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The Pharmacy Guild Of Australia

Submission to the Productivity Commission

The Health Workforce

August 2005

	Contact
Ms Wendy Phillips
Director Strategic Policy
PO Box 7036 Canberra BC  ACT  2610
tel: 02-6270 1888    fax: 02-6270 1800
email:  guild.nat@guild.org.au
Internet:  www.guild.org.au	

Table of Contents

Introduction

1.	The Essential Roles of Community Pharmacy
2.	The Capacity of Pharmacy to Satisfy Government and Community Needs
2.1	The Impact of Ageing and Chronic Illness
2.2	The Challenge is the Total Health Workforce
2.3	Service Delivery and Funding Models
2.4	Reporting and Administration are Pivotal Concerns

3.	Pharmacy Deals with Competing Demands Embedded in a Single Business Model
3.1	Community Pharmacy Offers a Strategic Platform to Meet New Demands
3.2	The Clinical Role is Likely to Grow
3.2.1	Pharmacy has a Proven Quality Model
3.2.2	Non-Prescription Medicines are Cost-Saving
3.2.3	Medication Reviews Reduce Risk and Error
3.2.4	There are Value-Improvement Opportunities in Aged Care
3.2.5	Pharmacists Prevent Medication Errors
3.3	Infrastructure Costs and Complexity are Growing
3.4	Chronic Disease Management is Increasingly Important
3.5	Health Education, Screening and Illness Prevention are Vitally Important
3.6	Harm Reduction is a Pharmacy Activity
3.7	Pharmacy Delivers other Health and Community Services

4.	Addressing Workforce Issues
4.1	Addressing Workforce Structural Issues
4.1.1	Will There be Enough Community Pharmacists
4.1.2	Supply of New Graduates
4.1.3	Distribution of Pharmacies and Pharmacists
4.1.4	Using Pharmacy Assistants to Cover Shortfalls and Increase Quality of Care
4.1.5	Retention of Graduates and Registered Pharmacists
4.1.6	Improving Quality of Care in Pharmacies
4.1.7	Covering Short-Term Shortfalls
4.1.8	Immigration is Not the Answer
4.1.9	Regulation of Pharmacies and Pharmacists Limits Flexibility
4.1.10	Data Collection and Reporting Can be Improved
4.2	Community Pharmacy has a Program to Lead Change
4.3	Enhanced Use of Technology by Pharmacies is a Way of Reducing Workforce Pressure and Improve Outcomes

5.	Enhancing the effectiveness and efficiency of community pharmacy
5.1	Enhancing Effectiveness
5.1.1	Addressing Workforce Coverage Issues
5.1.2	Addressing Workforce Education and Training Issues
5.1.3	Addressing Health Workforce Silos
5.1.4	Increasing the Use of Technology
5.1.5	Working more Effectively with Indigenous Communities
5.1.6	Managing Change and Enhancing Efficiency within Community Pharmacy for Effective Health Care
5.2	Enhancing Efficiency within Community Pharmacy
5.2.1	Reducing Transaction Costs
5.2.2	Medication Continuance Program
5.2.3	Enhanced Use of Technology
5.2.4	A National Registration System

Introduction

This submission is made by the Pharmacy Guild of Australia in response to the Productivity Commission Health Workforce Issues Paper which invites responses to such key issues as:

•	the clarification of stakeholder objectives;
•	ways to better align incentives, improve coordination and promote good regulatory practice;
•	possibilities for extending the use of ‘market-friendly’ mechanisms within the regulatory framework;
•	the scope to better align and/or simplify fiscal gate keeping mechanisms; and
•	opportunities to meet core health workforce objectives in new ways.

The Pharmacy Guild of Australia represents nearly 4,000 community pharmacies covering all demographics and pharmacy types in locations throughout Australia.  It recognises the importance of working with governments, other health care professionals and consumers so that the role played by pharmacy can continue to meet the needs of the community it serves.

This submission draws on the knowledge being generated through a range of research projects conducted through our Research and Development Program, which is funded through the Third Community Pharmacy Agreement between the Guild and the Australian Government.  Much of the work of this Program is informing our work aimed at further developing the role of the community pharmacist as a member of the health care team.

Contributions to this submission were also provided through discussions held with representatives from:

•	Pharmacy Schools;
•	Pharmacy Boards;
•	Australian Pharmacy Examining Council;
•	Pharmaceutical Society of Australia;
•	The Society of Hospital Pharmacists of Australia;
•	National Australian Pharmacy Students’ Association;
•	Young Pharmacists’ Association;
•	Australian College of Pharmacy Practice and Management; and
•	Australian Association of Consultant Pharmacy.

1.	The Essential Roles of Community Pharmacy 

Community pharmacy is well placed to be part of the total solution to the challenge of providing cost effective health care in Australia over coming decades.  However, community pharmacy can only play its role effectively if the mix of incentives, risk and opportunity designed to attract and retain the workforce, and encourage the investment of private capital is in place.

In putting forward this submission we point out that community pharmacy plays a number of multifunctional and simultaneous roles in our community, including:

Community pharmacy plays a number of multifunctional and simultaneous roles in our community

•	a clinical role;
•	a health information and education role;
•	a governance role;
•	a retail role;
•	management of other essential community services infrastructure such as banking, photographics and private health fund payments

Community pharmacies are the most accessible of all primary health care services, and pharmacists are one of the most trusted health care professionals. The presence of community pharmacy is a major cost saver to the health system through its role as primary health gate-keeper, assisting consumers with management of minor health complaints, or, when necessary, providing appropriate referrals to general practitioners or other health providers.  This role could be further developed with better integration of community pharmacy into the primary health care team and the offering of better aligned incentives for increased activity in this area.

Delivery of services in the health industry in Australia relies heavily on funding and interventions by Government to ensure that quality outcomes and equity of access are guaranteed.  The community pharmacy sector is uniquely positioned, compared to other health service providers to deliver a range of services within the privately financed, commercial environment of the pharmacy which is supported and paid for by small business pharmacy owners.  The value of this business base (4,925 premises) is estimated to be around $10 billion – a value that is able to be directly translated into savings to public funding bodies.  For funders of health services, there are significant savings to be gained by fully utilising the existing pharmacy infrastructure and harnessing the capacity of the pharmacy workforce to support provision of health services.

Additionally, the location of community pharmacies within communities provides a convenient central location for both delivery and distribution of the relevant services.  This includes rural and remote communities where, in contrast to other health services, since 2000, the number of rural pharmacies has grown for the first time in 20 years.

More than 90 per cent of community pharmacies are Quality Care Pharmacy Program accredited.  This provides the Government and community with the assurance of reliable delivery of product and service and demonstrates the capacity and commitment of community pharmacists to the provision of quality health care.  

Pharmacy has also proven itself willing to embrace technological as well as operational change. The Guild has taken a positive approach to assisting the Government with projects such as MediConnect and HealthConnect.

The services provided by pharmacies are multi-functional and simultaneous and include:

Clinical Services
Traditional clinical services routinely provided by pharmacies are outlined in section 3.2 and include:

In more recent times pharmacies have been encouraged to take on additional roles related to the primary health care role of early intervention and prevention of health issues

•	dispensing and overseeing quality use of medicines;
•	supply of Pharmacy Medicines and Pharmacist Only Medicines and delivery of primary health care;
•	participation in the Home Medicines Review program;
•	provision of dosing administration aids to elderly, chronically ill and disabled consumers, both in the community and in institutional care.  With an increased emphasis on ageing in place this will be an expanding role for pharmacies to play in minimising adverse events; and
•	contributing to medication safety by monitoring, reviewing and advising on medications.

In more recent times pharmacies have been encouraged to take on additional roles related to the primary health care role of early intervention and prevention of health problems including in relation to smoking cessation, continence management, asthma and diabetes management programs.

Such programs have demonstrated:

•	the capacity of pharmacy to play an enhanced role in the delivery of health services; and

•	that substantial health promotion benefits and opportunities are provided when customers walk though a pharmacy door.

A further extension of the clinical role of pharmacy into this domain would support current national and State and Territory health initiatives aimed at early intervention/prevention.  In rural and remote areas the possible impact of the role that pharmacy can play in this area is inflated by the lack of availability of some other health professionals.

Governance Services
Pharmacies can and do play a significant and essential role in the collection, recording and reporting of health data to government and in administering the PBS on behalf of Government.

Retail Services
As outlined above the strength and capacity of pharmacy to contribute to healthy service delivery lies in its retail base.  However, the ongoing sustainability of that base is also an issue for future development of the pharmacy role.  If pharmacies are to continue to deliver and expand services to meet community and government needs, adequate financial returns will need to be guaranteed.

This could be through:

•	increased flexibility in structures;
•	implementation of change management techniques in regard to work-flow practices; and
•	adequate incentives and support.

Education and Information Services

Pharmacies within the community has been shown to be an ideal environment for providing health information and education to individuals and to the wider community

The central location of pharmacies within the community has been shown to be an ideal environment for providing health information and education to individuals and to the wider community.  Traditionally this has been in relation to safe use of medications, but future roles could include education on wider health issues and the provision of space within the pharmacy to enable other health professionals to provide information and advice.  Examples include pharmacies operating as Carelink centres, and providing bone density testing, providing space for baby health centres and having a visiting continence care nurse.

These roles give rise to increasingly competing demands and expectations from those who fund and benefit from them.  They also lead to competing economic and managerial pressures within the pharmacy. It is a common mistake in government policy and the media to deal with these as more or less distinct separate functions. This leads to a process where pharmacists are characterised as less than fully efficient retailers, because they incur the costs of also delivering unfunded clinical or managerial services, at the same time as suffering criticism for being unwilling to invest even larger amounts of time and effort in unfunded administrative or other services (which would in turn increase the costs of the retail function). The Pharmacy Guild of Australia is of the view that the complex relations and cost/efficiency impacts, and the roles and economics of the sector must be assessed as an integrated whole rather than as set of functions that can be disaggregated. We stress this because the choice to take on these complex and competing roles is voluntary, and pharmacists will ‘vote with their feet’ if the mix of incentives and supports is insufficient to justify taking on the total suite of roles and costs that will be increasingly expected of pharmacists.

