailored to local and individual needs.

14. The Victorian Department of Health should commission further research into coordinated care models under which pharmacists provide monitoring of risk factors in patients with chronic disease and provide early advice to GPs.

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1. Monash University Faculty of Pharmacy & Pharmaceutical Sciences

As Australia's number-one and the world's sixth-best pharmacy and pharmacology program (2012 QS World University Rankings by Subject), we are leading pharmacy and pharmaceutical science educators and researchers based at a specialist campus located in 'the Parkville strip', Australia's premier health and biomedical precinct.

Our challenging undergraduate, postgraduate and research courses prepare students for frontline roles in modern patient care and drug discovery and development. Our graduates are highly employable locally and internationally. They are found in community pharmacies, hospitals, research centres and drug companies the world over.

Amongst the program we offer are a four year Bachelor of Pharmacy program and a one year Pharmacy Internship training program which together lead to registration to practice as a pharmacist. Both programs are accredited by the Pharmacy Board of Australia. In the Bachelor of Pharmacy program pharmacists are educated in the following disciplines:

• Enabling sciences: physical, organic and medicinal chemistry, physiology, biochemistry, microbiology, molecular biology and immunology.

• Drug delivery: formulation of medicines, pharmacokinetics (what happens to the medicine in the body) and the different dose-forms used in therapeutics.

• Integrated therapeutics: major disease states, their epidemiology, pathophysiology, diagnosis, the chemistry and pharmacology of the medicines used to treat these conditions and the clinical and practice aspects of treating patients.

• Pharmacy practice: role of the pharmacist, professionalism, dispensing, health and the individual, and healthcare in our society

The Monash University Pharmacy Internship training program assists graduates in making the transition from a student to an independent, competent health professional and to consolidate and build upon their knowledge and skills gained as an undergraduate.

We also offer opportunities for further study at Graduate Certificate, Master and Doctoral levels in areas including clinical pharmacy, pharmacy practice and wound care.

1.1. Keeping patients safe

The appropriate and effective use of medicines and achievement of patient safety are the essential outcomes of a patient's treatment plan. The Centre for Medicine Use and Safety (CMUS) within the Faculty undertakes multidisciplinary research into preventive, acute and chronic care to deliver high-quality medication management and ensure enhanced patient safety. Based at our Parkville campus and the pharmacy department of The Alfred hospital, CMUS integrates academic and applied research to address medicine use and safety issues in the home, community, hospitals, residential aged-care facilities and their interfaces. We are focused on delivering innovative research which optimises the health outcomes for

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individuals and communities in Australia and around the world through the safe and effective use of medicine.

Within CMUS we have expertise in the areas of:

•health services - the examination of preventive, acute and chronic care in the primary, hospital and aged-care sectors, where delivering medicines safely, effectively and cost-efficiently is paramount. •pharmacometrics - measuring variability in drug effects and disease. •pharmacotherapy - focused on the optimisation of drug therapy. Encompassing clinical and translational research to improve the safe, appropriate and economical use of medicines. •public health and pharmacoepidemiology - focused on a broad range of urgent public / population health issues which are likely to benefit from better pharmacy practice. •pharmacy education- the use of research to enhance education outcomes at all stages of lifelong learning. Our ability to address current and emerging issues in pharmacy education has made us leaders in innovative education.

2. Community pharmacies & pharmacists – why they exist and what they do. Medicines are an essential part of health care. They are often expensive, involve complex dosing and administration protocols and frequently carry risks of toxicity, adverse events and interactions with both other medicine and with foods. The pharmacist’s role is focused on helping patients achieve the greatest benefit from the use of medicines while minimizing the risk. The Joint WHO/FIP Guidelines on good Pharmacy Practice describe pharmacists as ‘specifically trained and educated health professional who are charged by their national authorities with the management of the distribution of medicines to consumers and to engage in appropriate efforts to assure their safe and efficacious use’. In addition the Guidelines state that ‘pharmacists are accepting greater responsibility for the outcomes of medicines use and evolving their practices to provide patients with enhanced medicines-use services’.ii These principles align with the roles for pharmacists within Australia’s National Medicines Policy which has four central objectives:

• timely access to medicines that Australians need, at a cost individuals and the community can afford;

• medicines meeting appropriate standards of quality, safety and efficacy; • quality use of medicines; • maintaining a responsible and viable medicines industry.

