What do you want from the 7CPA?


conference audience with speaker (David Quilty) at front

The Pharmacy Guild had the opportunity at APP to gauge pharmacy sentiment about a range of issues affecting the sector

Pharmacy is coming up to the end of the third year of the current Community Pharmacy Agreement, and Guild leaders pointed out at the conference that now is the time to start taking stock of what the sector wants from the Seventh Community Pharmacy Agreement.

With that in mind, the Guild hosted an interactive session on the last day of the APP2018 conference to find out just what pharmacists think.

Generally, the outlook on pharmacy life was mildly positive. While 44% of the attendees to the 7CPA session said that they would rate the current business conditions for their pharmacy as “average,” another 28% said conditions were good (compared to 15% who said they were poor) and nearly 4% said they were very good (compared to 0% who said they were very poor).

More than 40% of respondents said that the 2018-9 financial year is set to be better than the current year, with only 10% saying it would be worse, and almost 40% expecting things to remain more or less the same.

The Guild looked at several bugbears affecting pharmacy, including the controversial $1 copayment discount, asking whether the audience members would like to see it abolished.

The results were clear: 86% of the delegates strongly agreed that the discount needs to go, with another 9% agreeing and nearly 3% feeling neutral on the subject. Only 2% wanted to keep it.

Guild executive director David Quilty told the audience that Health Minister Greg Hunt has said that “he doesn’t, in effect, want to get our hopes up too much,” with regard to the Government’s review of the discount, but “you can be absolutely assured that that is an issue we will continue to advocate for on your behalf”.

There was strong support for the Guild’s stance on exclusive direct supply. Just over 96% of delegates said that manufacturers should be required to make all PBS-listed products available to all wholesalers participating in the CSO. Only 1.6% disagreed.

Queensland branch president Trent Twomey said that exclusive direct supply was frustrating because medicines are not a free market.

“I don’t have a right to decide what part of national medicines policy I do or don’t want to implement,” he said. “If you want to play in a socialised system of health care, play by the same rules as the rest of us.”

David Quilty said that the Guild is getting a “very good hearing” from Minister Hunt on the matter.

There was strong support for community pharmacy gaining access to specialised medicines currently only available in hospitals: nearly 87% approved, with 3% disagreeing and just over 10% unsure.

And nearly 90% of pharmacists wanted to see changes to the way in which high-cost medicines move through the supply chain (just under 4% seem content with the way they are currently).

A healthy 57% of respondents said their pharmacy had registered for the My Health Record, and 95% wanted to see pharmacies be paid directly for uploading patient data to it.

As for professional programs, just over 87% want to see their range expanded in the 7CPA; and on the topic of additional funding in the 7CPA, the audience was largely split, with just over 48% wanting to see it directed to professional programs, and 49% hoping to see it go to remuneration for dispensing.

The 7CPA professional programs should focus on a combination of primary health care and medication management, with 86% of the audience keen on both. Just over 9% had a stronger focus on medication management, with nearly 2% preferring a balance shift to primary health care.

As for what the programs themselves could look like, there was a clear favourite: 50% of audience members said post-discharge medicine is the one program they’d like to see rolled out more broadly in the 7CPA.

Guild president George Tambassis told the audience that “that’s the most important one, and we haven’t even rolled it out”.

“Make sure you advocate for that program every opportunity you can,” he advised. “We’re trying to roll that out – [former health minister] Sussan Ley announced that at our conference here more than two years ago, and we haven’t even rolled it out yet.”

Next were diabetes screening, at nearly 23%; pain meds checks, at nearly 10%; indigenous medicine and cardiovascular screening, each at just under 5%; and asthma management, at nearly 4%.

The Guild also asked which current 6CPA funded services the delegates wanted to see as the highest priority to be continued in the 7CPA: and DAAs were the clear priority, with nearly 62% selecting these as their top option. DAAs were followed by MedsChecks/Diabetes MedsChecks, at just over 21%; clinical interventions, at 10% and HMRs, at 4%.

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22 Comments

  1. Debbie Rigby
    07/05/2018

    “A healthy 57% of respondents said their pharmacy had registered for the My Health Record, and 95% wanted to see pharmacies be paid directly for uploading patient data to it.”

