Battle of the borders

Regional Australia is feeling the strain on health services due to the pandemic, and the situation is especially acute—and tense—in areas close to state borders. How are pharmacists coping with the unprecedented situation?

Facilitating access to healthcare in rural and regional Australia has long been a challenge. And the COVID-19 pandemic, as well as some of the measures Australia is taking to help prevent the spread of the disease, is making that challenge harder.

It’s well-established that inequities exist in access to healthcare, and the use of healthcare services, in different parts of the country, as shown by resources such as the Australian Atlas of Healthcare Variation.
Outside metropolitan areas, patients in many locations are struggling to access doctors, specialists and allied healthcare.

Pharmacy Guild data submitted to the National Rural Health Commissioner in August 2019 showed that there were about 307 towns in Pharmacy Access/Remoteness Index of Australia (PhARIA) 4–6 (moderately accessible, remote, very remote) that had only one pharmacy, “and in many cases the pharmacist is the only health professional in the town”.

“Data indicates that there are 57 towns in PhARIA 4–6 with one pharmacy and no medical centre,” the Guild said at the time.

The PhARIA system is being replaced with the Modified Monas Model (MMM) for rural classification, which Health Minister Greg Hunt said would mean “greater support for regional, rural and remote pharmacies”.

But in the meantime, access to healthcare remains difficult for many—and COVID-19 has added fuel to the fire.

Alex Elfeki, from the Wentworth Pharmacy, lives in one of the towns where the pharmacy is the only place patients can access healthcare.

He said that the local council has spent nearly $300,000 in the last couple of years attempting to lure a doctor to town; it did sign a contract which would have seen a practice move in in April 2020, but this is yet to happen, and Wentworth has been without a doctor for the last eight months—and not for the first time.

Fear of contracting COVID-19, and of experiencing difficulty crossing the border into Victoria, has made it even harder for Wentworth residents, many of whom are older, to access healthcare.

Problems of retention

Alex Elfeki told the AJP that the border town has had ongoing problems not just attracting a doctor to town, but keeping one—and keeping allied health services as well.

As a result, locals rely on the pharmacy—and he says that, thanks to COVID-19, it’s harder than ever for them to access any other care, with the nearest big centre, Mildura, on the other side of the Victorian border.

“We are in a town that doesn’t have any doctors at all, and it’s a problem that’s been going on for 10 years now,” he said.

Doctors who come to the town “stay somewhere between six months to two years, and then they leave, and then the town has no doctors whatsoever for God knows how long, and then we do it again. It’s a vicious cycle.”

When doctors leave, they take other essential services such as pathology labs with them.
Mr Elfeki said that he and a number of other local stakeholders have been trying for some time to establish a medical centre owned and operated by the town itself, but that the local council has not been coming to the table.

“If the town has its own medical centre, owned and run by community members, if a doctor chooses to leave it doesn’t mean shutting down the pathology lab, the nurses, the midwives, all the other health professionals,” he said. “It means we can get a locum twice a month, or for a week. But now, when they go, they take with them all the healthcare facilities except for the pharmacy.”

He said that there have been several close calls with patients, citing the case of one woman who came to the pharmacy with symptoms of a blood clot.

“Trust me, if I wasn’t lucky enough to be able to pick it up—and it’s really hard to pick it up—she would’ve lost her leg or could have died,” Mr Elfekl said.

The lack of doctor access is particularly problematic for Wentworth’s ageing population, he said, particularly given that even when patients do access a doctor, there is no medical history—the Wentworth practice having closed.

And he’s already seeing his patients’ health deteriorate as the prospect of seeing a doctor becomes even more daunting, due to the pandemic.

“For people who are elderly, and a lot don’t have licences, the idea of going to Mildura, which is 30 minutes away, is like going overseas,” he said.

“Adding the border restrictions adds insult to injury. They say they’ll just go without the medicine—we have a whole list of patients who aren’t coming back for repeats, and I have to personally chase their doctors, and that puts a burden on us.”

The pharmacy staff had also taken to filling out permit forms for crossing the border, but when patients see what’s involved, they “freak out”, he said.

Pick a side

Initially, when the NSW/Victoria border was closed, allowances were made for eligible people to cross, including those who did not live in the border zones—but in late July, the AJP reported that these had been tightened so that only essential workers could come through.

The criteria classed hospital pharmacists as essential. Community pharmacists, however, were not. This meant that staff who reside in or need to travel to just outside a defined “border zone” are unable to do so without having to quarantine for 14 days.