It should also be noted that the unfunded or under-funded public goods and services include the provision of professional health care advice at the point of sale (for which there is no direct remuneration), non-dispensing or diversion to less costly therapies, and positive interventions to prevent diversion of medicines to illicit use. Some of these services involve either foregoing income, or taking personal risk or responsibility, and most involve restructuring the pharmacy business in ways that reduce trading profit. The hidden retail subsidisation of public good activities must be recognised, and the total mix of incentives and security must be seen to justify continuation of these, if pharmacy is to continue to increase its contribution to productive ageing and the health of our community.

The capacity of community pharmacy to continue and expand its role in health care will entail:

•	addressing workforce structure and supply issues
•	effective change management
•	application of technology

In addressing the key issues identified above, this submission discusses the challenges and changing demands facing the future pharmacy workforce and the current and emerging role of community pharmacists within the health care system.  Those challenges are:

•	the ageing and changing nature of the Australian population;
•	the provision of cognitive services through community pharmacy;
•	technologies and service models;
•	workforce gaps in the health workforce;
•	complexity in funding;
•	proliferation of service demands and delivery;
•	innovation in health service networks;
•	the need for greater safety in the provision of health care, and
•	increasing complexity of the role of community pharmacy together with increased time and resource demands.

Our submission then discusses pharmacy’s capacity to meet the challenges, identifies the key issues that need to be addressed by governments and suggests appropriate strategies for government to implement in order for pharmacy to work effectively in meeting the future health needs of the Australian population.

2.	The Capacity of Pharmacy to Satisfy Government and Community Needs 

Australia’s health care system is facing significant challenges.  Meeting those challenges will require the active and constructive involvement of community pharmacy in developing and implementing solutions.

Community pharmacy is well placed to play a role in meeting the demand for accessible, effective and efficient health care services

In the future our health care system will need to meet a growing demand for products and services as well as increased costs of treatments and technology.  To do this, Australian governments must ensure that services are delivered with maximum efficiency and effectiveness in order to meet the health needs of the community.

Community pharmacy is well placed to play a role in meeting the demand for accessible, effective and efficient health care services.

•	In large part this capacity comes from the deployment of substantial sums of private capital, in part reducing the capital demands on the public system.

•	Community pharmacy offers an efficient, easy-to-access ‘main-street’ presence, only part of the cost of which is met from health budgets due to the subsidisation effects of more generalised retailing.

•	Pharmacists are highly knowledgeable about medicines, skilled in front-line counselling, and provide an increasing range of professional services including medicines management, monitoring and referral and in the assessment of minor conditions.

•	Community pharmacy involves not only the application of professional skills, but also substantial retail investment, to provide the platform that permits low cost and flexible service provision.  This characteristic imposes on the profession a commercial pressure in deciding where and how to invest scarce time and financial and human resources.

•	Pharmacists, as business people, possess a pragmatic discipline, coupled with administrative reliability and efficiency that may be lacking in other parts of the health care system.

2.1	The Impact of Ageing and Chronic Illness

Australia’s population is ageing, and will continue to age for at least the next four decades.  The Australian Government’s Intergenerational Report noted that overall, the proportion of the population that is very old (over 85 years of age) is expected to triple, while the proportion in the prime working age range of 15 to 64 is expected to fall.

However, medicines are a pivotal investment in reducing the costs of ageing. Effective early diagnosis and medicine use reduces the costs associated with later more serious ill-health, diverts patients from far more costly institutional care, and maintains workforce productivity. Delaying or avoiding onset of debilitating conditions allows the maintenance of earning, maintains mental well-being, and prevents human resources (including unpaid care) being diverted from economic production to patient care. This relationship has been demonstrated by the Systems Simulation Modelling of the Value and Future Role of Pharmacists in the Australian Health System developed by The Pharmacy Guild of Australia.

The Guild has explored the use of this simulation modelling to demonstrate the value of medicine use within Australia. The modelling allows an understanding of the potential contribution and constraints of the pharmacy workforce in contributing to the nation’s health and economic growth and how the sustainability of the Pharmaceutical Benefits Scheme (PBS) is linked to improving worker participation and productivity, especially in older workers.

Medicines used to prolong life and quality of life also prolong the period of time that these same patients are productive in the community and continue to pay taxes. Medicines should be seen as an investment as, on purely economic grounds, they allow a person to maintain productivity and continue paying taxes, delay admission to nursing homes with all related costs and avoid or delay hospitalisation for a variety of disease states and conditions.

As the population ages, the demand for pharmaceuticals and other services provided by pharmacists will increase.  The Intergenerational Report notes that of all the components of Commonwealth health expenditure, spending on PBS subsidies is projected to grow the fastest.  The projected increase is more than five fold – from 0.6 per cent of GDP in 2002 to 3.4 per cent of GDP in 2041-42.  In the same period, expenditure on the MBS is expected to grow by 60 per cent.  According to the Report, spending on aged care will also increase from 0.7 per cent of GDP in 2001-02 to almost 1.8 per cent of GDP in 2041-42. It should be noted that the medicines of greatest cost are those used in the last five years of a person’s life and generally relate to medicines used in hospitals.

As people age, their medication use increases, with many older people taking multiple medications.  The use of multiple medications needs careful management and oversight by experienced pharmacists because the likelihood of experiencing an adverse drug interaction increases as people take more and more medications.  (The issue of medication safety and the invaluable role that community pharmacy plays in preventing mishaps is explored in section 2.1 of this submission.)

As people age, their medication use increases, with many older people taking multiple medications

In addition, a growing number of people in the Australian community are likely to be living with chronic illnesses that are increasingly treated with medications.  Data published by the ABS in 1995 and 1997 show that at least 10 per cent of the Australian population are affected by a chronic condition and many of those chronic illnesses are associated with ageing.  Many medicines are taken without a change in symptoms by the patient so the pharmacist plays a vital role in medication compliance and concordance. In conditions such as cardio-vascular disease and diabetes there is no immediate symptom change in taking a dose or in fact missing a dose.  Many of these chronic conditions are related to lifestyle factors and are considered to be preventable.

Community pharmacy is well-placed to use its expertise and accessibility to meet the growing demand on our health care system.  Through our Research and Development Program, the Guild, in partnership with the Australian Government, has demonstrated the role that community pharmacy could play in preventing illness and in identification and management of chronic disease.  (This role is explained in sections 3.4 and 3.5 of this submission.)

2.2	The Challenge is the Total Health Workforce

As noted in the Productivity Commission’s Issues Paper, there is little dispute that service quality and access in some areas are under pressure because of workforce shortages.  Those gaps are likely to be exacerbated as the population ages, rural and regional areas become less attractive for health professionals and workforce participation decreases. The decreasing number of hours worked by many health workers will also contribute to the increasing gaps in health service provision.

The Issues Paper also notes that there is a mal-distribution of the health workforce in some areas, with some of the more affluent urban areas being oversupplied, while people in rural and remote areas of Australia suffer from an undersupply of health practitioners.

Community pharmacy has already played a significant role in addressing problems caused by workforce shortages in the health care sector.  For example, its development and supply of Dose Administration Aids for the aged care sector has reduced a reliance on the need for nursing staff to administer medications to clients in aged care facilities.  This important role is further explained in section 3.2.4 of this submission. 

Dose Administration Aids used in the community setting help patients or their carers to effectively manage their own medicines and continue living independently.  This helps avoid the need for residential care, as one of the major trigger factors for patients to move from independent living to a nursing home is when they are unable to comply with their medication regime. Dose Administration Aids assist them to manage their medicines without assistance or supervision.  However, this service is currently provided as a user pay system and the economic benefits of a Government subsidised system to help consumers pay for their medication management is yet to be explored by the Australian Government.

Projections for the future community pharmacy workforce by the Systems Simulation Modelling of the Value and Future Role of Pharmacists in the Australian Health System also shows that supply will not be able to meet demand.  This is explored in section 4.1.1 of this submission.

2.3	Service Delivery and Funding Models

The delivery of health care in Australia occurs in a variety of settings including general practice, medical specialists’ consulting rooms, hospitals (public and private), aged care facilities, health clinics, ambulatory care services and patients’ homes and workplaces. Community pharmacy also plays a significant role as a primary health care provider with over 200 million visits and consultations occurring on average in Australia’s 4925 community pharmacies each year (see section 3.2.1)

Community pharmacy has already played a significant role in addressing problems caused by workforce shortages in the health care sector

While much of the health care provided in our health care system is of high quality and contributes significantly to the health of our community, the system as a whole is fragmented and poorly coordinated.  It leads to inefficiencies, care that is not coordinated, and often to unnecessary costs to governments and consumers.

As governments and private funders seek to ensure greater efficiency and effectiveness and more coordination between services, new models of service delivery and funding are being developed.  While much of this work is to be welcomed, it can lead to a greater burden of bureaucracy on health care providers, thus detracting from their role in health care delivery.  The impact of government accountability requirements on the work of community pharmacy is discussed in sections 2.4 and 5.2.1 of this submission.

2.4	Reporting and Administration are Pivotal Concerns

Pharmacists are required to complete a significant amount of clerical work to satisfy the requirements of dispensing Pharmaceutical Benefits Scheme (PBS) items which comprise the great majority of prescriptions. This clerical work helps to limit entitlement fraud, that is, where patients may be illegally claiming a concessional benefit as a pensioner or a concession card holder. It also helps to stop non-citizens claiming a subsidy on PBS medicines. These tasks are completely clerical but if the information which is provided to the Health Insurance Commission is inaccurate or incomplete, the pharmacist is not reimbursed for the service.

Some of the information is recorded to comply with jurisdictional legislation with respect to drugs and poisons and international treaty obligations. However, checking the prescriber’s provider number, patient’s Medicare number, entitlement number for concession benefits, and authority number are PBS requirements.  Each of these numbers contains a check digit which provides an alert if the number is incorrect and consequently a lot of time is spent checking and correcting information to make sure it is accurate.