    Great progress with registration for My Health Record – the goal is for ALL community pharmacies to be registered by the end of the year. But uploading of dispense records is seamless with conformant software (all dispense software will be conformant soon), so why is there an expectation to be paid??

    • GlassCeiling
      07/05/2018

      I thought access to My Health Record required pharmacists to ascertain safety and appropriateness of meds before dispensing based on the e- health record. Liability ++- hence payment is not only preferred but contingent on access.

      • Debbie Rigby
        07/05/2018

        We always need to assess safety and appropriateness of prescriptions as part of the dispensing process. My Health Record will enable access to additional information not currently available eg diagnoses, allergies and previous ADRs, medicines view to assist in this assessment of safety and appropriateness. But it is not expected that a pharmacist would view the MyHR when dispensing every prescription.

        My point was the uploading of prescription and dispense data is seamless (i.e. no additional work, not even a mouse click) so expectation of additional payment seems unjustified. Payment for interventions based on accessing MyHR information (or other reasons) is currently remunerated by the Clinical Interventions program.

        • GlassCeiling
          07/05/2018

          Safety and appropriateness of medication dispensing can only be achieved by an e health record assessment Debbie. I have always believed we are guilty of professional misconduct every time we have dispensed without an indication and history = professional misconduct at every dispensing .

          I believe you will find that the e health record will have to be looked at for every new presentation of a script and repeat as pharmacists will be liable if we dispense in the presence of any contraindication or precautionary medical history overt or non- overt embedded within the history . I don’t believe individuals will accept a professional supplying them with potentially toxic pharmaceuticals was not required to assess their record at any time.

          I agree an upload does not require payment but CI payment does not adequately pay for my professional assessment of an electronic health record . I may not find a clinically relevant intervention but I have to clinically assess the record and in so doing deserve a reasonable payment and hence a provider number . E health changes the game – the days of employee pharmacists just checking a label and picking up obvious errors are over.
          My electrician would not look over my house for $2 and nor should we as pharmacists and in particular employee pharmacists give away our skill and knowledge on the cheap.

          • Anthony Tassone
            08/05/2018

            GlassCeiling

            I would suggest reading the MyHealth Record guidelines that were recently released by the PSA:

            http://www.psa.org.au/wp-content/uploads/My-Health-Record-Guidelines-for-Pharmacists.pdf

            On page 16 under the ‘Viewing records’ section there are some passages that I think may be of interest:

            “Pharmacists have a professional obligation to ensure they have sufficient patient information to optimise professional service provision and ensure a safe dispensing process.⁴ Pharmacists should use professional judgement to determine if they have sufficient information, or if further clinical information is required, based on the episode of care being provided. ”

            and then further:

            “It is important to note that the My Health Record is only one of a number of potential sources of patient health information, and should not be assumed to be a complete record. Pharmacists should consider the need to consult other appropriate sources of information (e.g. the patient/carer or prescriber) in addition to, or instead of, a patient’s My Health Record, in order to provide safe and appropriate patient care. Pharmacists should ensure reasonable attempts are made to access information required to inform appropriate clinical decisions.”

            It is not required that a pharmacist accesses a patient MyHealth record for each and every prescription dispensed.

            It is about using professional judgement to assess whether there is sufficient information to make a decision whether it is appropriate to supply to the patient.

            In your post, you claim that pharmacists have been guilty of ‘professional misconduct’ when dispensing and supplying a medicine without an indication and history.

            Under the Health Practitioner Regulation National Law Act 2009, professional misconduct is defined as;

            “For the purposes of this Law,
            “professional misconduct” of a registered health practitioner means–
            (a) unsatisfactory professional conduct of a sufficiently serious nature to justify suspension or cancellation of the practitioner’s registration; or
            (b) more than one instance of unsatisfactory professional conduct that, when the instances are considered together, amount to conduct of a sufficiently serious nature to justify suspension or cancellation of the practitioner’s registration. ”

            That’s a serious statement to make in these instances, particularly when the guidelines themselves for MyHealth Record use do not explicitly state that it should be checked each and every single time a prescription is dispensed.