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The Victorian public requires community pharmacies to be an accessible network of responsible and viable practice locations from which they can obtain their medicines in a timely manner. Furthermore individuals being treated with medicines need to be able to access pharmacists’ expertise to help ensure safe and effective use of their medicines. These principles apply equally to medicines available on prescription [written by a doctor, dentist etc] and medicines that are restricted to distribution by pharmacists [Pharmacist Medicine] or from pharmacies [Pharmacy Only Medicine].

On average each person in Australia accesses a community pharmacy 14 times per annum. Regular visits result in long term relationships and many people have longer standing and more frequent associations with their community pharmacist than with their GP. Even high risk patients will often see their pharmacist more often and for longer periods than they see their GP. Patients treated with medicines for chronic or long-term conditions will visit their pharmacist at least monthly to have repeat prescriptions dispensed but might only visit their GP every few or only every six months.

3. Risks associated with the use of medicines

While providing significant benefits, the use of medication entails notable risks. The level of risk and incidence of medication-related problems correlates with the number of medications used by the patient, the acuity and complexity of their treatment and the level of coordination of their care. Problems can occur due to system failures, iatrogenic issues, poor patient compliance or they may be idiosyncratic. They may include intentional and unintentional over or under-dosing, interactions between medicines and side effects.

A rate of 2.8 medication-related problems per person has been identified amongst people in the community considered to be at high risk of problems. This is supported by data collected during home medicines reviews which report between 2.5 to 5 medication related problems per person identified as part of the reviews. Surveys have confirm that between 8.5% and 12% of people attending general practice had experienced an adverse medication event in the previous six months and 11% - 12% of these adverse events were considered severe with approximately 5% required hospitalisation.

Repeated studies have indicated that between 2% and 3% of all hospital admissions in Australia are medication-related. There were 2.46 million separations from Victorian hospitals in 2011-2012 and at an average cost per separation of $5,200, it is postulated that medication-related hospital admissions cost the state $320 million per annum.

A range of medication-related issues arise on transition of care into and out of facilities including on admission to residential aged care. Studies have reported 20% of patients in both metropolitan and rural settings experience significant delays in being administered their medicine upon arrival at the facility. Further medication-related problems in people

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living in aged care have been identified during medicines reviews with an average of four medication-related problems per person.

This submission aims to describe how appropriately resourced community pharmacists can help address these medication-related problems.

4. Primary care by pharmacists in community pharmacies

While the supply of medicines with appropriate counselling is an obvious and core function which occurs in all community pharmacies there is a range of other primary health care services that are provided every day in every community pharmacy. These services are focused on helping patients and consumers manage their health care and achieve best outcomes from the use of their medicines however much of this primary care is unseen, unmeasured and unvalued within the broader health care system.

Examples of non-supply based primary care functions include the provision of advice to mothers regarding the use of medicines while breastfeeding or the care for their babies and children, sexual health and contraception advice, assessing ailments such as minor wounds and sporting injuries and providing assistance to elderly and other people regarding the health system and their access to social welfare and other community services.

This advice is provided to members of the public who are able to walk in to community pharmacies without the need for an appointment and seek a consultation with a pharmacist free of charge. In assessing peoples’ request pharmacists apply their knowledge and skills to determine which patients they are able to treat and which they should refer to other primary health care providers such as GPs or physiotherapists or which they need to refer to secondary or tertiary levels of care. In this way, pharmacists have served by default and without widespread recognition as an alternative to GPs as an entry point into the health care system.

Other primary care services provided by pharmacists include needle and syringe programs to reduce harm from shared syringes [NSP]1, opioid substitution [methadone and bupremorphine] programs to assist people to control drug dependency and to maintain effective livelihoods, the preparation of patient’s medicines into dose administration aids [DAA]2, receiving unwanted medicines for safe destruction [RUM]3 and home delivery to elderly and house bound patients.

