Response to Productivity Commission Position Paper
“Australia’s Health Workforce”

Introduction

The Pharmacy Guild of Australia commends the Productivity Commission for identifying potential areas for reform that will produce more sustainable and responsive health workforce arrangements. However, the Guild is disappointed that minimal reference and consideration of issues relating to the pharmacy workforce are made in the Position Paper. Nonetheless, the Commission has made a number of key proposals that, if implemented, would impact on all health professionals and we offer the following comments in response to the proposals from the perspective of community pharmacists.

Draft Proposal 3.1

In its upcoming assessment of ways to improve the level of integration within the health care system, the Council of Australian Governments (CoAG) should consider endorsing the National Health Workforce Strategic Framework (NHWSF), subject to broadening of the self sufficiency principle, in order to enhance cohesion between the various areas and levels of government involved in health workforce policy.

The Guild supports the self-sufficiency principle whereby Australia’s health workforce does not rely heavily on overseas health professionals.

As stated in the Guild’s original submission under section 4.1.8 (page 32) there is limited scope for increasing pharmacist immigration rates unless Australia finds overseas labour markets which have a current or emerging oversupply of pharmacists labour and which also have comparable standards of training.

The Guild reiterates its position that the workforce should be primarily sourced locally and targeting overseas pharmacist graduates should not be considered as a primary strategy, particularly given the shortage of pharmacists in overseas countries which have pharmacy competency-based educational and experiential standards comparable with those in Australia.

The pharmacy curriculum in pharmacy schools in Australia incorporates the principle of Australian health policy such as the National Medicines Policy and the Quality Use of Medicines. The scheduling system of medicines in Australia and the protocols to facilitate the supply of these medicines is also uniquely Australian. 

The Guild believes that the employment of overseas trained pharmacists should be used only as a ‘top up’ to existing numbers. In such cases, this would require assurance of equivalence of Australian training and no winding back of evaluation and supervisory requirements for overseas trained pharmacists. Further training may be required in order to ensure any overseas-trained pharmacist has the competence to practise in the Australian health environment.

Draft Proposal 3.2

CoAG, through its Senior Officials, should commission regular reviews of progress in implementing the NHWSF. Such reviews should be independent, transparent and their results made publicly available.

The Guild is supportive of this proposal.

Draft Proposal 4.1

The Australian Health Ministers’ Conference should establish an advisory health workforce improvement agency to evaluate and facilitate major health workforce innovation possibilities on a national, systematic and timetabled basis.

•	Membership of the board should consist of an appropriate balance of people with the necessary health, education and finance knowledge and experience.

The Guild supports the establishment of an advisory health workforce improvement agency which will examine workforce innovation opportunities as we believe this would lead to efficiencies in healthcare delivery. Existing models of shared care could be extended further to include pharmacy. The Guild believes the draft proposal 4.1 should include a reference to the importance of maintaining a balance between expertise derived from the private/ community sector and the hospital sector. The current proposal assumes that there are experts with knowledge across both sectors but the Guild would challenge this view.

Draft Proposal 5.1

The Australian Government should consider transferring primary responsibility for allocating the quantum of funding available for university-based education and training of health workers from the Department of Education, Science and Training to the Department of Health and Ageing. That allocation function would encompass the mix of places across individual health care courses, and the distribution of those places across universities. In undertaking the allocation function, the Department of Health and Ageing would be formally required to:

•	consider the needs of all university-based health workforce areas; and
•	consult with vice chancellors, the Department of Education, Science and Training, other relevant Australian Government agencies, the States and Territories and key non-government stakeholders.

The Guild supports the proposal to transfer responsibility for the allocation of funding for university-based education and training of health workers to the Department of Health and Ageing. However, it is imperative that this is done in consultation with the key health professional organisations to ensure better alignment of the mix of funded health course places with the health needs of the community and the workforce needs.

Draft Proposal 5.2

The Australian Health Ministers’ Conference should establish an advisory health workforce education and training council to provide independent and transparent assessments of:

•	opportunities to improve health workforce education and training approaches (including for vocational and clinical training); and
•	their implications for courses and curricula, accreditation requirements and the like.

The Guild is pleased that the Commission has acknowledged the problems associated with funding of clinical training for health professionals. As stated in the Guild’s submission under section 4.1.2 (page 27), the provision of ‘on-site’ training under the supervision of an experienced pharmacist is a vital component of undergraduate education.

The same issue we address in the draft proposal 4.1 regarding hospital vs. private/ community would apply to this proposal.

A balanced pharmacy education would see students receive training in the community setting as well as the hospital setting. However, not only there is a severe shortage of suitable training sites but also too few places are available in those sites, with the same sites generally being used for both undergraduate and pre-registration pharmacists.