            The My Health Record will be a welcome and become a useful tool (providing it is populated with information from other clinicians). As stated earlier, the context of the professional judgement being able to be made and the pharmacist being able to satisfy themselves with sufficient information to make a supply decision must be considered.

            Anthony Tassone
            President, Pharmacy Guild of Australia (Victoria Branch)

          • Debbie Rigby
            07/05/2018

            I am a Clinical Reference Lead for the Digital Health Agency. I can confirm there is no expectation that pharmacists look at MyHR with every dispensing of new or repeat prescriptions; nor for GPs or other prescribers to do this. PDL has provided similar advice at many events. Having said this, access to medical information through MyHR is a huge step forward in search of medication safety.

          • GlassCeiling
            07/05/2018

            I appreciate your view Debbie. I will wait to see what happens when the first coroners case addresses ehealth in an avoidable death case.
            A pharmacist not needing to look at an individual’s record is akin to a GP saying they don’t need to take note of HMR advice or specialist review. Avoidable errors will be litigated and a consensus on not needing to look every time will be no defence .

          • Debbie Rigby
            07/05/2018

            I hear what you are saying GlassCeiling. As a pharmacist working in a general practice and conducting HMRs, I would not perform my role without access to this type of information. Dispensing prescriptions with access to MyHR will be a game-changer for pharmacists and potentially reduce adverse events, and enhance QUM – no doubt. High risk episodes such as after hospital discharge, new diagnoses and new medicines, plus access to lab results such as renal function, sUA, and TDM results are just a few examples of when it would be considered clinically necessary to view MyHR.

          • Willy the chemist
            08/05/2018

            Yes, very very exciting, can’t wait. It will ultimately be good for our profession. Imagine having all these information at our fingertips, it’ll help us be part of the integrated team of health professionals!

            So often pharmacists (esp. community) do not get timely assess to clinically important information. I can see the MyHR establishing pharmacists as one of the critical links within primary healthcare.

          • Jarrod McMaugh
            07/05/2018

            You don’t have to wait – it’s already happened.

            I’m not sure what the concern is….. Is it that you think pharmacists should access or shouldn’t access MHR? It seems that you are going both ways.

            MHR is a tool to aid clinical decisions that you contribute to in order to assist the next clinician. It’s similar to barcode scanning or dispense automation…. A tool that assists but doesn’t replace your role.

            Likelihood is that within a few years of MHR being available the systems will be very integrated. In the short term, there will be a need for mindfulness around the information we have access to…… I don’t see this as a bad thing.

          • GlassCeiling
            07/05/2018

            Hi Jarrod,

            I am saying we should always use a health record and in turn we should be paid for it . I think it is great for pharmacists and rather than simply contributing to our role I feel it validates our role .

            We as pharmacists can fulfill our rightful place as medication experts when we have access to the medical algorithm that leads to the prescribing of said medication.

    • Willy the chemist
      08/05/2018

      Well doctors get incentivise to get on the My Health Record.
      It still requires a pharmacist to have an actual conversation with the patient at some point.
      And on a more basic level, there should be more push for equal pay for equal work.
      A GP gets paid something like $140 to read a HMR report whereas the pharmacist has to home visit, spend one hour on writing up the report and submitting it.

      Or a GP gets paid for bulk billing for flu vaccine. A pharmacist don’t get paid. Yet both provide similar primary health outcomes.

      Does not seem very equitable on a bigger picture. For all the health care services in the world, it is the primary healthcare providers who make the biggest contribution to outcomes, pound for pound. That is why the US has the best health care available if you can afford it but then perform badly on total health outcomes and cost to healthcare system.

  2. GlassCeiling
    07/05/2018

    I would like to see PPA and the CHF at the table with the Guild to negotiate the next agreement

    I would like and expect to see removal of location rules and have pharmacist only ownership of pharmacy.

    John Bronger is right about toughening up princesses. He stepped up to consolidate his personal and others strangle hold on pharmacy by increasing NSW pecuniary interest from 3 to 5 pharmacies during his presidency serving not the community but his and his fellow Guild members pockets. He prevented young pharmacists and aspiring owners from standing in his arena by lobbying government to bend to Guild will thus putting ownership out of reach for many and placing the weight of increased prices as a mill stone around the necks of those people able to pay.