This administrative role of policing consumers’ PBS entitlements is important to Government as a strategy to maintain the sustainability of the PBS. However, the time spent in such clerical tasks may detract from the pharmacists ensuring that the right patient receives the right medication in the right dose, strength and form with the right information to provide for its safe and effective use, consistent with the Australian Government’s Quality Use of Medicines policy.

Time spent on these administrative tasks can be a distraction from a pharmacist’s professional duties and is frequently a contributing factor to dispensing errors.

Information systems and technology are needed to be used to minimise these clerical activities in the dispensing process.  However it is predicted that this ‘medication policing’ role will in fact increase in the future to prevent inappropriate medication use, in line with national guidelines in the Australian Government’s Quality Use of Medicines Policy. Expanding this role will also help avoid unnecessary MBS costs where some medical practices might manipulate the use of prescription repeat entitlements to have people return to the surgery earlier than they are otherwise required.

3.	Pharmacy Deals with Competing Demands Embedded in a Single Business Model 

Community pharmacy plays a critical, although at times poorly recognised, role in the health of our community.  Pharmacists are, in fact, an essential member of the primary health care team.  The central place of medications in curing or managing illness means that the pharmacist, as the dispenser of pharmaceuticals and as the provider of point-of-sale advice and risk management, is uniquely placed to ensure that medicines are accessible and are used wisely and safely.  In this clinical role pharmacists also provide an invaluable service to Government as they record and report information about drug dispensing and use.

The pharmacist, as the dispenser of drugs and poisons, is uniquely placed to ensure that medicines and other pharmaceuticals are accessible and are used wisely and safely

As our population ages, the role of community pharmacists in dispensing and managing medication will become even more critical.  As medication regimens become more complex, as financing and governance models become more complex, and as the price of pharmaceuticals increase, pharmacists will play a significant role in ensuring that medicines are accessible and are used wisely, and that unnecessary or inappropriate prescribing and `dispensing is discouraged.

The increasing need to reduce hospital stays to a minimum means that patients will be discharged on an ever increasing number of medicines and this process needs to be managed by a community GP and a community pharmacist. At present the uncoordinated approach of state-run hospitals and federally funded GP and pharmacy programs means there is a gap in the system which leads to an unnecessary level of hospital re-admission.

The clinical role of community pharmacists facilitates a close relationship between pharmacists and consumers.  It provides an ideal basis from which to develop the role of the community pharmacist as a member of the health care team, and to play an even more significant part in caring for the health of our community.  The Pharmacy Guild of Australia strongly believes that further development of the role of the pharmacist would bring benefits in terms of outcomes for consumers and greater efficiencies for the funders of health care.

3.1	Community Pharmacy Offers a Strategic Platform to Meet New Demands

The retail nature of community pharmacy provides an essential platform for the delivery of health care.  There is a network of community pharmacies spread throughout urban, regional and rural Australia. As well as individual pharmacist proprietors, this involves 40,000 staff made up of pharmacist employees and pharmacy assistants, operating in 4,925 premises in every significant town or suburb in Australia.  On average an Australian goes into a community pharmacy 14 times per year, which means that there are at least 14 opportunities each year for pharmacies to provide low cost access to advice or other health interventions. Pharmacies are in highest traffic locations of all health professionals and as such provide the most cost effective vehicle for health promotion initiatives.

Each pharmacy is staffed at all times by a pharmacist who is able not only to dispense and give advice about medicines but also to assist in the delivery of health services in a variety of other ways.

Over $10 billion of private capital is invested in community pharmacies.  This ensures that the services provided by retail pharmacy benefit from the efficiencies inherent in the private sector in delivering its important health care service.  Pharmacists can deploy their capital and abilities in many different ways, depending on the needs of the government and the community, if given the opportunity and the incentive to do so.

Many pharmacy-delivered services are provided at no cost to the Government or the public – drug recalls are an obvious example, as are pseudoephedrine sales monitoring and needle exchange programs.  With regard to drug recalls, community pharmacies successfully managed the recent Pan Pharmaceuticals debacle and the more recent total withdrawal of Vioxx from the market. Pharmacies have cooperated with law enforcement bodies in an attempt to minimise the diversion for pseudoephedrine to illicit drug manufacture which frequently means refusing sales. In addition community pharmacies frequently suffer hold-ups and break-ins.

Pharmacists also provide valuable community services by assisting consumers to return goods associated with extortion attempts such as in the case of potentially contaminated paracetamol products, as happened in 2001, and in the return of unwanted medicines which would otherwise be disposed of by consumers in an environmentally unsound way resulting in environmental contamination.

3.2	The Clinical Role is Likely to Grow

As pressures on the health system mount with the impact of Australia’s ageing population, it will be expected that the clinical role of pharmacies will increase.

3.2.1	Pharmacy has a Proven Quality Model

Pharmacists’ central role in the health care system revolves around the dispensing of medications and overseeing the quality use of medicines.  A survey of community pharmacies conducted in 2002 shows that in that year over 214 million prescriptions were dispensed by community pharmacies.

Over $10 billion of private capital is invested in community pharmacies

Community pharmacy is a primary source of information, advice and counselling on effective and appropriate use of medicines.  Community pharmacists are able to identify people who are at high risk in regard to medication problems and are careful to provide advice and counselling about medications when multiple medications are used.  The 2002 survey shows that counselling occurred in private locations within the pharmacy on 14.42 million occasions, that 3.71 million patients required special counselling owing to poor English language skills, computerised medicines information was provided on 6.76 million occasions and other written or printed drug information to 8.61 million patients.

Pharmacists in community pharmacies also play a key role in identifying prescribing errors and intervene to improve safety and quality of medicines use, such as to prevent adverse interactions with other medicines already being taken by that patient.  The 2002 survey shows that pharmacists intervened in an estimated conservative total of 1.075 million prescriptions during the previous 12 months for inappropriate drugs or doses, suspected adverse effects or prescription defects.

While this involves a loss of income for pharmacies it represents a considerable cost saving to Government in terms of the avoided cost of the drug and other health care costs, such as hospital and other costs, involved in dealing with an adverse event related to inappropriate medication.

There is potential for the role of pharmacists in medication management to increase.  A study currently being undertaken and nearing finalisation entitled Improving Australians’ Access to Prescription Medicines:  Development of Pharmacy Practice Models has explored a number of different models by which pharmacists could be involved in medication continuance programs; that is, where pharmacists are authorised to continue a supply of medications under certain conditions, thus relieving pressure on medical practitioners.

This research will generate a discussion document for the Australian Government, possibly leading to a trial of pharmacists providing ‘medication continuance programs’ in Australia. The draft report of this project suggests that current Australian prescribing arrangements do not fully meet the needs of the community in terms of timely, cost effective and convenient access to prescription medicines.  It describes four models that should be explored in future demonstration projects.  For example, one of these models involves pharmacists continuing supply of medication, initially prescribed by doctors, to patients in residential aged care facilities, according to a patient-specific treatment plan devised by the doctor. This would avoid the need for doctors making unnecessary visits to nursing homes just to spend their time writing out repeat prescriptions.

The draft report suggests that these models provide an opportunity to improve efficiency through addressing aspects of current practice that lead to a less than optimal use of scarce resources.  It sees efficiency gains that can be achieved through a better use of pharmacist and medical practitioner time and a more streamlined approach to medication management.

Development of this role for community pharmacy would also relieve pressure on the general practice workforce as well as reduce costs to the MBS.

3.2.2	Non-Prescription Medicines are Cost-Saving

Efficiency gains can be achieved through a better use of pharmacist and medical practitioner time and a more streamlined approach to medication management

Pharmacists in community pharmacy also play a key role in the provision of non-prescription medicines.  Some over-the-counter medicines are assessed as having a higher risk. These medicines (Pharmacists Only Medicines) require intervention by a pharmacist prior to their supply.

This level of restriction is based on the Therapeutic Good Administration risk-management framework for medicines. Consumers’ access to community pharmacists ensures that the appropriate level of risk management is applied.

A recent cost-benefit analysis of these medicines shows that teamwork between pharmacists and assistants around these medicines helps save lives and keep people out of hospital.  The project used a number of studies and various methodologies to address the issue of non-prescription scheduling and the Standards for the Provision of Pharmacist Only and Pharmacy Medicines in Community Pharmacy.

The project estimates that, each year, pharmacy staff prevents 30,808 visits to Accident and Emergency at hospital, 76 cases of admission to an intensive care unit and 84,650 urgent visits to a general medical practitioner.  The pharmacist or pharmacy staff performs 485,912 interventions every year, with about 101,324 interventions classified as ‘high significance’ interventions which averted emergency medical attention, serious harm or were potentially life-saving.  The most common estimated annual cases avoided were exacerbations of asthma, peptic ulcers, hypertension and unspecified adverse effects of drugs.

The draft report quotes several case studies where pharmacy teams have prevented serious health crises, including the prevention of death by anaphylaxis in a patient with an allergy to bee stings, a woman who asked for cold and flu medication who was directed to a doctor by the pharmacist and found to have meningitis, and the assessment by a pharmacist of a cold sore which proved to be cancerous, after referral to a doctor.

It should be noted that the Pharmacy Medicines and Pharmacist Only Medicines schedules do not exist in all markets of the world. In the United States where there is a low level of service, products are only available on prescription or as open sellers. This causes significant additional health costs. The best example is the drug codeine which is used in headache medication (eg Panadeine, Mersyndol) and cold and flu medicines. If Australians were expected to make a special visit to their doctor to get access to these products the MBS (medicare) fees alone would be over $600 M per annum.

3.2.3	Medication Reviews Reduce Risk and Error

Consumers who take multiple medications can experience many problems.  They may not fully understand when they need to take each medication or how to take it.  They are at risk of not getting proper benefit from the medication or experiencing an adverse event related to those medications or combination of medications.

The HMR process utilises the specific knowledge and expertise of each of the health care professionals involved

Home Medicines Review (HMR) is a service for consumers living at home in the community and was introduced in October 2001.  The goal of HMR is to maximise an individual consumer’s benefit from their medication regimen, and prevent medication-related problems through a team approach, involving the consumer’s general practitioner and preferred community pharmacy, with the consumer as the central focus.  It may also involve other relevant members of the healthcare team, such as nurses in community practice or carers.