Anthony Tassone, Victorian branch president of the Pharmacy Guild, said this was a “massive slap in the face” to community pharmacists.

The Guild and the Victorian branch of the PSA jointly wrote to NSW Health Minister Brad Hazzard, calling for community pharmacists to be reclassified as essential workers.

The NSW State Emergency Operations centre responded saying that, “We acknowledge that closing the border has had significant impacts on residents of both states. NSW Health continues to carefully monitor the effects of the Public Health (COVID-19 Border Control) Order 2020”.

“The border closure with Victoria is a necessary part of NSW’s strategy to contain the spread of COVID-19. The arrangements will remain in force until it becomes safe to ease the restrictions.”

Mr Tassone said that the authorities did not appear to be willing to consider the pharmacy groups’ request.

“This issue continues to present challenges for community pharmacies and their teams on both sides of the border—and it’s extremely disappointing that the criticality of a pharmacist’s role, expertise and importance seems to have been determined by ‘where’ they practice rather than ‘who’ they are as a health professional and ‘what’ they do for patient care according to the NSW government and public service.”

“While the Guild acknowledges an increased number of active cases being prevalent in regional Victoria—these may not necessarily be impacting the border town areas where the requested exemption would apply.

“What we don’t want to see is a bad health crisis made worse by unintended consequences of causing more gaps to an already stretched health workforce and potential interruptions in access to medicines and care for patients.”

For Steve Reid, the border closure meant making a difficult choice. He lives in the NSW town of Moama, and owns pharmacies in Echuca and Shepparton, across the border.

“I got told I wasn’t able to travel to my Shepparton store unless I wanted to isolate for two weeks every time I went—which is not feasible since I’m there two or three times a week,” said Mr Reid, who is instead home schooling his three young children in Moama and running his businesses remotely.

He said that after he approached his local member and Mr Hazzard, “they came back and said community pharmacy are not deemed a critical health service”.

He is concerned that if his pharmacist in Shepparton becomes ill or cannot attend work for any other reason, and he was unable to source a locum, the store will have to close, risking his patients’ health.

He said that while the Guild has been helpful, he is frustrated at authorities’ lack of understanding of the key role played by community pharmacies, and at receiving what he said are conflicting messages.

“Hospital pharmacists can cross, but community pharmacists can’t—it doesn’t make sense,” he said. “You could argue that neither one is more important, but in terms of community access, community pharmacy is going to give more continuity to maintain people’s health and well-being.”

Lucy Walker: “The restrictions are much tighter this time”

Northern exposure

On the other side of NSW, Queensland has also just moved to tighten its border after cases of COVID-19 were brought into the state by residents who had visited Melbourne.

Queensland Health told the AJP that “In recognition of the close proximities of some communities to the Queensland–NSW Border and the need to ensure that border communities are able to continue their normal lives and have access to essential services, a limited number of NSW postcodes have been identified as part of a border zone.

“Persons in those postcodes are able to enter into the border zone within Queensland without quarantining.

“We understand there will be some communities close to, but not immediately abutting the border, that won’t fall into these border communities and may be inconvenienced by these restrictions. These are difficult decisions, however these restrictions are in place for the protections of all Queenslanders.”

David Heffernan, NSW Guild president, pointed out that it’s not uncommon for people in the country to drive 100km for work, placing them well outside border zones.

Lucy Walker, proprietor of the award-winning Terry White Chemmart Goondiwindi, said the initial border restrictions were manageable, but is concerned that the new regulations will limit access to medicines for some of her patients.

Goondiwindi is on the Queensland side of the border, and is the closest pharmacy for a number of patients in NSW, including those in the nearby town of Boggabilla.

“When the restrictions first started, the commute across the border took longer than usual, but once they were up and running, the transition was quite smooth,” she told the AJP. “We will always have patients who will have to travel a bit further to cross the border at the right spot, but people were readily adapting to the system.

“When it first happened, I was really worried. 15 to 20% of our patients live on the other side of the border, and the nearest pharmacy on the NSW side is 1.5 hours away. Some of our patients who live in Boggabilla don’t have transport themselves to travel the 10km to Goondiwindi, let alone a longer journey.”

The pharmacy began a delivery service, which included a once-a-week drop across to NSW.

When Queensland moved in August to close the border again, Ms Walker said she expected the pharmacy to offer the same service again due to allowance for movement within a “border bubble”—but at the time of writing, it appeared that even this concession could be revoked.