    I will be toughening up by working with my local member to break the broken, inefficient and elitist system location rule system that denies pharmacists a chance to practice in a self determined and affordable manner. I will work to put consumers and health before profit .

    • Anthony Tassone
      07/05/2018

      GlassCeiling

      Other stakeholders have previously been invited to and will be invited to upcoming Community Pharmacy Agreement stakeholder forums that are co hosted between the Guild and the Department of Health to provide input to matters related to the CPA’s.

      Both houses of parliament, with the support of the opposition have legislated to remove the sunset clause of the Pharmacy Location rules. The pharmacy location rules are supported by both the government and the opposition.

      Regarding pharmacy ownership laws, this is dealt with at a State and Territory level and not through community pharmacy agreements.

      Pharmacy location rules help provide an efficient distribution of pharmacies and promote accessibility by consumers to pharmaceutical benefits which is an objective of national medicines policy.

      With regards to your comments on former National President John Bronger, I would have expected moderators to consider the suitability of this post directed at an individual. John Bronger has been considered a great mentor to many early careers, aspiring and now more experienced pharmacists.

      John Bronger and many of his NSW colleagues helped stave off the big push by supermarkets to get into pharmacy ownership in their state in the early to mid 2000s, and infact have helped give young and aspiring pharmacists a greater chance of owning their own pharmacy rather than our industry be consumed by supermarket and corporate interests.

      Anthony Tassone
      President, Pharmacy Guild of Australia (Victoria Branch)

      • GlassCeiling
        07/05/2018

        Anthony,

        The location rules do not conclusively meet the objectives of national medicine policy as described by the Harper and King reviews to simply identify the two most recent reviews.

        The sunset clause does not lock in current location rules ( they are always subject to change) but in the event any location rules are still supported in 2020 it simply means pharmacy owners do not have to desperately await royal ascent of legislation that acts to simply extend the status quo.

        I mention former National President of the Guild John Bronger in response to the recent AJP reported article where John was quoted to advise pharmacists to ” toughen up princesses” . It is no insult to state that the Guild under his leadership lobbied for a NSW 3 to 5 pharmacy pecuniary interest change that was legislated. I recognise that John was President when supermarkets made their most recent push to take pharmacy and succeeded in holding them back with my support as well as countless others.
        I would have fought the 3 to 5 pharmacy change as well but there was no forum to do that. Now we have a corporatised pharmacy industry in the hands of relatively few and often wealthy owners that use pharmacy purchases as a financial investment rather than a personal investment one pharmacist makes to a community when they own and work in one pharmacy .

        As a Guild state president you are fathful to your cause of supporting existing ownership and location rules.
        I am opposed to the Guild cause and will be faithful to that end until location rules are removed, ownership is an unrestricted choice for a pharmacist and when all pharmacists are professionally and financially rewarded for skill and consumer benefit over birth right , ability to pay large sums of money for an existing pharmacy or being simply lucky enough to find a new approval accepted by a developer or medical centre owner . I shouldn’t forget those pharmacists that somehow receive ministerial approval for a store that does not meet the existing rules.

        • Jarrod McMaugh
          07/05/2018

          Out of interest, how would removal of either location rules, ownership restrictions, or both, help pharmacists become owners?

          I’m always interested to see if people have an actual argument/insight in to the concept, or if it stops at “it’s just bad OK”

          Your familiarity with the history suggests you do…

          • GlassCeiling
            07/05/2018

            I could go on and on with how and why removal of location rules would help pharmacists .

            First I believe little would change in the existing numbers of pharmacies. Removal of location rules in my opinion would see equitable arrangements between employees and owners , increased partnership opportunities , sales of pharmacies run under management and a large number of pharmacists with a real stake in their professional and financial future working together to innovate and advance our pharmacist role.

            Pharmacy in the community has been the focus and not pharmacists . Location rules support the brick and mortar approach to our industry whereas location rule removal promotes the skill and ability of ‘the pharmacist’ to grow and maintain a business and following .

            Dentists , physios and optometrists do not need location rules. Pharmacists do not need location rules .

            I can go on and on and despite the one argument that has some logic in that rural locations will suffer from pharmacist shortage I know that rural incentives will remain as they do with other health professions . Not every pharmacist wants to work in the city.

