The King Review: Discussing the future

Jo Watson (centre) with fellow review panelists Professor Steven King (l) and Bill Scott.

The long-awaited pharmacy remuneration and regulation discussion paper has raised a lot of questions about how pharmacy operates, but what will be its answers?

The Pharmacy Remuneration and Regulation (King) Review discussion paper has been released, incorporating 140 wide-ranging questions which include the need for Community Pharmacy Agreements, and whether S2 and S3 medicines should be restricted to pharmacy.

The paper is presented as a discussion of how community pharmacy currently operated, dotted with questions for consideration, rather than recommendations.

“Some stakeholders will see parts of this Paper as contentious and provocative,” the panel wrote.

“That is deliberate. In order to properly analyse the current system of pharmacy remuneration and regulation, existing approaches must be critically examined.

“While many parts of the system will stand up to such close scrutiny, other parts may be revealed as inadequate and in need of reform.”


CPAs queried

The Review highlighted the unusual nature of the Community Pharmacy Agreements between the Pharmacy Guild and the Government, and queries whether it is consistent with the National Medicines Policy, with the sustainability and affordability of the PBS, and good government practice in terms of value for money, clarity, transparency and sustainability.

It asks whether, if the CPA process is not the best way to organise medicine distribution and remuneration, then what would be a preferable approach?

Community pharmacy programs within the CPA include some professional services that could be delivered by non-dispensing pharmacists, it says.

“Should the CPA be limited to dispensing and professional programs provided by community pharmacy only?” it asks.

It also asks whether it is appropriate for the Government to negotiate formal remuneration agreement agreements with the Guild on behalf of or excluding other stakeholders.

Question Nine asks, “Should the Government move away from a partnership agreement?”

And the Review also asks to what degree it is appropriate that community pharmacies be protected at all from the normal operations of consumer choice and protected in their business operations.


Raising questions

The Review discussion paper examines the way in which pharmacy is remunerated for dispensing – highlighting that some dispensing interactions may not involve a great deal of contact between the pharmacist and consumer, while others require a considerable amount of consultation.

It asks whether dispensing fee remuneration should more closely reflect the level of effort involved – for example, should initial and repeat scripts be remunerated the same?

Issues around high-cost medicines such as the recently PBS listed Hepatitis C drugs are discussed, as are whether there should be limitations on some of the retail products that community pharmacies are allowed to sell.  Professional services remuneration is also queried.

“More generally, is there a need for new business models in pharmacy?” it asks.


A question of location

An examination of the Location Rules is a key part of the discussion paper.

“There are differing views across the sector and in the community on the appropriateness of the current pharmacy location rules,” the panellists wrote.

“Those that support maintenance of the existing pharmacy location rules, argue that they provide pharmacy businesses with the certainty and capacity to allow continued investment in providing a range of high quality pharmacy and related services to the community.

“Others who favour a removal of the pharmacy location rules, argue that they prevent competition in the sector and stifle innovation and consumer choice.

“They note that there are fewer community pharmacies in Australia today than there were in 1988, despite the considerable growth in population since that time.”

The Review queries whether the removal of the location rules with the retention of the current state ownership rules for pharmacies would increase or decrease accessibility and affordability for consumers.

Location Rule 124 – short distance relocation – is examined, with attention to the way it may inadvertently lock pharmacies into specific shopping centres and “transferring effective ownership of the pharmacy approval number to the shopping centre”.

And the S2 and S3 schedules are examined – the Panel heard that requiring consumers to purchase S2 and S3s from pharmacies may limit access to these medicines, though broader access could create some risk.

“Are the current restrictions on the sale of schedule 2 and schedule 3 medicines an appropriate balance between access and health and safety for consumers? If not, how could this balance be improved?”


Demonstrates commitment: Ley

The release of the discussion paper demonstrated the Turnbull Government’s commitment to ensuring Australians get the best experience possible from community pharmacy, said Health Minister Sussan Ley.

Minister Ley said that the Government wants to hear from the entire pharmaceutical supply chain – including consumers – on how to deliver this experience.

“As a regional member of parliament, I know first-hand that pharmacists are taking a greater role in a patient’s overall healthcare everyday – it’s no longer just about prescription medicines.

“This Government has made a strong commitment to recognising the important role pharmacists play through our Sixth Community Pharmacy Agreement and this review is aimed at ensuring the next agreement continues to meet the future needs of Australians.

“I thank the independent review panel for their hard work so far in developing this discussion paper and look forward to the thought-provoking submissions it will no doubt generate to inform the next steps of the process.”

“It contains a lot of questions. They are not an indicator of my thoughts or the government’s thoughts. We are simply taking the opportunity – as we should – to get everything on the table for discussion,” she said.

While the Pharmacy Guild of Australia said the pharmacy system “isn’t broken”, Ley stressed this is just one point of view.

“We all agreed to have this review. So it shouldn’t come as any surprise to anyone. My focus is that it covers the field – which it does, by virtue of the comprehensive nature of the discussion paper,” she said.


Consumer participation

The Consumers Health Forum (CHF) was funded by the Department of Health to consult on the King Review’s consumer survey, an “entirely appropriate” move considering the CHF is a peak consumer body, says Ley.