The Guild believes that there should be government funding for graduate and post-graduate clinical pharmacy placements. One solution that we have put forward is for clinical training in pharmacy courses to be recognised in the formulae used by the Australian Government to fund universities.

We wish to reiterate our recommendation as stated in the Guild’s submission under section 5.1.2 (Page 38) 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.

To that end, the Guild welcomes the Productivity Commission’s proposal to establish an advisory health workforce and training council to assess opportunities to improve health workforce education and training approaches and funding frameworks.

Draft Proposal 5.3

To help ensure that clinical training for the future health workforce is sustainable over the longer term, the Australian Health Ministers’ Conference should focus policy effort on enhancing the transparency and contestability of institutional and funding frameworks, including through:

•	improving information in relation to the demand for clinical training, where it is being provided, how much it costs to provide, and how it is being funded;
•	examining the role of greater use of explicit payments to those providing infrastructure support or training services, within the context of a system that will continue to rely on considerable pro bono provision of those services;
•	better linking training subsidies to the wider public benefits of having a well trained health workforce; and
•	addressing any regulatory impediments to competition in the delivery of clinical training services.

As stated in comments to the draft proposal 5.2.

Draft Proposal 6.1

The Australian Health Ministers’ Conference should establish a single national accreditation agency for university-based and postgraduate health workforce education and training.

•	It would develop uniform national standards upon which professional registration would be based.
•	Its implementation should be in a considered and staged manner.

A possible extension to VET should be assessed at a later time in the light of experience with the national agency.

The Guild agrees with the concept of “national accreditation” but we would need more information and consultation as to how this would work for pharmacy. Clarification is required as to how this proposal will affect the current system of registration and regulation. The Guild would support a national uniform registration system and accreditation agency as long as the State and Territory regulation authorities such as Pharmacy Boards maintain autonomy to administer the regulations at State and Territory levels and to ensure health care is delivered by registrants in a professional, safe and competent way, upholding standards of practice within the profession.

Draft Proposal 6.2

The new national accreditation agency should develop a national approach to the assessment of overseas trained health professionals. This should cover assessment processes, recognition of overseas training courses, and the criteria for practise in different work settings.

There needs to be further consultation with stakeholders as to what impact this proposal would have on the current structures. Pharmacy already has an effective system whereby the Australian Pharmacy Examining Council (APEC) exists to assist overseas trained pharmacists to obtain registration in Australia enabling them to practise their profession in Australia.

The Guild would be opposed to the creation of a new accreditation agency if it compromises the current effective system. As stated in the Guild’s submission under section 5.1.2 (page 37), employment of overseas trained pharmacists should be used only as a ‘top up’ to existing numbers. The Guild believes that this requires 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 to ensure they are competent to practise in the Australian health environment.

Draft Proposal 7.1

Registration boards should focus their activities on registration in accordance with the uniform national standards developed by the national accreditation agency and on enforcing professional standards and related matters.

The Guild concurs with the suggestion that registration boards should focus their activities on enforcing uniform national professional standards. As stated in the Guild’s submission under section 4.1.9 (page 32), each State or Territory has pharmacy and pharmacist-specific legislation consistent with its responsibility for regulating the profession and its practice. The Pharmacy or Pharmacists Boards in each jurisdiction administer the relevant Acts. 

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.

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

Draft Proposal 7.2

States and Territories should collectively take steps to improve the operation of mutual recognition in relation to the health workforce. In particular, they should implement fee waivers for mobile practitioners and streamline processes for short term provision of services across jurisdictional borders.

The Guild agrees that implementation of this proposal would remove problems associated with health professionals being required to register in more than one State/Territory and costs associated with that requirement and that it would facilitate movement of appropriately trained health professionals within Australia.

As stated in the Guild’s submission under sections 4.1.9 (page 33) and 5.2.4 (page 42), mobility is important to ensuring that both short term (locum) and long term demands can be met. 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. This would provide an opportunity to maximise linking of data related to practising pharmacists throughout Australia including rural and remote areas.

Draft Proposal 7.3

Under the auspices of the Australian Health Ministers’ Conference, jurisdictions should enact changes to registration acts in order to provide a formal regulatory framework for task delegation, under which the delegating practitioner retains responsibility for clinical outcomes and the health and safety of the patient.

While the Guild acknowledges that the absence of formal regulatory provisions for delegation of service delivery discourages efficient task allocation, we would urge caution in amending registration Acts to incorporate such provisions. This proposal needs further consultation about the most effective ways of improving use of the workforce.

This proposal does not take into account the varying approaches being taken by different institutions in different states. For example, currently in Queensland a curriculum is being developed in one university for Nurse Practitioners based on nurses having prescribing rights. Another state may have no desire to take this approach. Furthermore, some universities within the one jurisdiction are more innovative in developing areas of specialty practice than are others for different groups of health practitioners. This proposal does not deal sufficiently with some of the issues around the delegation of roles to other health professionals.

