0: Welcome to the AJP podcast,
A podcast for pharmacists by pharmacists where we discuss current events,
relevant topics, and emerging issues. I'm your host, Carlene McMaugh,
and together with the AJP,
I'm bringing you the opinions and expertise of different pharmacists to discuss
their views and insights on topics relevant to pharmacists.
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1: Is it okay to do your introduction and tell everybody? Let's do.
2: It.
1: Great. So you happy to introduce yourself?
2: Yeah, absolutely. My name's Anthony Tassone.
I'm a pharmacist co proprietor of a pharmacy in Clyde out of
southeast Melbourne.
I'm one of the national vice presidents of the Pharmacy Guild and the chair of
the health Economics and Policy Health Services committee in the Guild,
and I was the lead of the 8CPA negotiations.
1: Thank you. Anthony,
can you please talk us through the stages and the timeframe for the development
of the 8CPA?
2: Well, that's an interesting question, Carlene.
It was how long is a piece of string really? So let's go back a moment.
So the seventh Community Pharmacy agreement was a five-year agreement that was
due to end in June, 2025,
and the federal government announced 60 day dispensing as a policy
measure on the 26th of April last year in
2023.
And that sparked a strong response from the
community pharmacy sector amid concerns of what that
would mean for patient services,
staffing and viability of pharmacies to continue to
operate and trading hours and whatnot through the Save Our Local
pharmacy campaign.
And what it did was help bring forward the
negotiations for an eighth community pharmacy agreement to commence from the
1st of September, 2023.
So we had a seventh agreement in place that was meant to go through to 2025
and essentially through a public campaign and an advocacy,
we're able to bring forward the negotiations for the eighth community pharmacy
agreement. So a big thank you to community pharmacies across the country
and their teams in helping advocate for
the need for consultation with our profession and sector on such
important change and the need to have earlier
negotiations for the eighth community pharmacy agreement to have a sustainable
way forward to deliver more affordable medicines and cheaper medicines. I mean,
we all want more affordable medicines for patients.
Medicines are very useful to treat acute illnesses and manage chronic
conditions,
but they only work if you take them and you can't take them if you can't afford
them. So more affordable medicines is a good thing.
But the way that the federal government initially announced 60 day
dispensing and was looking to implement it without a new funding agreement,
the government was essentially shouting the bar but wanted the bar to pay for
it.
And that was a huge concern for our profession and what it meant for our
staff and our patients. So from September one,
we had the eighth community pharmacy agreement negotiations
and it took for the best part of almost nine months of
negotiation.
So I essentially was in Canberra every week,
and I've been in Canberra every week since the end of
March, 2023 through to June.
I almost lived in Canberra essentially during the week advocating on
60 day dispensing and negotiating the eighth
community pharmacy agreement.
It took 104 flights between Melbourne and Canberra alone.
I mean who was counting, but it was 104.
So a big thank you to members of the Pharmacy Guild for all their membership and
support because
we have the resourcing to be able to do that advocacy,
but we can't do that without your support in membership and supporting our
campaigning along with our health economics team,
our analysis and flying my negotiation team members from around the
country,
some coming from as far as Perth national counselor from Western Australia,
Natalie Willis. She was coming over most weeks from Perth.
So it was a big exercise, it was very involved,
but it was worth it in the end for our patients and for our pharmacies.
1: So when you started embarking on the process,
what I guess were your initial goals and I guess some things that
you really wanted to implement in the 8CPA discussions?
2: Yeah, thanks. So in any negotiation, whatever it's about,
whether it's your lease for your pharmacy,
whether it's a community pharmacy agreement or whatever it is you're negotiating
on, you need to understand what success looks like.
And we had some very clear principles,
what we felt were necessary to achieve success in the
A community pharmacy agreement. Firstly,
we wanted equity restored in the PBS.
We wanted to see an end to allowable discounting of PBS
copayments.
So essentially the $1 discount should be given to all patients and phased in for
everyone, not only for some patients depending on where they live.
We wanted to put an end to postcode lotto on cheaper medicines.
So these were our principles and not negotiables.
We wanted more affordable medicines for everyone.
And the end of allowable discounting,
we insisted that aggregate dispensing remuneration couldn't go
backwards year on year and over the course of the agreement. So that
was another firm principle. We
wanted to see a funded pathway towards full
scope of practice.
So there's going to be a new and then new and there will be expanded programs
within the community pharmacy agreement that are yet to be announced that will
help touch on that,
that basically help further expand the scope of
practice of pharmacists or at the very least,
fund those expansions of scope of practice to rerate
to help fund patient consultations with their pharmacist in these areas.
And whilst not a federal government matter pharmacy
ownership, it's a state and territory government matter,
we wanted to ensure that there was ongoing support for pharmacists only
ownership of pharmacies as
its regulation that is in the public interest and has served the public well.