CHF deputy chair, Jo Watson, is one of the three panellists of the review.

In welcoming the release of the King Review paper, CHF CEO Leanne Wells said yesterday that the Community Pharmacy Agreement arrangements “have been associated with the continued maintenance of the location rules widely viewed as anti-competitive and a potential barrier to consumer-focused service development and innovation, and with significant issues concerning the funding of pharmacy as found by the Australian National Audit Office”.

With the King Review actively welcoming submissions from stakeholders including pharmacists and consumers, CHF said it encourages the wider community and its members to engage in the panel’s consultations.

The consumer advocacy group also said it has been funded “to undertake targeted consultations with our members and consumer stakeholders to inform the panel’s deliberations”.

“It is a matter of good public policy that we can now review why such an important sector as community pharmacy should be protected from significant change to improve outcomes for consumers,” says Wells.


Where to now?

The Review Panel is now asking for submissions, which can be lodged formally at, or forwarded to Pharmacy Review (MDP 900) Department of Health, GPO Box 9848, Canberra ACT 2601.

All submissions will be treated as public and published on the Review website, in the interest of transparency.

A short online questionnaire will also be available (to both consumers and pharmacists) from the Review Website, open until 18 September 2016.

The Review will provide a report to the Minister for Health by 1 March 2017.


The response:

Pharmacy Guild: The King Review omitted one key question said Guild national president George Tambassis: should we take a system that is working well for consumers and taxpayers and dismantle it for the sake of an economic theory?

It won’t surprise people to know that the Pharmacy Guild’s answer to this question – let’s call it question 141 – is a resounding ‘no’.

Certainly, we oppose deregulation of the pharmacy sector for a range of evidence-based reasons – based not only on the best interests of our members who are the owners of community pharmacies and their hard-working staff, but also the best interests of Australian health care consumers.

But while we oppose untested, ideologically-driven deregulation which will only put a tried and tested system at risk, we do not oppose reform. We believe in building on the strengths of the current model of community pharmacy which is so well-regarded by Australian health care consumers. As Australia’s most accessible health care professionals, community pharmacists are well placed to broaden their services and add even more value to the health system.

That’s why we have been pleased to assist the King Review in its round of industry and stakeholder consultation since it began its work in 2015. We urge our member pharmacists to tell the Review panel their stories about the health services, support and advice they provide for patients, often seven days a week.

PSA: Dr Lance Emerson, CEO of the PSA, said the review was a “potential game changer” for community pharmacy. PSA would be undertaking an extensive member consultation process over the next month to develop its response to the paper, he added. 

The Discussion Paper outlines an extensive range of questions and issues that are critical to the future of the pharmacy profession, PSA said in a release.

The pharmacists’ peak body says it is “encouraging” to see many comments made by PSA in its briefing to the Panel as well as issues raised in the PSA 6CPA Discussion Paper appearing as critical questions from the Panel.

These include examining the potential for payment for professional pharmacist services through the MBS, the potential for payment level linked to complexity, the potential for improvement to HMR rules, the potential for improving rural and remote support and access and the potential for improvement to access to medicines management services by Aboriginal and Torres Strait Islander People.

PSA National President Joe Demarte says PSA will develop a comprehensive submission in response to the Discussion Paper as well as meeting with the Review Panel.

PPA: ‘Business as usual’ is not an option when it comes to the future of pharmacy, says PPA CEO Dr Chris Walton.

“The current model of pharmacy remuneration is too heavily focused on what a pharmacist does rather than what a health consumer needs – this runs contrary to the direction of the overall health system,” Walton says.

“The Review is right to question whether current arrangements deliver the best outcomes for patients.

“It is refreshing that questions about the pharmacy sector are at least being asked so that we can have an honest debate about the best way forward.

“In the past reviews have been thwarted as a few owners, making up a small proportion of the pharmacy profession, circle the wagons to protect business interests.

“That strategy has held back employee pharmacists and has not even worked for most owners,” Walton says.

“This discussion paper provides an important backdrop to a debate we must have if we want a model of pharmacy which leads to more time on complex interactions, medication reviews and collaboration with other health professionals

“With more than 230,000 medicine-related hospital admissions every year, ‘business as usual’ is not an option. The Review challenges all pharmacists to think deeply about the current situation and what models of pharmacy can deliver better outcomes for the community.

SHPA: The King Review has the potential to deliver “true reform” on how pharmacists deliver services, says Society of Hospital Pharmacists of Australia CEO Kristin Michaels.

Michaels welcomed the release of the discussion paper and said SHPA looks forward to providing advice regarding pharmacy remuneration and regulation, “so that the patient is at the centre of deliberation”.

“As we discussed with the Review Panel during a tour of the hospital pharmacy department at the Alfred Hospital, many stakeholders felt that the 6th Community Pharmacy Agreement was a pragmatic approach,” Michaels says.

“This Review has potential to deliver true reform to how pharmacists provide care and services to patients.

“Recognition should now be given to the changing health and economic landscape, as well as consumer needs and demands,” she said.

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