Draft Proposal 8.1

The Australian Government should establish an independent standing review body to advise the Minister for Health and Ageing on the coverage of the Medicare Benefits Schedule (MBS) and some related matters. It should subsume the functions of the Medical Services Advisory Committee, the Medicare Benefits Consultative Committee and related committees. Specifically, the review body should evaluate the benefits and costs, including the budgetary implications for government, of proposals for changes to:

•	the range of services (type and by provider) covered under the MBS;
•	referral arrangements for diagnostic and specialist services already subsidised under the MBS; and
•	prescribing rights under the Pharmaceutical Benefits Scheme.

It should report publicly on its recommendations to the Minister and the reasoning behind them.

The Guild agrees that establishing an independent review body to advise on services to be covered by MBS and on referral and prescribing rules would facilitate changes which would improve workforce efficiency and effectiveness and enhance patient outcomes. However, further consultation and clarification is needed as to how this would work, particularly in regard to proposals to change prescribing rights under the Pharmaceutical Benefits Scheme. We would see a consultative role for the Guild in this area.

As stated in the Guild’s submission under section 3.2.1 (page 14), 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 to supply prescription medications without a new script being attained under certain conditions, thus relieving pressure on medical practitioners. These models provide an opportunity to improve efficiency through addressing aspects of current practice that have been based on 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.

As mentioned in the Guild’s submission under sections 3.4 & 3.5 (page 20), the need for coordinated multidisciplinary management of chronic illness in the community is increasing within our health care system. Community pharmacists are ideally placed to help people manage their chronic illness. They have a substantial degree of contact with such people through their supply of medications and other pharmacy supplied products and services. As the Productivity Commission points out, 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/prevention programs. In many cases and, where appropriate, screening by pharmacists results in the consumer being referred to the GP.

Draft Proposal 8.2

For a service covered by the MBS, there should also be a rebate payable where provision of the service is delegated by the practitioner to another suitably qualified health professional. In such cases:

•	the service would be billed in the name of the delegating practitioner; and
•	rebates for delegated services would be set at a lower rate, but still sufficiently high to provide an incentive for delegation in appropriate circumstances.

This change should be introduced progressively and its impacts reviewed after three years.

The Guild maintains that pharmacy’s increasing focus on the 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.

As stated in the Guild’s submission under section 5.1.3 (page 38) and section 5.2.2 (page 41), in order to better meet community needs and improve ongoing patient care, we have recommended that:

•	greater networking and coordination between health professionals should be promoted and encouraged;
•	the general practitioners workforce should 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 should be recognised by government in funding medication management reviews and other medicine compliance and concordance programs;
•	the provision of dose administration aids in the supply of medicines in the community setting should be funded in order to avoid premature placement of patients in residential care; and
•	the Australian Government should explore the possibility of medication continuance rights for community pharmacists.

Draft Proposal 9.1

Current institutional structures for numerical workforce planning should be rationalised, in particular through the abolition of the Australian Medical Workforce Advisory Committee and the Australian Health Workforce Advisory Committee. A single secretariat should undertake this function and report to the Australian Health Ministers’ Advisory Council.

Supported.

Draft Proposal 9.2

Numerical workforce projections undertaken by the secretariat should be directed at advising governments of the implications for education and training of meeting differing levels of health services demand. To that end, those projections should:

•	be based on a range of relevant demand and supply scenarios;
•	concentrate on undergraduate entry for the major health workforce groups, namely medicine, nursing, dentistry and the larger allied professions, while recognising that projections for smaller groups may be required from time to time; and
•	be updated regularly, consistent with education and training planning cycles.

The Guild supports the proposal. As stated in the Guild’s submission under sections 2.1 & 2.2 (page 9 & 11), the Guild has explored the use of simulation modelling to demonstrate the value of medicine use within Australia. This Systems Simulation Modelling of the Value and Future Role of Pharmacists in the Australian Health System developed by the Guild allows an understanding of the potential contribution of and constraints on 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 of older workers.

This modelling system also has the potential to add simulation dimension to broader collaborative future work to assist in the development of a sustainable health systems policy, acute aged care interface policy and rural and remote models of care and research and development programs.

Draft Proposal 10.1

The Australian Health Ministers’ Conference should ensure that all broad institutional health workforce frameworks make explicit provision to consider the particular workforce requirements of rural and remote areas.

The Guild supports this proposal. As stated in the Guild submission under section 4.1.3 
(page 28), we have implemented a number of initiatives to address pharmacy supply and distribution issues in rural areas. 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.

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.