1 The Victorian Needle and Syringe Program (NSP) is a public health initiative to minimise the spread of blood borne viruses HIV/AIDS and hepatitis B and C by ensuring the availability of sterile needles and syringes to injecting drug users. 2 A dose administration aid [DAA] is a sachet or blister into which has been placed the dose of each medicine required by a patient for each dose time of the day. The packing of medicines into DAAs address the complexity created by the range of different medicines, their prescribed doses and varying dose schedules

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5. Formal and funded non-supply based professional services

In recent years, pharmacy practice research including research within CMUS at Monash University has demonstrated the benefit and value of a growing range of structured non-supply based professional service delivered by pharmacists. A number have been introduced in Community Pharmacy Agreements [CPA] between the Commonwealth Government and the pharmacy profession including, Quality Use of Medicines Programs and Residential Medication Management Review [RMMR] services in residential aged care facilities, Home Medicines Reviews [HMR] in peoples’ homes and Medicines Use Reviews [MedsCheck and Diabetes MedsCheck] in community pharmacies. A list of CPA funded programs is provided as an appendix.

Most of these CPA funded programs have yet to have wide spread impact, due to the limited overall amount of funding and the limited funding for any particular program. A total of $132 million per year is allocated in the current five year CPA [2010 – 2015] for non-supply based professional services. To place this amount into perspective, the total expenditure on the PBS is in excess of $9,500 million per year and the portion of the total PBS expenditure that is expended on the supply chain [wholesaler distribution and community pharmacy dispensing] is in excess of $2,890 million per year. Payments available for non-supply based professional services total less than 5% of the expenditure on the supply chain.

Of the $132 million allocated for non-supply based professional services, some of the funds are not directed to community pharmacies [e.g. funding for RMMRs, R&D, IT systems, program development & program management]. If the residual amount which is potentially accessible to community pharmacies was to be distributed equally between all community pharmacies in the country, it would amount to less than $20,000 per pharmacy per year.

The total amount potentially available per pharmacy is relatively small and the amount for any one program is capped and usually inadequate for the demand. Residential Medication Management Reviews and Home Medicines Reviews have been proven to be a cost effective health care intervention however access to reviews has been constrained for the remainder of the current CPA due to limited funding of these particular service.

unique to each patient. The patient or their care assistant is required to simply open the blister or sachet to administer the required doses of medicines rather than select and count from a range of different bottles and packets. 3 The Return Unwanted Medicines (RUM) Project is a national scheme which provides for unwanted and out-of-date medicines to be collected by community pharmacies from consumers. The medicines are then disposed of by high temperature incineration, which is the EPA approved method of disposal.

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6. Potential developments in professional pharmacy services

In addition to the historical primary care services and the limited number of programs funded by the current CPA, numerous other non-supply based professional services that could be delivered by pharmacists have been developed in Australia and overseas. These include immunization programs, smoking cessation programs, chronic disease management [for conditions such as asthma, diabetes etc.], monitoring and dosing of warfarin therapy, cardiovascular risk assessment, chlamydia screening, minor ailments programs, foot care, nutrition and oral care. A selection of these programs have been implemented as a mix of funded and fee-for-service programs in various countries including New Zealand, Canada, UK, Scotland and the US.

Combined with the core medication supply function, the growing range of non-supply based professional services could potentially result in community pharmacies developing as significant health care hubs for their local communities. The concept of community pharmacies being readily accessible locations providing a broad range of primary health care services as well as dispensing medicines is encapsulated in the UK concept of pharmacies as Healthy Living Pharmacies 4 iii and Pharmaceutical Society of Australia’s model of the Health Destination Pharmacyiv.

7. Developing practice within a regulated framework

Like all registered health professionals, the practice of community pharmacists is regulated via two principle mechanisms; an AHPRA Board, the Pharmacy Board of Australia and through their professional bodies which have developed competency standards, codes of ethics and practice standards.

In addition to these historical structures, the development of expanded professional roles for pharmacists in Australia has been accompanied by the introduction the concepts of focused practice and advanced practice and the principle of credentialing.