            There has been no better time to remove location rules . Pharmacist numbers , technology and the e health record only promote greater investment in invested pharmacists .

          • Jarrod McMaugh
            08/05/2018

            “I could go on and on with how and why removal of location rules would help pharmacists .”

            You will need to, as you have yet to make a convincing argument….

            “First I believe little would change in the existing numbers of pharmacies. Removal of location rules in my opinion would see equitable arrangements between employees and owners , increased partnership opportunities , sales of pharmacies run under management and a large number of pharmacists with a real stake in their professional and financial future working together to innovate and advance our pharmacist role.”

            You state that this is what you think will happen, but why?

            If location rules were removed, this doesn’t make any particular business more attractive to buy or place any imperative on the current owner to sell.

            You seem to be under the impression that location rules prevent people becoming owners of pharmacies… which I have yet to see any person explain adequately.

            For instance, why would a pharmacy currently under management be sold (I presume you mean to the current manager) if location rules were removed? This would happen if ownership quotas were reduced, but not if location rules were removed.

            PS the utopia you describe of pharmacists working together in ownership exists already. Look in to groups like Capital, where every managing partner owns the majority of their business, and every pharmacy has a minor partner who is a managing partner in another Capital pharmacy. This exists with the assistance of location rules, not despite it.

            “Pharmacy in the community has been the focus and not pharmacists . Location rules support the brick and mortar approach to our industry whereas location rule removal promotes the skill and ability of ‘the pharmacist’ to grow and maintain a business and following.”

            Location rules support the distribution of section 90 PBS licences. There is nothing stopping any number of pharmacies from opening anywhere, other than viability of operating without a PBS approval number. Pharmacists themselves are free to practice in any place they like. The location rules are only there to ensure the dispensing of PBS medications is geographically distributed. It makes no sense to talk about location rules being about anything other than “bricks and mortar” since the dispensary is the focus of the approval to dispense.

            “Dentists , physios and optometrists do not need location rules. Pharmacists do not need location rules.”

            Dentists, physios, and optometrists sure don’t need location rules, nor do pharmacists. Yet pharmacies do, as they are private business that are implementing and sustaining government policy through the supply of PBS subsidised medicines.

            “I can go on and on and despite the one argument that has some logic in that rural locations will suffer from pharmacist shortage I know that rural incentives will remain as they do with other health professions . Not every pharmacist wants to work in the city.”

            I think you are correct that incentives will still keep people in the country…. but if you think there wouldn’t be a land-rush of rural approval numbers to the city with the removal of location rules, you are being naive. There are already strategies being used by people who set up remote PBS pharmacies and run the business for the minimal number of years required before approval numbers become portable.

            “There has been no better time to remove location rules . Pharmacist numbers , technology and the e health record only promote greater investment in invested pharmacists.”

            The problem as I see it is, you are confused about which regulations are affecting the capacity of people to become pharmacy owners.

            I think what you are really arguing for is a restriction in the number of pharmacies a person can own.

            Location rules do nothing to prevent a person becoming an owner. Removing location rules will see migration of pharmacies to areas that are deemed to be more profitable. People often say they drive up prices, but this is yet to be demonstrated adequately. The price of all business types, cars, houses etc have all increased on the same trajectory as the price of pharmacies. location rules don’t contribute significantly.

          • GlassCeiling
            11/05/2018

            I am afraid no discussion will ever convince you of the benefit to pharmacists in removal of location rules . You are an owner that enjoys a benefit from the rules without recognising the obvious disadvantage to your colleagues.

            Location rules are not conclusively in the public benefit according to every independent analysis and hence advice to remove or significantly alter them.

            You fail to understand supply and demand – I recommend you read ‘ Economic Literacy’ by Jacob De Rooy. I admire your clinical skill and enthusiasm yet your comments past and present show your lack of business acumen- not an insult but advice to consider how you can improve .

            Please read ‘Ready, Prepared ‘ by Stephen Greenwood to see how The Guild lobbied at a challenging time in the 80s to satisfy an oppositional and austere government seeking efficiency ( manual claiming at great cost to gment) and also capture market share by reducing competition through location rules – rural consumer medication supply issues played no part in the rationalisation equation.
            The Guild knew that future pharmacist numbers would climb along with feminisation of the profession and the pharmacists owning or wanting to own at the time could all own a pharmacy without missing out even with amalgamation . The location rules satisfied gment and created high value assets for pharmacist owners in one fell swoop.