Draft Proposal 10.2 

The brief for the health workforce improvement agency (see draft proposal 4.1) should include a requirement for that agency to:

•	assess the implications for health outcomes in rural and remote areas of generally applicable changes to job design; and
•	as appropriate, consider major job redesign opportunities specific to rural and remote areas.

As per comments to draft proposal 10.1.

Draft Proposal 10.3 

The Australian Health Ministers’ Conference should initiate a cross program evaluation exercise designed to ascertain which approaches, or mix of approaches, are likely to be most cost-effective in improving the sustainability, quality and accessibility of health workforce services in rural and remote Australia, including:

•	the provision of financial incentives through the MBS rebate structure versus practice grants; and
•	‘incentive-driven’ approaches involving financial support for education and training or service delivery versus ‘coercive’ mechanisms such as requirements for particular health workers to practise in rural and remote areas.

There should also be an assessment of the effectiveness, over the longer term, of regionally-based education and training, relative to other policy initiatives.

As per comments to draft proposal 10.1.

Draft Proposal 11.1

The Australian Health Ministers’ Conference should ensure that all broad institutional health workforce frameworks make explicit provision to consider the particular workforce requirements of groups with special needs, including: Indigenous Australians; people with mental health illnesses; people with disabilities; and those requiring aged care.

The Guild supports this proposal. As mentioned in the Guild’s submission under section 3.2.4 (page 17), community pharmacy has made a signification contribution to the safety and efficiency of provision of medications within Australia’s health care facilities. Use of Dose Administration Aids (DAAs) such as blister packaging for people with complex medication regimens ensure that residents 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, at the same time alleviating workforce pressures on the aged care facilities.

DAAs are also used extensively in the community setting and assist consumers and their carers to effectively manage their own medicines and continue living independently. These include people with disabilities and people with a mental illness. The use of DAAs help avoid the need for residential care, as one of the major trigger factors for patients to move from independent living to residential care is when they are unable to comply with their medication regime. DAAs 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.

As stated in the Guild’s submission under section 5.1.5 (page 39), 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 in increasing the range of services they provide to support the Aboriginal Health Services (AHS) to implement Section 100 arrangements.

Other issues not addressed in the Position Paper

Data collection (importance of longitudinal tracking system)

The Guild notes that the Position Paper has not addressed the issue of data collection in their draft proposals. The Guild strongly feels that 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. (Ref. Guild sub: Sec: 4.1.5, page 30.)

The Guild believes that the registration system could be restructured to involve two levels such as active registration and passive registration. Active registrants would pay a higher fee and would need to meet the competency requirements to practise pharmacy, while passive registrants would pay a lower fee to remain on the pharmacists register but would not be required to undergo continuing education and meet other competency requirements. We feel that this system could assist in maintaining accurate data in relation to the number of practising and non-practising pharmacists in Australia and could also be a mechanism to reach those non-practising pharmacists for re-entry to the workforce.

Review of red tape (reporting & administration)

Another issue not addressed in the Position Paper is the issue of red tape in reporting and administration. As stated in the Guild’s submission under section 2.4 (page 11), 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 Medicare Australia 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, the patient’s Medicare number, the entitlement number for concession benefits, and the authority number are PBS/Medicare Australia 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. Medication misadventure places a significant financial burden on the health system through medication waste, unnecessary medical consultations, unnecessary hospitalisation and lost productivity. Time spent on these 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. To that end, the Guild has recommended that the Australian Government, in partnership with the Guild, conduct a review of red tape in pharmacy, PBS administration and its impact on the efficiency and effectiveness of the community pharmacy operations. (Ref. Guild sub: Sec 5.2.1, page 41.)

The Prime Minister’s Regulatory Review Taskforce which has recently been set up to reduce the regulatory burden on business provides an opportunity for the Guild to quantify the costs associated with these administrative tasks.

Addressing health workforce silos (coordination between health professionals)

Another important area that the needs addressing is the issue of coordination between health professionals. As the Guild stated in its submission under section 3.4 (page 20), 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.

The Commission had pointed out that 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.

As stated previously and also in the Guild’s submission under section 5.1.3 (page 38), the Guild believes that pharmacy’s increasing 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. Therefore, the Guild has recommended that in order to better meet community needs and improve ongoing patient care, a greater networking and coordination between health professionals be promoted and encouraged and that the general practitioner 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 Guild acknowledges that the Commission envisages this issue would be addressed by the proposed new agency which would look at innovative practices. However, the Commission should emphasise in the report the importance of the need for collaborative approaches between health professionals and a clear proposed response should be provided.

Conclusion

The Guild thanks the Commission for the opportunity to review and provide feedback on the Position Paper. It is hoped that the issues and recommendations raised in our submission are reflected in the final report by the Productivity Commission.