An example of a focused practice is the provision of medication reviews [RMMRs and HMRs]. These professional services require the pharmacist to be credentialed, to work on referral from the patient’s doctor and to conduct a consultation at the patient’s place of residence. The pharmacist applies their professional knowledge and clinical judgment to address issues that the patient may have in relation to their medicines resulting in advice to the patient and provision of a written report to their doctor. This model of practice more closely reflects the model used in other sectors of the health system [e.g. GP referring to a

4 The Healthy Living Pharmacy framework is a UK NHS tiered commissioning framework aimed at achieving consistent delivery of a broad range of high quality services through community pharmacies to meet local need, improving the health and wellbeing of the local population and helping to reduce health inequalities.

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specialist or an optometrist referring to an ophthalmologist] and is able to be replicated and applied to further professional services by pharmacists.

An example of advanced practice by pharmacists is prescribing. While pharmacists historically have initiated the use of Pharmacist Medicines and Pharmacy Only Medicines, they are now seeking to establish training and credentialing processes to be recognised as prescribers in the same manner as nurse practitioners, podiatrists, optometrists etc. Once the processes are in place, recognition of pharmacists as advanced practitioners will occur in most areas of their practice including therapeutic specialties [e.g. diabetes, asthma] health services [e.g. aged care, paediatrics, palliative care] or technical processes [e.g. compounding]. The introduction to the profession of formal recognition of advanced practitioners will help develop overall standards of practice.

A framework has been established to support the introduction of advanced practice and processes have been introduced to recognise advanced practitioner status through credentialing.

8. An international comparison

Numerous reports have been produced in England and Scotland on the status of community pharmacy and the role of community pharmacists in the health systemv vi vii. A report particularly relevant to this inquiry is The Future of Community Pharmacy in Englandviii. This report argues that “the economics of community pharmacy are under pressure and the business model, particularly for independent pharmacists, is at a tipping point”. It states that the five forces that will shape the future of community pharmacy include:

• squeeze on healthcare budgets: reduced funds and growing demand; • intensifying competition: supermarkets, group business entities and independent

pharmacies; • transformation of the supply chain: manufacturers and wholesalers; • emergence of new alternate channels: on-line pharmacy [remote dispensing]; • demand for convenience and expertise: patient expectations.

All five forces [other than remote dispensing] are to be found in community pharmacy in Victoria. In addition to these forces, there are a number of other factors including legislative, workforce and technological factors that exist within pharmacists’ practice framework and which influence the uptake of new and expanded roles and opportunities.

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9. Roles and opportunities for community pharmacy

The roles and opportunities for community pharmacists and community pharmacy should align with the philosophy of pharmaceutical careix. Pharmaceutical care is the direct, responsible provision of medication-related care for the purpose of achieving definite outcomes that improve a patients’ quality of life. It involves the process through which a pharmacist cooperates with a patient and other professionals in designing, implementing and monitoring a therapeutic plan that will produce specific therapeutic outcomes for the patient.

Australian and international evidence indicate that the roles and opportunities for pharmacists can be grouped within three principal areas; medication management [which includes but is more than supply], primary care and public health programs.

• Medication management. In the broadest sense, medication management includes advising patients and other health professionals on the appropriate use of medication, initiating medication therapy under a range of prescribed and over-the-counter frameworks, applying their pharmaceutical expertise to adapt prescriptions to enhance therapy, renewing prescriptions within agreed directives with the primary prescriber, monitoring drug therapy including ordering and reviewing laboratory tests, adjusting doses of medicines such as warfarin in response to patient and laboratory parameters, undertaking medication use reviews, medication therapy assessment and comprehensive medication management including independent prescribing, particularly for chronic therapies such as diabetes, hypertension and hyperlipidaemia.

• Primary care includes promoting patient self-care, the provision of health information, serving as a health-system entry-point by providing consultation and triage to other health services, health risk assessment, minor ailment treatment, monitoring of health status, medication reconciliation and case management.

• Public health includes supporting healthy lifestyles through health promotion and education, providing disease prevention, screening and chronic disease management, offering smoking cessation, sexual health [emergency contraception and chlamydia screening], weight management and immunization for influenza and other health risks such as travel related illness, co-ordination with health authorities to deliver medication safety and pharmaco-vigilance.

The following will address the specific matters listed in the public notice regarding the inquiry.

