The challenges and difficulties of running a rural, regional or remote pharmacy are well documented, says Anthony Tassone, but have any government remedies worked?
Successive governments have tried to establish systems and protocols which attempt to make pharmacies in these areas remain viable and sustainable.
Rural pharmacy workforce shortages and challenges featured in mainstream media coverage across ABC radio and television recently with spokespeople not only from the forefront of community pharmacy but also the Guild and pharmacy recruitment agencies.
Among the matters considered by government has been how to allocate funding to pharmacies in these locations and the development of the Pharmacy Accessibility Remoteness Index of Australia (PhARIA) was specifically aimed to address this.
This rural classification system was designed specifically for community pharmacy (as a variant from the principles of ARIA classification) in Australia to try to ensure that financial assistance to rural and remote pharmacies was distributed equitably and fairly. It is primarily used for administering the Rural Pharmacy Maintenance Allowance (RPMA) and other community pharmacy agreements rural workforce programs.
A complex and complicated system
To better comprehend how PhARIA works it is necessary to understand that it is based on a combination of the degree of remoteness, both geographic and professional, of pharmacies.
A composite index incorporates measurements of geographic remoteness, as represented by ARIA which is a continuous and varying index based on road distance measurements from more than 12,000 populated localities to the nearest service centres in five size categories based on population size.
PhARIA uses the ARIA system with a professional isolation component, which is represented by the road distance to the five closest pharmacies. Additional spatial rules are applied to ensure that anomalies do not occur in the treatment of areas closely surrounding urban centres. This includes buffer zones that are applied around a centre so that any location falling within that zone will receive the same index as that centre.
While the PhARIA system has been of some use and has provided a boost for rural, regional and remote pharmacies there are growing concerns that it has outlived its use-by date and that a better system is needed.
There are indications that the Federal Government is considering moving to a more updated model for pharmacy of determining remoteness (and therefore the areas that may require the assistance under the rural programs).
Current indications suggest that a move to the Modified Monash Model (MMM) reclassification system may be appropriate as it has improved categorisation of metropolitan, regional, rural and remote areas according to both geographical remoteness and town size. This is noting that the system was developed to recognise the challenges in attracting health workers to more remote and smaller communities.
The triple M model
MMM was launched by the then Minister for Rural Health, Senator the Hon Fiona Nash. In 2015 and uses the remoteness and population size of a town as a measure to determine how attractive it would be for a medical practitioner to work and live in that area. It is being used to address mal-distribution of medical services across Australia such as criteria for the Bonded Medical Places Scheme.
It is based on the Australian Bureau of Statistics (ABS) Australian Statistical Geographic Standard Remoteness Area (ASGS-RA) geographical classification system. MMM uses the ASGS-RA and further classifies locations in inner and outer regional classes by town size.
However, having one system for pharmacy and another for medical practices causes some often-bizarre anomalies.
One example is in my home State of Victoria where in Point Lonsdale on the Great Ocean Road the pharmacy is classified as PhARIA 1 but the general practice a couple of hundred metres away is classified as being rural under the MMM scheme.
What this means is that one primary health provider is able to access incentives and funding for rural health initiatives while the pharmacy can’t despite being in the same town because they are classified under different systems.
The pharmacy and the medical centre are in the same community treating the same patients but are classified differently by government for receipt of financial support for rural health service delivery. It just doesn’t make sense.
Which is the best model?
The anomaly in this instance arises from the fact that PhARIA considers the proximity of other pharmacies, while MMM seems to be a more objective model of demography and accessibility.
Another example is in Mildura in North Western Victoria on the NSW border. In this case when the most recent pharmacy opened it went from having a rural classification to be a PhARIA 1 following the opening of an 8th pharmacy and population size which is highly seasonal due to it being a produce growing area.
The result of this is that it is unable to attract RPMA funding despite the fact that Mildura is approximately 400km from Adelaide and 550km from Melbourne so the addition of another pharmacy in the town does not make it any more accessible from major metropolitan centres.
It is examples such as these which has seen the relevance of the PhARIA in the modern environment come under scrutiny with a view to consideration being given to the broader uptake of MMM as a classification system. This may better address the maldistribution of health services across Australia through health workforce policy and program rules.
Looking at the limitations
The limitations are highlighted in a breakdown of the mix of pharmacies in each PhARIA category. Out of a total of some 400 community pharmacies, those regarded as highly accessible fall into PhARIA Category 1 which accounts for 83 per cent of all pharmacies; Categories 2 and 3 (accessible) account for 10 per cent; Category 4 (moderately accessible) 3 per cent’ Category 5 (remote) 3 per cent; and Category 6 (very remote) 1 per cent.
Of course, there are arguments for and against each system.
In 2004, the Australian Institute of Health and Welfare (AIHW) published a report on the available remoteness classifications including discussion of their strengths and weaknesses. The AIHW report recognised that each remoteness classification and its underlying methodology has advantages and disadvantages depending on how it is used.
For example, the ARIA index values will only change if the population of one or more of the four service centres it is measured on changes significantly. The ARIA methodology can sometimes result in dissimilar areas being given the same remoteness score.
The report uses an example from 1999, where the City of Dubbo and the shire of Urana (with populations of 36,701 and 1,497 respectively in 1996) had similar ARIA scores and were therefore included in the same ARIA class (Accessible). Dubbo was in this class, mainly because it is a large regional centre, whereas Urana was in this class because of its proximity to Wagga Wagga and Albury.
Inner or outer regions?
The ASGC Remoteness Areas classification system, on which MMM is based and further classified by town size, defines the least remote areas more closely than the ARIA system. An example given in the report describes populations in outer Sydney (Baulkham Hills) and outer Perth (Mundaring) living in areas classified as Inner Regional acknowledging that there would be lower levels of access to goods and services than in areas closer to the CBD. This would not occur with the ARIA system.
Despite the positives and negatives of each system, it is clear that MMM has the edge over PhARIA and we must look to change and do so with urgency.
From July 1, 2019, we have the prospect of the Workforce Incentive Program allowing the employment of ‘non-dispensing pharmacists in general practice.
With the introduction of this category it is essential that community pharmacy is on a ‘level playing field’ so that it can attract and retain workforce in the face of essentially government funded pharmacists in general practice.
But just as importantly, to help maximise collaboration between health professionals and to achieve the best possible patient health outcomes there is a demonstrable need for pharmacists in rural, regional and remote locations to be at least ‘on the same page’ on rural health grants as our medico colleagues.
Anthony Tassone is the President of the Pharmacy Guild of Australia (Victoria)