The HMR process utilises the specific knowledge and expertise of each of the health care professionals involved.  In collaboration with the general practitioner, an accredited pharmacist comprehensively reviews the consumer’s medication regimen in a home visit.  After discussion with the pharmacist of the visit findings and report, the general practitioner and consumer agree on a medication management plan.

The Home Medicines Review Program (HMR), also known as Domiciliary Medication Management Review Program, has been funded through both the Third Community Pharmacy Agreement, and the Medicare Benefits Schedule (MBS) through the introduction of a Medicare item for GP involvement.  The HMR service is a structured and collaborative health service provided to consumers in the community to ensure that their medicine use is optimal and fully understood.  The goal of the review is to maximise an individual’s benefit from his/her medication regime as well as to improve their quality of life and health outcomes.

As at 30 June 2005 a total of 77,855 HMRs had been undertaken since October 2001 and approximately 81 per cent of community pharmacies are registered with the HIC to provide HMR services.  The success of the HMR Program has seen the Department of Veterans’ Affairs utilising the model to provide HMRs to veterans.

A study conducted in 2000 estimates that each HMR performed has a potential cost saving of $220, which is derived from PBS savings, and the combined reduction of PBS use of health care resources is estimated at $280.

Although a remunerated service, HMRs still require a considerable financial investment on the part of the community pharmacy and the accredited pharmacist. Development of incentives to increase the uptake of the program is well overdue. In addition mechanisms to increase referrals from GPs such as automatic referrals based on agreed risk criteria or upon reaching the PBS safety net should be developed.  This would maximise the health outcomes and financial savings of the program.

3.2.4	There are Value-Improvement Opportunities in Aged Care

Community pharmacy has made a signification contribution to the safety and efficiency of provision of medications within Australia’s health care facilities.  It now provides medications for people with complex medication regimens through Dose Administration Aids (DAAs) such as blister packaging, the main brand being Websterpak.  Use of these Dose Administration Aids ensure that the consumer and aged care service providers understand which medications are to be taken at any particular time.  This reduces the risk of people suffering an adverse event related to their medication use, and ensures that outcomes for the consumers are maximised.  

DAAs have proved to be so effective that aged care facilities have been able to reduce their reliance on fully qualified nursing staff to administer the medications

DAAs have proved to be so effective that aged care facilities have been able to reduce their reliance on fully qualified nursing staff to administer the medications.  Because DAAs have been proved to be a safe, effective method, they are able to be used by other less qualified less costly staff, e.g. enrolled nurses, with an appropriate level of training.

A recent study on the Effectiveness and Cost Effectiveness of Dose Administration Aids concluded that DAAs may be seen as effective in improving clinical outcomes.  DAAs such as blister packaging reduce the capacity for error in administering medicines in residential facilities and also reduce registered nursing hours which achieve significant cost savings, or at least frees up registered nursing time to devote to other aspects of resident care.

In addition to the provision of DAAs, Residential Medication Management Reviews (RMMRs) have been provided by accredited pharmacists to residents of residential aged care facilities since 1995.  Annually, 80 per cent of residents access this service.  This is approximately 130,000 reviews per year. There are currently 140,683 approved places covered by contracts.

It is also worth noting that DAAs are used extensively in the community setting and assist consumers and their carers with safe medication management. The use of DAAs in the community assists people, who would otherwise require costly care in a residential aged care facility, to remain in their own homes. 

However, pharmacies in general provide DAAs to patients at home and in residential care facilities at a financial loss because blister packaging is very labour-intensive and pharmacist supervision is required by law to ensure no errors are made.

3.2.5	Pharmacists Prevent Medication Errors

Medication safety is a critical issue in health care. Medication-related errors and adverse events result in poor outcomes for consumers and inefficient use of health care resources.  Community pharmacy plays an important role in avoiding medication related errors, thus avoiding poor outcomes for consumers and considerable cost savings to governments and other health care funders.

Most medicines can be dangerous substances if not used properly.  The prescribing and dispensing of medications is a complex process which is sometimes prone to error.  There are many different steps, from diagnosis and prescribing, through to when the medicine reaches the consumer.  When medicines do reach the consumer they can easily be taken in the wrong doses or at the wrong time.  They can also cause an adverse reaction in some people.  If more than one medication is being taken, risks of medication errors and adverse events are increased.

Medication related errors and adverse events result in poor outcomes for consumers and inefficient use of health care resources

Nationally, data indicates that between two and three per cent of all hospital admissions are related to problems with medicines which may originate within the community or within the hospital.  A recent publication of the Australian Council for Safety and Quality in Health Care estimates that at least 70,000 hospital admissions each year are associated with an adverse drug event.

The Quality in Australian Health Care Study which aimed to find out the incidence in Australian hospitals of adverse events that resulted in disability, death or prolonged hospital stay found that just under two per cent of hospital admissions were associated with adverse drug events, that the most commonly involved medicines were for heart disease and high blood pressure, antibiotics, anticoagulants, nonsteroidal anti-inflammatory drugs and medicines for cancer chemotherapy.  That study also found that 43 per cent of adverse drug events were considered potentially avoidable. 

People aged over 65 years have higher rates of medication incidents, partly because they are more likely to be taking one or more medicines.  A South Australian study of 1,000 patients considered to be at high risk of medication problems identified 2,764 medication-related problems (2.8 problems per person).  It also identified that 37 per cent of those problems related to medication selection, 17 per cent related to the medication regimen and 20 per cent related to patient knowledge and skills to manage their medicines and/or conditions. . 

The Australian Council for Safety and Quality in Health Care has identified a number of strategies that have been shown to reduce medication related adverse incidents including regular monitoring and review of medications, effective transfer of information between hospital and community settings and community based medication management and case conferencing.  Community pharmacists are ideally placed to play a central role in these strategies and to prevent many medication errors.  Because they are accessible, and because they enjoy a high degree of trust in our community, they are able to establish lasting relationships with patients, particularly those who have a high need for medication and/or who may be taking more than one medication. However, maintaining this role depends upon its viability in an economic sense, as part of a total business model for community pharmacy. While doctors are entitled to a fee for case conferencing, pharmacists are not.

3.3	Infrastructure Costs and Complexity are Growing

Pharmacists are required under provisions in the various State and Territory Drugs and Poisons legislations for ensuring the safe and proper storage of drugs and poisons, including taking measures to prevent the diversion of any drugs onto the illicit market.  Medicines must be stored in pharmacies in accordance with recommended standards or settings in regard to temperature, light, humidity etc.  The NHMRC standards set out the requirements for such storage.

In the future it is likely that pharmacy will increasingly be seen as the appropriate delivery point for all vaccines and temperature sensitive medical products

These cold chain requirements are leading to the increasing use by pharmacy of special temperature-adjusted and controlled refrigerators for vaccine and other medicines that need to be stored at between 2 and 8 degree Centigrade. 

The wholesale distribution of medicines has been developed to ensure the integrity of these medicines is maintained. In the future it is likely that pharmacy will increasingly be seen as the appropriate delivery point for all vaccines and temperature sensitive medical products. 

Furthermore, many new biological products are being developed that will be sensitive to temperature and will require special handling, leading to the need for specially trained personnel.

3.4	Chronic Disease Management is Increasingly Important

The need for coordinated multidisciplinary management of chronic illness in the community is increasing within our health care system.  The number of people living with a chronic illness is expected to grow as our population ages, and as advances in medical knowledge and treatments enable more and more people to live active lives in the community while living with a chronic condition.

Community pharmacists are ideally placed to help people manage their chronic illness.
They have a substantial degree of contact with such people through their use of medications and other pharmacy supplied products and services.  The Pharmacy Guild, in partnership with the Australian Government Department of Health and Ageing, is exploring ways in which pharmacy, by working in partnership with GPs, can play an increased role in identifying and managing chronic illness.  Through its Research and Development Program, it has funded a number of studies examining the role of pharmacy working with doctors in chronic disease management, including osteoporosis, cardiovascular disease, asthma, diabetes, continence management and hypertension.

There is already evidence of the effectiveness of this role, with the National Pharmacy Study of 2003 showing that enhanced services with trained staff were evident at high levels for asthma, diabetes, hypertension, smoking cessation and wound care, and that many of these services were provided at no charge.

3.5	Health Education, Screening and Illness Prevention are Vitally Important

As the Productivity Commission Issues Paper points out (p43), greater emphasis on health maintenance and disease prevention could reduce the rate of growth in demand for services and thereby ease pressure on the health workforce.  There is enormous potential to further develop the role of community pharmacists in preventing illness and increasing health education.

Community pharmacists are increasingly involved in providing a range of health education and illness screening and prevention programs.  Screening tests are done in many pharmacies for a range of health problems including cholesterol, glucose, blood pressure and bone density.  Illness preventive services include anti-smoking advice, nicotine replacement and provision of iron for anaemia and calcium for bone density.  In many cases and, where appropriate, screening by pharmacists results in the consumer being referred to the GP.

Community pharmacists are increasingly involved in providing a range of health education and illness screening and prevention programs

Over recent years the Pharmacy Guild, in partnership with the Australian Government Department of Health and Ageing has conducted, through its Research and Development Program, a number of studies exploring the current and potential role of pharmacies in keeping our population healthy.  These studies show promising results.

3.6	Harm Reduction is a Pharmacy Activity

There is great potential to increase efficiency by reducing harm from drug dependence. Community pharmacies already play a critical role in helping people to reduce their dependency on legal and illegal drugs, and to manage their addiction as safely as possible.  For example, community pharmacists work with general practitioners in benzodiazepine-reduction programs, where the pharmacy, in concert with the GP, oversees the administration of the benzodiazepine medication.  This sometimes involves labour intensive activity such as preparing individual prescriptions for one day supply of medicine at a time (daily dosing).