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9.1. The role of pharmacists in post-acute health care

Transition between different health care providers and different stages of health care are recognized as being occasions of increased risk for patients. Because of the wide spread use of medication particularly following an episode of acute hospital care and the frequency with which patients access community pharmacies, community pharmacists are in an ideal position to provide coordination between a patient’s acute health care facility and their post hospital health care providers to minimise medication-related risks. This also applies to patients about to be admitted to hospitals and to people being transferred to residential aged acre services.

The wide distribution of community pharmacies and the expertise of community pharmacists could be utilized to provide a convenient pre-admission medication assessment which may otherwise require the patient to travel some distance to attend a hospital-based pre-admission clinic. In a similar manner, on discharge patients could be referred to their local community pharmacist for a post-acute medication assessment and to ensure on going supply and monitoring of their prescribed medication. In addition to coordination of medication supply and counselling patients on the use of their medicines, pharmacists credentialed in wound care could provide convenient post discharge management of basic surgical wound dressings, again avoiding the need for the patient to travel back to the hospital.

Models should be established for community pharmacists to provide pre-admission and post discharge medication management and related services.

9.2. The role of pharmacist in aged care

The introduction of CPA funded Quality Use of Medicines Programs and Residential Medication Management Review services in aged care facilities have improved medication management for patients in these facilities. While constrained due to limited funding, these services have complimented the enhanced supply arrangements that have been introduced by pharmacists to aged care over the last decade.

Almost 100% of residents of aged care facilities are provided their medicines by community pharmacies packed in dose administration aids [DAAs]. A DAA is a sachet or blister into which has been placed the dose of each medicine required by a patient for each dose time of the day. The packing of medicines into DAAs address the complexity created by the range of different medicines, their prescribed doses and varying dose schedules unique to each patient. The resident or their care attendant is required to simply open the blister or sachet to administer the required

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doses of medicines rather than select and count from a range of different bottles and packets. Not only do DAAs provide efficiencies in aged care facilities, they also reduce the risk of error associated with the administration of medicines.

The packing of medicines into DAAs requires staff time, equipment and disposable materials and the associated costs have generally been met by pharmacists from PBS dispensing income. Reductions to community pharmacies’ PBS dispensing revenues which are occurring as a consequence of the Commonwealth government’s generic pricing reforms will potentially limit the capacity of pharmacists to provide these risk mitigating DAA services unless an alternate funding source is identified.

A cost benefit analysis of dose administration aid services to aged care should be undertaken to enable development of a sustainable model for ongoing delivery of these services.

9.3. The role of pharmacists in personalised medication management

While the community has the reassurance of being able to access medicines that meet appropriate standards of quality, safety and efficacy, the most effective use of those medicines will only occur when treatment is tailored to each individual patient’s situation. As medicines experts, pharmacists are qualified and responsible to provide patients the counselling that will help personalise the management of their medications. This role should be undertaken in coordination with the prescriber and other members of the patient’s health care team and will necessitate greater sharing of relevant clinical information.

A program of collaborative care between medical practitioners, pharmacists and other health care providers should be developed which ensures the expertise of pharmacists can be applied where necessary prior to and at the time of prescribing in addition to the time of dispensing.

On occasions, patients require further training in relation to the use of their medicines than what is provided as part of the counselling associated with the initial dispensing of their prescription. This is not uncommon for patients with chronic conditions such as diabetes or hypertension being treated with complex regimens of multiple medicines for whom compliance can be an issue.x A further example of when such further training may be needed is to check a patient’s technique in relation to the use of an inhaler device for treatment of asthma. Asthma remains a major cause of morbidity and mortality with 10.2% of Australians (or around 2.3 million people) had asthma in 2011-12.xi Correct inhaler technique is important in managing asthma and avoiding hospitalization from an acute asthma episode. While instruction will have been provided when the patient commenced treatment with

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the inhaler, long term use of these types of devices means checking and retraining to overcome adopted incorrect techniques and to reinforce correct techniques is frequently necessary. Currently no funding is available for pharmacists to deliver this type of personalised pharmaceutical care.

Funding should be established for pharmaceutical care in relation to specific chronic diseases such as hypertension, diabetes and asthma.