“The restrictions are much tighter this time.” she said. “We have lots of patients who can’t easily access us and are very worried about their medication supply.

“We thought over the weekend they’d make [the restrictions] more flexible for our border communities; but now they’re saying be prepared to not be allowed to come over the border at all.”

Particularly impacted could be small NSW towns like North Star, she said, far enough away that the “border bubble” would not apply, yet close enough that Goondiwindi is by far their closest pharmacy.

“So we’re in the process of organising delivery services, for these smaller communities,” Ms Walker said.
Meanwhile John Black, who owns a pharmacy in the northern NSW town of Casino, but lives in Brisbane, is considering his options.

Until he found another pharmacist to work at the store in March 2020, he had spent three-quarters of his working time at the Casino premises, but had been doing “a week on, a week off” where possible since.

His pharmacist is set to take two weeks off shortly for their much-delayed wedding, meaning Mr Black will need to be on duty at his pharmacy.

Now, since Casino is well outside the “border bubble,” he said that if he goes to work, “I’m on the wrong side—I’ll be working in a COVID hotspot”.

“I’ll be able to go back to Queensland, but I’ll have to quarantine for 14 days in a motel, and pay for that, so I’ll probably be better off staying in Casino at work. Then I’ll probably be there till this is all over.”

Beyond borders

The difficulty in crossing borders may have exacerbated existing health inequities in rural and regional Australia, but COVID-19’s other effects have been felt more keenly in these areas for other reasons, stakeholders say.

The efficacy of the medicine supply chain became a major debate, as during March and April, patients attempted to “stock up” on certain medicines, resulting in a spike in sales at many pharmacies—and out of stocks.

John Black told the AJP that March had been the busiest month in his 33 years in pharmacy, “as people tried to come to grips with what this COVID thing meant”.

With the resurgence of the disease in Victoria and to an extent in NSW and Queensland, that uncertainty is being felt again, he said.

“Last Tuesday, when I was in Casino, it was madness because of that flare-up in the last couple of weeks with Victoria and the small spike in NSW.”

“People get scared, they get anxious. It’s busy, it’s hectic, and you start having to do other things like sanitise, maintaining distance, answering the phone a lot more than normal—so the nature of the business changed and it tires you, especially when you can’t take holidays.”

In April, the Rural Pharmacy Network of Australia was concerned enough that it said temporary nationalisation of the supply chain should be considered.

“This is not just about resolving the short-term supply problems but also about the long-term issues with the CSO that have been going on for a long time now, and which have been exposed on a larger scale as a result of this crisis,” RPNA spokesperson Katie Stott told the AJP at the time.

Telehealth and the rise of e-prescriptions is expected to help make life easier for rural and regional pharmacists and patients.

“The joy is that our doctors have really embraced telehealth,” said Lucy Walker. “So for those people who live rurally, it’s possi22bly more convenient for them, because they don’t have to physically go in to the doctors to access quality healthcare—the tyranny of distance is removed.

Ms Walker told the AJP that she had done her first MedsCheck by telehealth only days earlier, for an older gentleman who lives on a farm.

“It was great to be able to talk about his medicines with him over the phone, and address his concerns.”

“I think patients are getting more used to those phone health conversations—so that’s opening up some new possibilities for us.”

She is also “looking for a better solution” than having doctors faxing scripts to the pharmacy and patients waiting in duress.

“We are preparing for e-prescriptions and hoping it will improve work flow and our patients experience,” she said.

It’s not for everyone, however. Mr Elfeki said that patients in Wentworth are often not tech-savvy and find accessing telehealth services difficult.

And Steve Reid pointed out that “not everything can be done by telehealth”.

“Getting access to specialists now is a real challenge,” he said.

“I’ve definitely noticed with COVID that people would rather not see or reach out to their GP. You hear a lot of stories about things that people would normally go to the doctor for, they won’t bother at the moment while these restrictions are on.

“We’re seeing that at the pharmacy level by not seeing new scripts for acute conditions. It’s really dropped off—and both my pharmacies are located next to medical clinics.

Lucy Walker noted that access to mental health services, always challenging, has become more so due to increasing need with the pandemic.

“We’re struggling with helping people… with mild mental health concerns, and how we can refer people to appropriate care quickly enough.”

All the pharmacists the AJP spoke to are keen to do their part in helping restrict the spread of COVID-19, and maintain or improve access to healthcare, despite the challenges.

David Heffernan said “We’re on a knife edge in NSW, and everyone’s on high alert—we do what we can.”

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