Australia’s pharmacies also rank highly in providing harm reduction programs, including methadone dosing which is now amongst the most widely practised and cost effective of the specialised services in community pharmacy.  Recent research projects have shown:

•	high acceptance of methadone services provided by community pharmacies;

•	retention in the community pharmacy-based programs to be significantly higher than retention in the clinic-based programs;

•	higher costs in both public and private clinic-based methadone services than in community-pharmacy based programs – the cost of dosing a patient in a public clinic with methadone is approximately $60 per week.  The cost of providing methadone in community pharmacy has been calculated at $25 per patient per week;

•	increased community pharmacy and drug user participation where government incentive programs are introduced such as those currently operating in NSW, ACT and Tasmania.

Community pharmacy also plays a major role in harm reduction by providing Needle and Syringe Availability Programs (NSP). The Guild is committed to examining all options to protect both injecting drug users and the wider community from blood borne disease associated with unhygienic injecting practices such as needle sharing and unsafe disposal. In the private sector such programs are almost exclusively through community pharmacy despite these products being able to be sold in many outlets. To date, community pharmacy, representing more than 50% NSP outlets around the country, has made a significant contribution to the prevention of blood-borne diseases among people who inject drugs and within the wider community.

The availability of sterile injecting equipment in pharmacy has resulted in the reduction of transmission of blood borne viral infections such as HIV and Hepatitis C within the community. The program has also made it possible to access people who inject drugs for medical reasons and to provide a gateway to other treatment and drug rehabilitation programs for drug users. In some states pharmacies also provide a point of disposal for used injecting equipment.

To ensure that this work continues through pharmacy, acknowledgement and support should be given to those pharmacies distributing sterile injecting equipment and health information to people who inject drugs. Options for disposal methods in community pharmacy should also be researched and considered as for this service to be effective, pharmacies need to be properly resourced to carry out this role.

3.7	Pharmacy Delivers other Health and Community Services

Community pharmacy plays a critical role in a number of other health and community services, including:

•	
Community services programs help people to stay healthy and mobile, and represent cost savings to government in terms of decreased used of health care services and institutional care

outreach educational programs that provide advice on a range of issues such as breastfeeding and baby care, aged care, chronic illness prevention and management;
•	provision of aids and equipment to enable people to live safely in their own homes rather than needing institutional care; 
•	immunisation advice for children and travellers; and
•	assistance and advice for parents of young children.

All these programs help people to stay healthy and mobile, and represent cost savings to government in terms of decreased used of health care services and institutional care.

4.	Addressing Workforce Issues

4.1	Addressing Workforce Structural Issues

4.1.1	Will There be Enough Community Pharmacists

Pharmacists, like other health professionals and business people, choose where they will invest their abilities and resources. As overall workforce demand increases, there will be more and more attractive alternatives for the pool of newly graduated pharmacists. If the balance of incentives, costs and risk are not attractive, the pool of those prepared to undertake the role will inevitably decline. It is this problem, rather than issues around training and regulation that is the ultimate determinant of the supply of community pharmacists.

There are national and international shortages of both community and hospital pharmacists, including in the United States, Canada, New Zealand and South Africa.

A complex range of factors affect the Australian pharmacist labour market and include:

•	structural issues—changes in the way that health services are organised and delivered, and the evolution of new management models;

•	technical changes—associated with the increasing complexity of medication;

•	workforce demographic change—associated with feminisation and ageing proprietors in community pharmacies;

•	extended working hours to seven day trading and evening trade;

•	security issues based on pharmacy being a soft crime target;

•	working arrangements—the way in which pharmacists work with assistants and technicians and collaborate with the medical profession;

•	demographic change in the general population—and its impact on the demand for the services of pharmacists;

•	educational—marked by increases in pharmacy student enrolments;

•	political and cultural— the application of new professional standards, government and consumer expectations concerning safety and the quality use of medicines, and the implementation of new Government policies;

•	rural concerns—associated with ensuring adequate service access in rural and remote localities;

•	addressing the specific needs of Indigenous communities; and

•	information technology—characterised by the integration of professional care with electronic data interchange.

The supply data confirms that out of a total workforce of almost 18,000 pharmacists:

•	almost 80 per cent of pharmacists work in community pharmacy, and about 17 per cent in hospital pharmacy while the number of pharmacists engaged in other areas of pharmacy-related work, such as academia, administration, the pharmaceutical manufacturing industry and consultant pharmacy, remains comparatively small. There are approximately 1600 accredited consultant pharmacists.  There is a reported shortage of hospital pharmacists and there have been suggestions that increasing job placements of pharmacy graduates in their pre-registration year in hospital pharmacies may go some way to addressing this shortage, since there is very high retention of hospital pharmacists, despite relatively lower income levels.

•	
80 per cent of pharmacists work in community pharmacy

the community pharmacy workforce is ageing and the age profile mirrors that of the total population. This is highly unusual since the working population usually draws from a considerably younger aged profile.  It suggests that pharmacists retire at a later age than the rest of the workforce, but despite this, a sizeable proportion of the workforce will be retiring within the next 10 years. :

­	24% are less that 34 years old
­	25% aged between 35 and 44
­	21% aged 45- 54
­	21% aged 55-65 and 
­	8.5% older than 65

•	the proportion of females in the pharmacy workforce has steadily grown and now approximates the number of males (47.5 per cent female and 52.5 per cent male).  However female pharmacists tend to be younger than males:

-	more than 60 per cent of female respondents were less than 45
-	more than 60 per cent of male respondents were 45 or more, including 30 per cent aged 55-64

This seems to foreshadow a significant restructuring of the pharmacy workforce and work practices in the next 10 years, as older male pharmacists become due to retire and are replaced by younger female pharmacists and there is an expected increased demand for flexibility in working arrangements.

•	nationwide the average hours worked by pharmacist remains fairly stable at 38.6 hours per pharmacist per week.  The workforce pharmacy survey (2000) revealed that almost half of those surveyed worked 41 hours or more.

Pharmacies generally open seven days a week and operate extended hours, with 60.67 hours per week being the average opening hours per week - ranging from 40 to 84 hours per week.  This is enabled by extensive use of part time pharmacists and other staff who are prepared to work longer hours.

•	Total enrolments in pharmacy schools have grown by nearly 4 per cent per annum for the past 15 years.  Overall FTE pharmacist workforce supply will grow from 11,188 in 2000 to between 13,594 and 14,147 in 2010, representing an average annual growth rate ranging between 1.98 per cent and 2.38 per cent depending, respectively, whether one adopts high or low values for net workforce loss.  The conversion factor for calculating workforce numbers is .86.

Projected new graduate supply and net migration to 2010 jointly represent an average annual net contribution to the workforce of about 6.6 per cent

Pharmacy workforce growth is the joint product of new graduate supply and net migration, whose year-to-year contributions are in turn offset by losses occasioned by retirements of ageing male pharmacists, reduced per diem average hours of participation, largely as a consequence of increasing feminisation, and a relatively high rate of occupational separation.  Projected new graduate supply and net migration to 2010 jointly represent an average annual net contribution to the workforce of about 6.6 per cent. With annual net wastage of 7 per cent the workforce is barely capable of maintaining constant numbers.

•	It is predicted that volume of demand for other pharmacists will grow roughly in proportion to growth in demand for pharmacists in the community and hospital sectors. ‘Others’ include academics, research pharmacists, accredited consultant pharmacists and pharmacists who are employed as facilitators in general practice divisions and other organisations such as the National Prescribing Service.

In the past seven years there have been growing opportunities for pharmacists in the Divisions of General Practice network in the facilitation of improved health professional pharmacy health care practices. These roles require health professional knowledge and skills and pharmacists have proved to be valuable in these roles. While a few pharmacists are employed in Divisions as primary health care program coordinators/managers, most have been engaged as National Prescribing Service (NPS) facilitators or Medication Management Review (MMR) facilitators. These roles draw upon the pharmacy background through a social marketing framework to influence change management within pharmacy and general practice.

These roles are providing new career opportunities for pharmacists, usually on a part time bases and often in conjunction with other pharmacy positions. For example many facilitators also work part time in community pharmacy and/or as an accredited consultant pharmacist or in hospital pharmacy.

4.1.2	Supply of New Graduates

The graduate supply rose from 338 in 1985 to 619 in 2001.  Although there have been substantial year-to-year variations, this represents overall an annual growth rate of about 3.8 per cent— a very significant increase in graduate numbers.  Projected enrolments in pharmacy courses in the 15 pharmacy schools of pharmacy across Australia are predicted to continue to rise at much the same rate: from 1,100 in 2005 to 1,170 in 2008.

By applying a broad rule of thumb that 80 per cent of enrolled students graduate (and allowing for a further loss of overseas students), a projected estimate for new graduate supply to 2008 can be calculated as being:
­	2005 - 1100
­	2006 - 1000
­	2007 – 1100
­	2008 - 1170

This does not take into account any future changes in the structure of pharmacy undergraduate courses.  For instance, pharmacy course structures might move to further extend the term of training or to a postgraduate training structure similar to medicine or to fast tracking of students.

The key requirement is to have an appropriately managed response so that the source of training supply can be managed to meet workforce demand. Wherever infrastructure investment is required to enable an increase or decrease in student numbers, there could be difficulty in flexibly responding to unforeseen demand reductions or increases.  This implies that significant changes in student intake should occur only at educational institutions where increased infrastructure investment was not required.

Industry representatives report that significant negative influences on attracting undergraduates include:

•	alternative career pathways that do not attract HECS debt;
•	the increasing attraction of non degree career pathways;
•	university funding issues that have resulted in increased class sizes;
•	cost of establishment or purchase of pharmacy businesses;
•	access to sufficient high quality training sites;
•	the attractiveness of pharmacy as a career.  The Intergenerational Report identified the following key drivers for future undergraduates will be:
­	incentives and the security of those incentives
­	pressures of the job and capabilities required; and
­	the ‘attractiveness’ of the career, including accompanying status and value.