9.4. The role of pharmacists in vaccination and immunization services

International evidence which is being validated with local trials has demonstrated that people who would not otherwise access seasonal influenza vaccination do so when this service is offered by community pharmacies and by community pharmacists. Once seasonal influenza vaccination has become established as a service available from community pharmacies, a range of additional vaccination services may be able to be delivered from these sites providing greater choice and access to patients. International experience has shown that community pharmacies can provide patients safe and effective travel vaccination and vaccination against a range of other conditions including human papilloma virus.

Once vaccination is established as a community pharmacy based service and a portion of all community pharmacists have been credentialed to administer influenza vaccine they will jointly become an additional resource able to be utilized for widespread vaccination programs in the event of an influenza pandemic.

Legislative change should be enacted to enable the implementation of community pharmacy based and pharmacists administered vaccination, initially but not limited to influenza.

9.5. The role of pharmacists in making referrals to other health care professionals

It is accepted within the health care system and the wider community and that GPs are the principle entry point for patients to mainstream health care, the main source of referral to other mainstream health care providers and they remain the coordinators of patients’ overall care. However gaining access to GPs themselves can be delayed due to their work load or hours of service and it can be expensive depending on the individual GP’s bulk-billing practices.

As has been described in this submission, many patients already use community pharmacists as a source of health care advice and being able to gain access without an appointment and without charge means many people consult pharmacists as an

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alternative to a GP. A consequence of patients currently seeking advice from pharmacists is for them to frequently be referred to another health care provider such as a GP, dentist, optometrist, podiatrist or physiotherapist.

This existing role of pharmacists as an entry point to the health system is provided without health system funding and frequently without any form of remuneration. As demand on GP services increases, the role of pharmacists as an alternate entry point and as a source of referrals is likely to grow.

Community pharmacists should be formally recognized and remunerated as an entry point to the health system and a source of referral to other health care providers with a standard documentary process established for referrals.

9.6. The role of pharmacists in rural and remote Victoria

The Grattan Institute report ‘Access all areas – new solutions for GP shortages in rural Australia’ highlights the potential benefit to the community of making greater utilisation of pharmacists’ skills as a way to overcome the shortage of GPs in rural areas.xii The report indicates that up to 16% of GP consultations in rural areas is for ‘less complex’ visits such as colds and hayfever which could be managed by pharmacist and has been in other countries. The authors suggest that ‘with additional training ….pharmacists could take on 5% of the workload of GPs in the lowest-access rural and remote areas.

In locations where GP resources are inadequate, community pharmacists should be commissioned to manage less complex consultations under a shared-care model.

9.7. Remuneration, workforce and financial issues with respect to any expansion of the role of community pharmacy

Pharmacists are one of the few health professions that have had a notable growth in workforce capacity in recent years. While capacity exists, a major impediment to pharmacists being able to expand their primary care services and to them being more engaged in strategies to help address the issue of medication-related problems is that, other than in the rarest cases they are not funded for any professional services other than dispensing. In fact, pharmacists are not recognized within the national funding model for health care professionals and are frequently omitted from existing funding primary care programs.

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Medicare funds at least 18 different types of health care providers including medical practitioners, dentists, optometrists, mental health nurses, occupational therapists, osteopaths, psychologists, social workers, speech pathologists, dietitians, diabetes educators, chiropractors, audiologists and chiropodists to provide direct patient care. Medicare does not fund pharmacists. In a similar manner, private health insurance funds consultations with a wide range of primary health care providers including dentists, chiropractors, osteopaths, physiotherapists, dietitians, psychologists, speech pathologists, occupational therapists, remedial massage, naturopathy and acupuncture. They do not fund consultations with pharmacists. Pharmacists are funded via the PBS for dispensing medicines and patients may receive minor rebates from private health insurance for prescriptions for non PBS medicine. Pharmacists are funded to a very limited extent under the CPA for a small number of very specific non-supply professional services. The public do not have the capacity to consult their pharmacist on a fee-for-service basis as they might consult one of the numerous other health professionals funded by Medicare and medical insurance. Pharmacists are frequently omitted from the list of health professionals able to be engaged in and funded by existing integrated primary care programs. This scenario is not unique to Victorian pharmacists and can only be explained by the fact that pharmacists have historically been associated with dispensing and sale of medicinal products. The major source of revenue for the majority of community pharmacies is dispensing of Commonwealth funded PBS prescriptions and associated patient co-payments. There is a very small amount of funding available for structured non-supply based professional service that are part of the CPA but there is no funding support for the broad range of other professional services able to be delivered by pharmacists in community pharmacies. This results in most non-dispensing primary care services being cross subsidised from dispensing. In addition to this being a less than ideal and far from secure funding arrangement for health services, there exists the potential for conflict between the need to generate revenue through dispensing in order to sustain the community pharmacy and the demand to commit [unfunded] time to requests for health related advice and other services that enhance the rational use of medicines.