            The location rules are anachronistic, gment efficiency is solved in this digital age and Section 90 with location rules does not adequately service the community whilst market share makes many owners wealthy and supply and demand has given developers and med centre owners a huge windfall.

            Location rules disadvantage consumers and non owner pharmacists. Consumers have little choice of pharmacist as a direct result of location rules – they get what they get and potentially better service providers and communicators are locked out. Location rules also see owner pharmacists lose their business in instances where leases are not extended and there is nowhere zoned within 500m to move the pharmacy. The rules are a double edged sword.

            The Guild do not offer support to owners losing their businesses to location rules or competitors approved outside of the rules in order to prevent the exposure of the rules to the general public.

            I support pecuniary interest rules reducing ownership numbers. Pharmacy was a health profession that has become since the first cpa an investment and cashflow generator for pharmacists and banner / marketing groups.

            If location rules were beneficial to the community we would see them extended to all industries. Location rules are not ubiquitous because it impairs innovation , impairs choice particularly to poorly mobile consumers and prevents the free market principles and benefits of service , quality, price and choice.

            I know if I only had limited electrician , plumbing, medical , supermarket service etc with others prevented from trading where I live I would feel constrained for choice and I know I would be paying too much as our friends in big yellow box tell us as a result of reduced competition in service, quality of knowledge/ experience and price.

            If you intend to spruik location rules explain how location rules benefit the community in your opinion whilst limiting competition and choice for consumers. The argument is contradictory .

            I would like to remind you again that all independent reviews have found location rules to be of inconclusive benefit to the community . If they were of benefit there would be conclusive benefit. There are other models that need to be entertained for the benefit of consumers and the innovative pharmacists relegated to the sidelines.

          • Jarrod McMaugh
            14/05/2018

            First point – I can be convinced of anything; the argument just needs to be convincing.

            Second point – I have been an owner for 2 years….. prior to that I expected to be a manager for my career. I now have a controlling interest in a pharmacy business because of an innovative group that values owner-operator run pharmacies. Suggesting that I would not recognise the obvious disadvantages of my colleagues is a bit unfair, but then again how could you know my personal circumstances?

            To the discussion
            The main issue I have with every argument I have heard about removing location rules is two-fold.

            1) There is no discussion of the potential negative impacts on the market of removing these regulations. There always needs to be an impact assessment. Most of the discussions on the topic are made from the perspective of these rules never having existed in the first place. That is short sighted.

            Maybe the positives outweigh the negatives, but we can’t discount them without any discussion at all.

            2) Those calling for the removal of location rules fail to make a coherent argument for why it would make it easier for pharmacists (especially young pharmacists) to become owners. In my opinion, this would not be the case, as there would be no pressure on existing owners to sell existing business, nor incentives for investors (ie banks) to fund new pharmacy business in the current environment.

            If, on the other hand, there were changes to the number of pharmacies a person can own (which you’ve discussed before), this would certainly put pressure on a small percentage of owners to sell existing pharmacies.

            Without this, any relaxation of location rules would only favour those who already own pharmacies. These people (groups?) have the capital and the capacity to take advantage of such changes. Those pharmacists who are currently not owners, on the other hand, will be a a distinct disadvantage.

            It may well be the case that removal of location rules would result in a capacity for more pharmacies to exist….. maybe it wouldn’t.
            It may actually lead to shrinkage if multiple pharmacies relocate to desirable areas then merge or drive each other out of business.

            In any instance, removal of location rules doesn’t give an automatic “in” to those pharmacists who are not currently owners.

            Another point I would make is that if you assume the person you are in a discussion does not understand the topic they are discussing, then you may as well stop the discussion on the spot. It is really poor form to assume that people who disagree with you just don’t understand the topic…. you close yourself off to learning anything new.

  3. Nicholas Logan
    11/05/2018

    It’s a pipe dream but in my perfect world PBS prices would be fixed nationally and competition for supply would depend on service provision and health outcomes rather than discounting.

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