Additionally, reported changes in the attitudes of generation X and generation Y members may require a rethink about workforce structure and job design, to reflect these different values, beliefs and attitudes.  It could be expected that there may be particular pressure to build in flexibility, creativity and change, embrace the use of new technology and increase the focus on social and community needs.  For the pharmacy profession, this will mean better marketing of pharmacy career pathways and work structures, including access to part time work; and for education providers, ensuring programs are meaningful and engaging.  Whilst the absolute numbers of graduate will increase due to some extent to an increase in the number of schools offering pharmacy courses, and the growth of the Masters’ programs linked to a Bachelor’s degree in an appropriate health discipline, the challenge will be to retain these graduates in an increasingly competitive employment market.

These issues will need to be addressed if the number of undergraduates attracted to pharmacy is to increase.

Training Sites for Undergraduates

The provision of ‘on site’ training under the supervision of an experienced pharmacist is a vital component of undergraduate education.  The incorporation of ‘clinical training’ for undergraduate pharmacy students was made possible by the extension of pharmacy courses from three to four years at Australian universities from 1997.  The extent to which the various schools of pharmacy have incorporated clinical training varies across Australia, with some universities having 15-20 weeks during the final years of the BPharm whereas some other universities only have one or two weeks in total.

A balanced pharmacy education would see students receive training in the community setting as well as the hospital setting. It should be noted that there is an inconsistent approach across all states where the responsibility lies with the state governments. By way of example in Queensland the public hospital sector has reduced the number of placements.

There are too few places in pre-registration training sites. There should be government funded placements for graduate and post graduate clinical pharmacy placements 

However, clinical training is expensive in terms of people’s time and in terms of the funding required.  By way of comparison, no government funding is provided for clinical training in pharmacy courses whereas funding is provided for courses in medicine, dentistry and veterinary science.  The solution is for clinical training in pharmacy courses to be recognised in the formulae used by the Federal Government to fund universities.

It this was to be achieved, hospitals and community pharmacies would receive funds to provide the training, and that would greatly increase the number of sites available - at present there are too few sites willing and able to participate.

Pre-Registration Training Sites

The issue of pre-registration training sites have similar difficulties in that there are too few places, with the same sites generally being used for both undergraduates and pre-registration pharmacists and this is exacerbated by the increasing number of graduates from pharmacy schools.

At present there is a severe shortage of suitable sites. In the pre-registration year all ‘students’ are paid a ‘training’ salary of about $30,000 pa.  This severely limits the number and nature of pharmacies, both community and hospital, that participate.  The problem is becoming acute because of the rapid increase in the number of pharmacy graduates emerging from the growing number of schools of pharmacy in Australia.

It is quite possible that some pharmacy graduates will not be able to find a site for pre-registration training in the very near future.

The Training Workforce

The limiting factor at present is the acute shortage of suitably qualified and experienced pharmacists to provide core aspects of the required training.  Put simply, there is a serious shortage of pharmacy academics, to the extent that some schools of pharmacy, particularly the new ones, are severely under-staffed.

In effect, the supply of pharmacy graduates by the schools of pharmacy is in a very brittle state - some schools are just ‘hanging in there’.  There are several solutions, including the closure of some small schools of pharmacy or their amalgamation to provide a ‘critical mass’.  This is not consistent however with current developments, where the pressure on universities to provide full fee paying places is resulting in increased offerings in pharmacy which is perceived as an attractive option.

Another solution is for additional funds to be provided to enhance clinical training by pharmacy practitioners.

4.1.3	Distribution of Pharmacies and Pharmacists

Restructuring of pharmacies under the Third Pharmacy Agreement has established a framework for ensuring ongoing supply and distribution of pharmacies within the community.

A number of initiatives have been implemented to continue to address pharmacy supply and distribution issues in rural areas:

•	
Since the commencement of the Program, only one rural pharmacy has closed as a result of a lack of buyer for a remote pharmacy

The Rural Pharmacy Workforce Development Program (RRPWDP) aims to implement strategies to strengthen and support the rural and remote pharmacy workforce in Australia.  The RRPWDP consists of interventions on a variety of levels, including continuing education scholarships for rural pharmacists, an emergency locum placement service, scholarships for students from rural and remote areas wishing to study pharmacy, internship scholarships for undergraduate students, specific scholarships for Indigenous students, rural and remote pharmacy infrastructure and support grants, placement of pharmacist academics in rural areas, a national rural pharmacy promotion campaign and a rural pharmacy newsletter.

The effectiveness of the RRPWDP has been assessed as part of the Rural Initiatives Program Evaluation.  The Guild is aware that since the commencement of the Program, only one rural pharmacy has closed as a result of a lack of buyer for a remote pharmacy (Brewarrina, where the pharmacists just left).  This compares to at least five closures in the six months preceding the introduction of the rural pharmacy package.

•	The Rural Pharmacist Pre-registration Incentive Allowance aims to encourage young pharmacists to practise in rural and remote areas.  The Scheme offers a financial incentive of up to $10,000 to QCPP-accredited rural pharmacies in PhARIAs 2-6 that employ a pre-registration pharmacist for a period of six to twelve months.  The scheme commenced in 2004 and has received a total of 110 applications to date.  This program should continue and include a tracking process (for the purpose of future evaluations) to help determine if the rural pre-registration setting is resulting in more pharmacists in rural areas.

•	One area of work that needs to be undertaken is an investigation of models of innovative pharmacy practice involving greater hospital/community pharmacy collaboration and the joint Commonwealth and State/Territory funding of flexible pharmacy positions moving between the two areas of pharmacy practice.

4.1.4	Using Pharmacy Assistants to Cover Shortfalls and Increase Quality of Care

The Pharmacy Guild has been at the forefront of industries in Australia in relation to training of pharmacy assistants.  National competency standards for pharmacy assistants were developed in the early 1990s, ten years before other sectors of the health industry, and the Pharmacy Guild has acted as the main Registered Training Organisation for providing training and assessment services to pharmacies across Australia.

Recent and emerging initiatives include:

•	national take up of new apprenticeships for pharmacy assistants;
•	development and delivery of training for dispensary assistants; and
•	a proposal to award scholarships of $2,000 to encourage Indigenous workers to consider training as a pharmacy assistant.  It would be eligible to PhARIAs 2-6, and a total of 20 scholarships would be offered per year.  This scheme would be developed in cooperation with NACCHO.

The Pharmacy Guild has been at the forefront of industries in Australia in relation to training of pharmacy assistants

Unlike many other countries, Australia has Pharmacy Medicines drug classification for non-prescription medicine (over-the-counter medicines). These medicines may be supplied by a pharmacy assistant under the supervision of a pharmacist so that the person has access to a pharmacist if required. The system relies on the skills of the highly trained pharmacy assistant workforce.  Continuance and expansion of the skills of pharmacy assistants to provide a multi skilled workforce that has identified career pathways and defined level of expertise, as articulated in the national qualifications of the Retail Industry Training Package will continue to be a major focus of industry activity.  As the Training Package is reviewed (commencing mid 2005) it could be expected that this will continue to be a key area of focus for ensuring the provision of high quality health services.

4.1.5	Retention of Graduates and Registered Pharmacists

The number of registered pharmacists in each State and Territory from June 2003 to 30 June 2005 are as follows:

Jurisdiction	2003	2004	2005
	
NSW	7234	7389	7582	
VIC	4919	5040	5248	
QLD	3712	3575	3808	
WA	1811	1870	1951	
SA	1269	1331	1399	
TAS	474	488	514	
ACT	358	365	395	
NT	480	539	598 *	
Total	20,257	20,597	21,495**	

*Currently registered without expiry date.  The new Act will require annual renewal and is estimated that this may drop to approximately 100.

**It is estimated that 5,000 are either registered in more than one State/Territory or currently not in workforce.

Growth for the past year is 4.4 per cent, well up on 1.7 per cent for the period 30 June 2003 to 30 June 2004.

Key issues facing retention of graduates and registered pharmacists are:

•	reducing the wastage from the projected 3 per cent – 7 per cent range down to 2 per cent per annum (or lower);

•	retaining younger, female pharmacists, both in the active workforce, and in a more fully participating capacity. In other similar workforces, female participation rates appear to be enhanced by having an ownership stake in the practice in which they work; and

•	engineering an enhanced ebb and flow of pharmacists, instead of attempting to impede the movement of pharmacists from hospital to community practice (to arrest the ‘leakage’).

Accurate location and tracking of pharmacy graduates and monitoring their career paths are important for developing and evaluating strategies for the retention of pharmacists.  The development and implementation of a longitudinal tracking system of graduates to determine their subsequent career moves and to more accurately calculate the wastage rate would be invaluable.

4.1.6	Improving Quality of Care in Pharmacies

Pharmacies routinely undertake and participate in a very wide range of professional development activities aimed at both pharmacists and pharmacy assistants.  Many educational programs are conducted by the Pharmaceutical Society, the Pharmacy Guild, which has for many years provided nationally accredited training to pharmacy assistants, and by manufacturers and other companies.  Underpinning the commitment and practice of professional development is the Quality Care Pharmacy Program (QCPP), a quality assurance, self-regulation program for Australian community pharmacy that consists of an integrated system of performance standards, supporting tools and processes.

The QCPP program provides a framework for improving processes and implementing structural changes to pharmacy to improve productivity 

Imbedded in the QCPP is the requirement for ongoing professional development.  The provision of substantial funding in the Third Community Pharmacy Agreement for quality professional pharmacy services and programs recognised for the first time the important contribution that pharmacists make to the health of the community in an ongoing way and the ongoing commitment of pharmacies to continuously improve.

Apart from its impact on professional development, the QCPP has also become an important vehicle for industry quality assurance and self-regulation.  Proprietors of pharmacies which have gained accreditation attest to improved performance of the pharmacy team in delivering a consistently high level of service to pharmacy customers, to staff empowerment and higher levels of productivity, to an improvement in business management as a result of properly-documented processes, and to higher levels of customer satisfaction in the quality of the services that the pharmacy delivers.

The QCPP program also provides a framework for improving processes and implementing structural changes to pharmacy to improve productivity. Community pharmacy is now familiar with a systemised approach, a standard approach, and the same template could be used to implement health programs. Many health programs are currently unable to be delivered by other professions as it requires a system wide change in management processes. The QCPP provides the mechanism to remove barriers and implement workforce change.