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Reductions to community pharmacies’ PBS dispensing revenues which are occurring as a consequence of the Commonwealth government’s generic pricing reforms will further limit the capacity of pharmacists to maintain the current broad range of unfunded services and limit the opportunity to introduce the wide range of proven but unfunded new services. This is emerging at a time when there is increasing demand on the health system, creating back logs at GPs and hospital emergency departments. Pharmacists have been suggested as part of the solution to the growing demand for health care and may be seen by patients as a cheaper alternative to visiting their GP when proposed copayments are introduced, further increasing the level of demand of people seeking primary health care from pharmacists. Community pharmacies are locations that provide retail services in addition to health care services. Just as it is not sustainable to cross-subsidise professional primary care services from dispensing revenue, it will not be sustainable to delivery health care services via cross subsidy from general retail activities. These trends create a challenge for the traditional model of community pharmacy as a health care focused business and for the regulatory and funding agencies that share responsibility for the provision of health care. Victorian legislation should recognise community pharmacists as primary health care providers able to be funded through establish primary care programs. The Victorian government should offer contracts for the delivery of professional pharmacy services and related programs required by local communities or by subsets of the population with funding based on performance. The Victoria government should work with governments of other jurisdictions to have pharmacists funded as health care practitioners on a fee-for-service basis though both Medicare and medical insurance. The credentialed status of the pharmacists, the requirement for referral from a GP and the source of funding would be dependent on the specific pharmaceutical care being delivered.

9.8. Any other issues relevant to the role and opportunities for community pharmacies in primary and preventative care

9.8.1. The role of pharmacists in GP clinics

A number of local studies including research conducted by CMUS at Monash University have demonstrated that the placement of a pharmacist within a GP clinic can enhance the delivery of care.xiii Interventions have included the

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compilation of a detailed medication history prior to the patient’s consultation with their GP, providing medication related advice to prescribers, other clinic staff and patients and performing in depth medication review with select patients. This research demonstrates the value of engaging community pharmacists in areas of primary care in addition to community pharmacies.

9.8.2. The role of community pharmacies in public health programs

Public health programs entail preventing disease and promoting health at both a community and an individual level. Community pharmacies and pharmacists can play a significant role at both levels. Pharmacy based public health programs have been growing in the UK since the Minister for Health, Rosie Winterton stated in 2004 that:

“To date pharmacists have been a major untapped resource for health improvement. The track record of community pharmacists in areas such as stopping smoking, sexual health advice and substance misuse is evidence of how integral they are to tackling public health issues. But we would like them pharmacists to do even more”xiv.

Since that time public health programs have been incorporated into the range of service that are commissioned from community pharmacies by the English government and in 2006 the Scottish government commenced paying pharmacies an annual fixed fee to mount up to four agreed public health campaigns each year.

Victorian community pharmacies currently provide a number of public health services on an individual basis including opioid replacement services [pharmacotherapy] and the provision of emergency hormonal contraception. Both of these services should be supported to ensure sustainable programs in all geographical areas of need. They could be supplemented by the provision of support for chlamydia screening and smoking cessation.

A further public health issue that has emerged in the Victorian community is dependency on the analgesic codeine and risk from excessive use of over-the-counter combination analgesics containing codeine. Concurrent with this public health issue is the growing use of prescription narcotics including diversion to illicit use. Community pharmacists should be supported to provide assistance for people demonstrating codeine and prescription narcotic dependency or abuse. A range of measures may be required including training, access to support programs and public health messages able to be mounted in pharmacies.