4.1.7	Covering Short-Term Shortfalls

There is estimated to be a huge pool of about 5,000 registered pharmacists not working in pharmacy. An increase in re-entry rates would require:

•	research into the characteristics of ‘non-practising’ pharmacists (age, gender, location, etc),  their reasons for leaving (such as long working hours, switching to medical degree,  etc), and the types of re-entry courses that would suit their needs; 

•	a national effort to provide innovative and flexible models for re-entry, including part-time training, on the job training, existence of infrastructure, etc.

Given the age distribution of retired pharmacists, this is not perceived as an available long term strategy to address perceived workforce shortages unless, through changes to working arrangements, women and younger people who have left pharmacy can be enticed back to make longer term contributions.  Such changes are likely to include more flexible working conditions, better alignment of work and non-work arrangements, ‘suitable’ remuneration and more flexible (i.e. shorter) working hours.  It would be a worthwhile exercise to conduct an analysis of non registered pharmacists to scope the opportunities for recruiting them back into the pharmacy workforce for the longer term.

4.1.8	Immigration is Not the Answer

There is limited scope for increasing pharmacist immigration rates

The total intake of immigrant pharmacists annually is equivalent to one Australian university pharmacy school. However there is limited scope for increasing pharmacist immigration rates unless Australia targeted overseas labour markets with a current or emerging oversupply of pharmacist labour, and where the standards of training were acceptable.  A difficulty here is that many countries comparable with Australia also face likely pharmacist shortages  and such a strategy is unlikely to address demand.

Changes to the United Kingdom pharmacist registration reciprocity arrangements with Australia after 2006 may deter pharmacists migrating to United Kingdom and consequently may affect supply to the Australian labour market.

4.1.9	Regulation of Pharmacies and Pharmacists Limits Flexibility

Each State or Territory has pharmacy and pharmacist-specific legislation consistent with its responsibility for regulating the profession and its practice.  In general such regulation is aimed at protecting the public by ensuring health care is delivered by registrants in a professional, safe and competent way, upholding standards of practice within the profession and maintaining public confidence in the profession. The Pharmacy or Pharmacists Boards in each jurisdiction administer the relevant Acts.

State/Territory Health Departments also have a role in administering the regulations and ensuring practice standards are met.

The Commonwealth also has a regulatory interest through its National Health Act 1953.  The Act sets out statutory requirements for the administration of the Pharmaceutical Benefits Scheme (PBS), including the power to determine which pharmacies may ‘supply’ pharmaceutical benefits to the public, and where these may be located.  The Commonwealth imposes strict controls on approving a new pharmacy, and on relocating existing pharmacies, for PBS purposes.  These location-based controls help to give effect to the Australian Community Pharmacy Agreement between the Commonwealth and The Pharmacy Guild of Australia. 

The protection of the public through these regulatory arrangements is a social responsibility that should be resourced adequately by government.

Mobility is important to ensuring that both short term (locum) and long term demands can be met. The Guild supports the need to have state-based uniform pharmacy regulatory structures and a unified system of administration of regulation throughout the country, particularly with regard to pharmacist-ownership of pharmacies as a means of ensuring community needs including in rural and remote communities are addressed.  In addition, the introduction of a national registration scheme for pharmacists would facilitate across-border services, particularly in rural and remote areas, which currently require registration in each jurisdiction of operation. Currently Australian medical boards are developing a scheme for the national registration of doctors.  Such a scheme may ultimately provide a template for the national registration of pharmacists.

The Guild supports the need to have uniform pharmacy regulations throughout the country

There is an opportunity to further explore the regulatory arrangements, particularly by applying the QCPP as a means of industry self-regulation and using government powers to regulate the service site (i.e. the pharmacy) in much the same way that the aged care accreditation system operates.

Such a shift would place emphasis on the requirement for very effective change management strategies including for succession planning, customer service strategies that address changing consumer expectations and changes in workforce requirements (both structural and skill-sets).

4.1.10	Data Collection and Reporting Can be Improved

Pharmacy workforce data which is collected by Pharmacy Boards and the Australian Institute of Health and Welfare needs to be collated, analysed and reported upon in a timely and effective manner. Currently the data gathered by the Boards is supplied to State and Territory governments for processing where delays occur. Consequently, current data is frequently out of date when reports are received.  The use of annual renewal of registration as an opportunity to disseminate and collect data should be undertaken. Given that Pharmacy Boards are not sufficiently resourced, it could be done instead by health workforce sections of state and territory governments. This would provide an opportunity to maximise the linking of data related to practising pharmacists throughout Australia including in rural and remote areas. 

4.2	Community Pharmacy has a Program to Lead Change

Clearly community pharmacy needs to be ready to take on the challenges in the changing health care environment, and the different sorts of demands placed on pharmacy services in the future.  A recent research report investigating the need for change in community pharmacy made a number of recommendations about the way forward, including a recommendation for a need to move from a model of service delivery based primarily on ‘all pharmacies offering all services’ to a more flexible model where all pharmacies offer a core set of services but in addition specialised services are offered by a more limited number of pharmacies.  Other change management support that would be required includes:

•	moving to a primary health care focus including providing education and health promotion strategies;
•	developing more team based approaches to service delivery;
•	moving out of the pharmacy environment to take services to older customers at home and in residential aged care settings;
•	networking and providing services in conjunction with other heath service providers; and
•	utilisation of technology in the workplace.

Change management support might be delivered by consultant pharmacists, specialist health business management services and through developing networks of pharmacies, including via the internet.

4.3	Enhanced Use of Technology by Pharmacies is a Way of Reducing Workforce Pressure and Improve Outcomes 

Information Technology represents one of the key areas of strategic change currently underway in community pharmacy and one which will have a profound impact on the practice of pharmacy but more importantly on health outcomes.  While there are many initiatives in progress, two projects in particular will have a far reaching effect on the way information is shared both within pharmacy and in the wider health care sector.  These are MediConnect and e-Dispensing and e‑Claiming Standards.

There is widespread agreement about the merits of a national electronic health information system, where that information is seamlessly shared among pharmacist and prescribers, with the Health Insurance Commission (or other funds) and with the main beneficiaries of such a system being consumers.  The Guild shares this vision with government and other stakeholders. Recent independent research, undertaken by research and communications strategists Crosby Textor, shows that consumers value the service, discretion and confidentiality provided by community pharmacies and trust pharmacists with their health data, related address and entitlement details. Pharmacy has a strong record and reliability in maintaining accurate records and ensuring that privacy requirements are met. Pharmacists as health professionals have used this information only as required.

There is widespread agreement about the merits of a national electronic health information system

For over five years, Australia has been grappling with the idea of a national health information system, tracing its history from the Health Ministers National Health Information Management Advisory Committee (NHIMAC); to the Better Medication Management System (BMMS); through to MediConnect; and now to HealthConnect (which technically incorporates MediConnect). The field tests in Ballarat (Victoria) and in Launceston (Tasmania) have been invaluable in separating the functional from the ‘nice to have’.  Nevertheless, development of a national system has been inordinately slow.  HealthConnect trials, scattered across various States and the Northern Territory, are still in progress with varying degrees of maturity.  Evaluations are ongoing.

Standardisation of dispensary systems is critical to the rollout of not only MediConnect but also other initiatives such as PBS On-line and would ensure the seamless transfer of health information.

The Guild recently rolled out the ‘Broadband for Pharmacy’ program, funded by the Commonwealth, designed to encourage pharmacies to embrace broadband technology.  The level of incentive was designed to match the most cost-effective provision of service in a given region and included the cost of installation.

Despite bureaucratic limitations, preliminary results suggest that the program was an unqualified success, with an uptake rate of over 75%.  In most cases the physical connections will be put in place in the course of the next six months.

However, the critical challenges facing pharmacists (and doctors) are only partially met by the physical construction and delivery of network infrastructure.  The real challenge is management of perceptions, mind-sets and change.  This is why the Guild has proactively pursued the initiative (funded by the Australian Government) not only to prepare pharmacy systems (through standardised systems) but also to provide a change management plan to pave the way for future e-commerce based initiatives.

5.	Enhancing the effectiveness and efficiency of community pharmacy 

Community pharmacy is well placed to be part of the total solution to the challenge of providing effective and efficient health care.  However, governments have an important role to play in ensuring that community pharmacy is able to continue and develop its role in the health care team.  It can only play that role effectively if the mix of incentives, risk and opportunity designed to attract and retain the workforce, and encourage the investment of private capital is in place. Governments need to be aware that decisions that undermine the attractiveness of the retail business, or which increase unrewarded activities, will reduce the capacity of pharmacy to meet either current or growing expectations of what they can and will do.

This section of our submission makes a number of recommendations aimed at enhancing the efficiency and effectiveness of community pharmacy.  They are also aimed at ensuring that community pharmacy is seen as an attractive and viable business that is able to attract and retain a workforce with the skills necessary to work as part of the health care system.  Our recommendations, if accepted, will lead to:

•	security of the pharmacy business model;
•	continuation and strengthening of the regulatory framework;
•	management of the total role mix, so that ‘inefficiencies’ in retailing are traded off against unfunded healthcare services;
•	the opportunity to strengthen and expand the cognitive services offered by community pharmacy.

5.1	Enhancing Effectiveness

Pharmacies have shown that they can play an integral role in the delivery of health services in Australia and to effectively operate as a member of the health care team.  There are productivity issues that can be addressed to enhance future effectiveness and to further improve the capacity of pharmacy to deliver health services.

5.1.1	Addressing Workforce Coverage Issues

The demand for pharmacists is assumed to be governed by the demand for the professional services they provide.  Traditionally in Australia the demand for professional services by community pharmacists relates primarily to those associated with dispensing prescription medicines. This contrasts with the report The Pharmacists Workforce – A Study of the Supply and Demand for Pharmacists of the US Department of Health and Human Services 2000 which identified the critical issue as the delivery of needed pharmaceutical care services to consumers, not simply the dispensing of prescriptions.  