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The wide spread distribution, ready access and long opening hours of community pharmacies and the public profile and high level of trust of pharmacists make them excellent potential partners for the Victorian Department of Health government to promote community-focused health and life style messages.

Community pharmacies should be commissioned to deliver a program of community focused health messages.

Community pharmacists should be supported to implement public health programs in response to and tailored to local and individual needs.

9.8.3. The role of pharmacists in chronic disease management

Patients with particular chronic diseases such as heart failure, cardiovascular disease and chronic obstructive pulmonary disease are at high risk of re-hospitalisation. For example patients with heart failure may be admitted to hospital up to ten occasions per year. Patients with these chronic diseases require long term use of medication and consequently have frequent contact with their community pharmacists who are well placed to monitor the status of the patients’ health. Both patients and well people visit community pharmacies much more often than GPs, and community pharmacists are therefore ideally placed to provide health status monitoring and open access screening in areas such as cardiovascular and diabetes health. This can be particularly valuable for people who infrequently visit GPs and may otherwise be missed.xv Studies have demonstrated that pharmacist are in an ideal position to monitor the health status of both existing patients and people with undiagnosed conditions or at risk of disease, with attention given to specific risk factors and early detection of changes or initial detection of risks able to be communicated to the patient’s GP. The Victorian department of Health should commission further research into coordinated care models under which pharmacists provide monitoring of risk factors in patients with chronic disease and provide early advice to GPs.

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10. References

i Jackson J. et al. 2014. Building Upon Pharmacists’ Practice in Australia – A vision for the profession [in press] ii Good Pharmacy Practice. Joint FIP/WHO Guidelines on GPP: Standards for quality of pharmacy services. Available at: https://www.fip.org/www/uploads/database_file.php?id=331&table_id= iii Evaluation of the Healthy Living Pharmacy pathfinder work program 2011-12. Available at: http://psnc.org.uk/wp-content/uploads/2013/08/HLP-evaluation.pdf iv Roberts A. A real health destination. Aust Pharmacists, Jan 2014: 28-29 v Health on the High Street [2013] The NHS Confederation. London. Available at: http://www.nhsconfed.org/Publications/reports/Pages/Health-on-high-street-rethinking-community-pharmacy.aspx vi Now or Never: Shaping pharmacy for the future [2013] The Royal Pharmaceutical Society, London vii New models of pharmacy: what is emerging and what is possible. The Royal Pharmaceutical Society of England, London viii Anscombe J. Thomas M. The Future of Community Pharmacy in England. 2012. A.T.Kearney, Inc. London. ix Hepler C., Strand L. Opportunities and responsibilities in pharmaceutical care. Am J Hosp Pharm. 1990, Vol 47: 533-543. x Stewart K., George J., McNamara K., et al. 2014. A multifaceted pharmacist intervention to improve antihypertensive adherence: a cluster-randomised, controlled trial (HAPPy trial), J Clin Pham & Therapeutics, doi;10.1111/jcpt.12185 xi Australian Bureau of Statistics: Available at: http://www.abs.gov.au/ausstats/abs@.nsf/Lookup/by%20Subject/4338.0~2011-13~Main%20Features~Asthma~15 xii Ducket S., Breadon P. & Ginnivan L., 2013, Access all areas: new solutions for GP shortages in rural Australia. Grattan Institute, Melbourne. xiii Tan E., Stewart K., Elliott R. & George J. 2013. Stakeholder experience with general practice pharmacist services: a qualitative study. Bmjopen-2013-003214 xiv Choosing health through pharmacy: A program for pharmaceutical public health 2005 – 2015. Department of Health, London. Available at: http://www.nhsalliance.org/publication/choosing-health-through-pharmacy-a-programme-for-pharmaceutical-public-health-2005-2015/ xv McNamara K. et al 2012. A pilot study evaluating multiple risk factor interventions by community pharmacists to prevent cardiovascular disease: The PAART CVD Pilot Project. Annals of Pharmacotherapy, v46: 183-191.