Pharmacist demand may be augmented by a range of cognitive services. In the case of community pharmacists these activities divide into two broad classes:

•	medication management in nursing homes and hostels and in domiciliary settings;

•	interventions delivered in conjunction with dispensing services for prescription medicines as well as for over the counter sales of non-prescription, ‘pharmacist’ and ‘pharmacy only’ (S2 and S3) medicines.  This is unique to Australia.

For prescriptions, they may be to determine the appropriateness of a prescription and / or for proactive communication with consumers to ensure appropriate use of a medication; for over-the-counter sales, they may include advice on the most appropriate medication and counselling on its use.

Pharmacists in Australia have a higher ‘duty of care’ than in the United States with tort law largely based on the English system their legal liability, and indeed, their professional responsibility is greater. Pharmacists act as the ‘safety valve’ between the prescriber and the consumer to ensure that the prescription is safe and that consumers understand how to safely and effectively use the prescribed medication.

Other enhanced roles for pharmacists include a greater focus on primary health care; including screening, education and health promotion activities.  Such an enhanced role may act to curb rising health costs, particularly as the population ages.

Recommendation

That recognition be given to the value of pharmacists in taking on an enhanced professional health-care role that is compatible with their training, knowledge, skills and experience, to meet community needs and to improve health outcomes, whilst making best use of the accessible community health and commercial nature of pharmacy premises.

5.1.2	Addressing Workforce Education and Training Issues

Changes to pharmacy roles will be accompanied by a concomitant change in demand for professional development and education and for assistance with change management.

It must also be noted that expanding the health care role of pharmacists may increase the demand and therefore the shortage of pharmacists.  The position of the Pharmacy Guild is that:

•	the workforce should be primarily sourced locally and use of overseas graduates should not be turned to as a primary strategy, particularly given the shortage of pharmacist in overseas countries which have compatible pharmacy competency based educational and experiential standards to those in Australia;

•	employment of overseas trained pharmacists should be used only as a ‘top up’ to existing numbers.  This would require assurance of equivalence of Australian training and no winding back of evaluation and supervisory requirements for overseas trained pharmacists.  For overseas trained pharmacists entering Australia through normal immigration processes top-up training may be required and competence to practise in the Australian health environment assured;

•	relying on pharmacists who are retired and/or not in the workforce should only be regarded as a short term fix, particularly given the average retirement age of pharmacists;

•	training for pharmacists and pharmacy assistants should focus on development of a multi-skilled, flexible workforce to work within the community pharmacy team;

•	processes for tracking student destinations and career pathways should be implemented to monitor workforce design and distribution issues;

•	registration processes that impede effective workforce participation should be examined and reviewed as necessary;

•	strategies that support better and more accessible pharmacy and healthcare services to indigenous communities should be implemented;

•	programs should be implemented to maximise the skills of pharmacy assistants to enable them to assist with dispensing and other activities that would free up the pharmacist to provide an increased range of cognitive services;

•	the system and processes of preceptor training for new graduates should be examined to ensure:

­	sufficient high quality placements are available
­	placements include rural and remote areas with particular consideration being given to incentives for having graduates placed in rural areas and staying there after registration

•	there should be examination of funding options for the pre-registration year, involving preceptor training in order to increase access to quality sites and quality preceptor-training placements.

The solution to the shortage of training sites for the pre-registration year would be to treat that year as part of a total ‘package’ of education that produces registered pharmacists, and to fund the pre-registration year as if it is equivalent to the clinical training provided for medical, dental and veterinary science students; that is, it is an extension of the issue addressed for the clinical training of undergraduate pharmacy students but with the added complexity of there being a training wage paid in the pre-registration year.

Recommendations

That pharmacist education and training be enhanced through:

•	recognition of clinical training in pharmacy courses in the university funding formulae; 
•	review of the system and processes of preceptor training for new graduates to ensure availability of high quality pre-registration training sites; and
•	adequate funding of training placements by state and territory governments.

That the Government, in partnership with the Pharmacy Guild of Australia, conduct an examination and review of registration processes that impede effective workforce participation.

5.1.3	Addressing Health Workforce Silos

A greater focus on delivery of cognitive services would be complemented by improving collaboration with other health professionals, including GPs, to deliver primary health care programs and by engaging nurses, allied health workers and naturopaths as part of the health services offered in pharmacy.  These services could also be taken into the community and into residential facilities.

Recommendation

That in order to better meet community needs and improve ongoing patient care:

•	greater networking and coordination between health professionals be promoted and encouraged;
•	general practitioners workforce be supported by extending ‘patient health care’ MBS items remuneration to other health care professionals including pharmacists, so that they can work with general practitioners as part of the health care team in accordance with their training and skills set;
•	the role of pharmacy and medication management be recognised by government in funding medication management reviews and other medicine compliance and concordance programs;
•	dose administration aids be funded in the community setting in order to avoid premature placement of patients in residential care.

5.1.4	Increasing the Use of Technology

The Guild believes that far more value creation and savings are possible than have currently been identified by increasing the use of information technology in pharmacies.  Information technology represents one of the key areas of strategic change currently underway in community pharmacy and one which will have a profound impact on the practice of pharmacy but more importantly on health outcomes.  While there are many initiatives in progress, two projects in particular, MediConnect and e-Dispensing and e‑Claiming Standards, will have a far reaching effect on the way information is shared both within pharmacy and in the wider health care sector.

Recommendation

That the trust patients place in their pharmacy and their medication records be acknowledged by government and utilised to implement efficiencies in a complete medication profile record.

5.1.5	Working more Effectively with Indigenous Communities

Addressing health issues in indigenous communities is a core focus of Australia’s current health policies.  Pharmacies can play an expanded role in supporting initiatives that address these issues and expand the capacity of indigenous communities to deliver effective services.  This will entail pharmacists providing a range of services to support the Aboriginal Health Services (AHS) to implement Section 100 arrangements.  The range of services to be provided is by agreement with the relevant AHS, and should be documented in a work plan before the service commences.  The services might include:

•	providing assistance to the AHS in developing an implementation plan for the Section 100 arrangements;

•	providing assistance in the implementation of appropriate procedures and protocols for managing Section 100 arrangements, including the development of a medicine store;

•	assisting the AHS staff with stock control and medication management procedures;

•	developing a range of other appropriate measures to enhance the quality use of medicines (which might include assistance with Dose Administration Aids), participation in regular meetings with health staff, and review of patient medication;

•	providing continuing education to AHS staff in aspects of medication management or stock control;

•	assisting clinical staff in the AHS with any clinical inquiries; and

•	implementing other agreed measures which aim to enhance the Quality Use of Medicines.

Other initiatives include:

•	provision of scholarships (similar to those offered to RN’s for training) to support training of Indigenous pharmacists;

•	support for delivery of pharmacy assistant training of Indigenous people

Recommendation

That Section 100 be sufficiently funded to enable community pharmacists to visit remote communities more regularly in order to provide assistance to ensure appropriate and safe medication management.

5.1.6	Managing Change and Enhancing Efficiency within Community Pharmacy for Effective Health Care

Community pharmacy will need support and leadership in order to position itself to meet the demands of a changing and ageing population, and to effectively fulfil its role as a member of the health care team.

As pointed out earlier in this submission the retail model of community pharmacy providing clinical services offers considerable efficiencies.  However, those efficiencies could be increased and community pharmacy could further develop the opportunities to play a greater role in health care that is offered by its accessibility and close contact with consumers.

Recommendation

That the Australian Government in partnership with the Pharmacy Guild develop a change management strategy to streamline workflow practices in community pharmacy so that the time of the pharmacist is freed up to take on an enhanced professional role.

That resources be made available for implementation of this strategy.

5.2	Enhancing Efficiency within Community Pharmacy

5.2.1	Reducing Transaction Costs 

Medication misadventure places a significant financial burden on the health system through medication waste, unnecessary medical consultations, unnecessary hospitalisation and lost productivity.

Pharmacists are required to complete a significant amount of clerical work to satisfy the requirements of dispensing Pharmaceutical Benefits Scheme (PBS) items which comprise the great majority of prescriptions.  If this information is inaccurate or incomplete the pharmacist is not reimbursed for the supply.

Time spent on PBS administrative tasks can be a distraction from a pharmacist’s professional duties and may contribute to dispensing errors. Although some tasks are supported by IT systems, many are paper-based and efficiency gains could be made to ensure any imbalance in administrative and professional tasks does not compromise patient care.

Recommendation

That the Australian Government in partnership with the Pharmacy Guild of Australia conduct a review of red tape in pharmacy PBS administration and its impact on the efficiency and effectiveness of the community pharmacy operation.

5.2.2	Medication Continuance Program

Earlier in this submission we discussed the possibility of community pharmacists having rights to continue medication supply under certain conditions.  This would make some aspects of health care more efficient without compromising patient care.  It would lead to considerable savings to government because there would be a decrease in the costs of the MBS with no increase in cost to the PBS.

Recommendation

That the Pharmacy Guild, in partnership with the Australian Government, continue to explore the possibility of medication continuance rights for community pharmacists.

5.2.3	Enhanced Use of Technology

Information Technology represents one of the key areas of strategic change currently underway in community pharmacy and one which will have a profound impact on the practice of pharmacy but more importantly on health outcomes.  It is possible to use technology to enhance health care for pharmacy customers and to reduce misuse and unsafe use of medications.

Recommendation

That the Government, in partnership with the Guild, examine the possibility of linking dispensary systems with the sale of Pharmacy Medicines and Pharmacist Only Medicines to enable safer and more effective use of medications.

5.2.4	A National Registration System

Pharmacy workforce data which is collected by Pharmacy Boards and the Australian Institute of Health and Welfare needs to be collated, analysed and reported upon in a timely and effective manner.  Current data is frequently out of date when reports are received.  As pointed out in section 4.1.10, the use of annual renewal of registration as an opportunity to disseminate and collect data should be undertaken. Given that Pharmacy Boards are not sufficiently resourced, it could be done instead by health workforce sections of state and territory governments. This would provide an opportunity to maximise the linking of data related to practising pharmacists throughout Australia including in rural and remote areas.

A national registration system would enable greater efficiency in the community pharmacy regulatory system.

Recommendation

That a national registration system be developed.