So we had a set of principles that we were not going to sign an agreement
unless it helped achieve those things,
and we could have had an 8CPA signed earlier and done earlier,
but until our principles were met, we were not going to enter into an agreement.
1: Can you tell us a little bit about the work behind the 8CPA as well?
2: Yeah, it was massive. As I said, there was the travel,
there was essentially being in Canberra for at least
two days a week, every week, often longer.
It was the health economics analysis and modeling behind
the scenes and running scenarios and all sorts of different things.
It was seeking advice from external consultants,
whether they were of an economic nature,
legal advice, nature, that piece,
there was a really important collaboration with Nostra data who
a company that provide data and analytics insights into community
pharmacies.
And I don't feel we would've got the successful outcome we did without that
collaboration. I strongly believe that without data,
you're just another person with an opinion.
And having that collaboration ensured that we didn't turn up
with a knife to a gunfight so to speak,
but it was a massive team effort that I'm very humbled that I was able to lead,
that we had a greater purpose to
achieve an outcome that ensured that our pharmacy,
our pharmacies amongst our members and across the network
had a sustainable way forward to deliver cheaper medicines for patients,
deliver health services and be there for their communities.
That was the greater purpose, and that's what drove us all the way.
There was many late nights. There was work every weekend,
there was pre-meetings before the meeting with the Department of Health and
there was debrief meetings and so on and so forth and rinse and repeat every
week.
And it takes a big sacrifice for quite a few people having to be away from home
a lot. My kids would joke with me and say, how's your Canberra family going,
dad? And I'd say, oh, the Canberra kids are good. They behave.
They don't back chat me like you do. And we'd just have a bit of a chuckle.
But it was a big relief to all of us when it was over. When it ended,
it was a nine month slog of negotiation after a five month
public campaign. So it was a 14 month exercise essentially.
1: You must have felt a lot of pressure.
Obviously there was the response to the 60 day dispensing members
wanting outcomes. You must have felt a lot of pressure during the process.
2: Yeah, at times I did. However, I was convinced we were going to succeed.
So in my mind,
I was sure that we were going to succeed.
And on those 104 flights I did to and from Canberra,
I did a lot of reading.
And one of the things that I did read was this book by Steven Greenwood,
he's a former executive director of the Pharmacy Guild called Ready Prepared,
and it was a book that was a chronicle of the Guild's history around its
80th anniversary at the time. So it was written around 2008 and published then.
And that book gave me such a rich insight into the history of the guild and the
genesis of the first agreement,
which is probably the most similar to the eighth,
that there was a public dispute with the government that government was rushing
reform without consultation at the time in the late eighties,
was going to reduce pharmacy markup from 25% to 10%. Pharmacies were very
concerned about their viability, what it would mean for their patients.
There was strikes, there was a public dispute.
It led to the formation of the first community pharmacy agreement,
and it's been five yearly agreements since reading that book.
It gave me the confidence that
it was history repeating itself.
This was the game plan of what our predecessors had undertaken
to succeed that not only is it possible we will succeed,
it's in our DNA to succeed for our patients and our pharmacy team.
So I'd read that book,
I'd get off the plane and people are sick of my sporting analogies,
but I'd get off the plane,
I'd walk off the plane and that air bridge that you go back into the airport and
I felt like I was in the players race going out onto the field. I was ready.
I was ready to rumble with the Department of Health. I was good to go and I was
convinced that we were going to succeed. And
I love a sporting quote,
and Vince Lombardi is a legendary grid iron coach or American football
coach, and he had this saying that was,
winners never quit and quitters never win.
So we just continued to turn up and we continued to be relentless in our
advocacy and we were never going to let public servants or politicians outlast
us in advocating for our patients and our industry because it's not only our
livelihoods, it's the livelihoods of our friends,
our colleagues and their teams and what it means for their community.
So we would never going to be outlasted. So that was that.
But there were stressful moments car, absolutely. I mean,
I remember on Father's Day last September,
I woke up to a message from a pharmacy colleague who was in his pharmacy
and was in a very fragile mental health state and wanted to
self-harm and take his own life because of what he felt 60 days
was going to mean to him and his pharmacy and his family.
So the first part of my Father's Day last year was
talking to and working with this colleague to make sure he didn't hurt himself,
and that was very confronting. So there were those sorts of moments.
But overall,
I have to say I was really well supported within the Guild by my
family who I couldn't have done this without
being able to play a role in the overall process.
There were so many people who played a role that together we,
I think achieved something really important, very special.
1: Brilliant.
So what are you most proudest from the 8CPA
and is there anything,
because I know that lots of pharmacists are talking about some of the main
principles of 8CPA,
but is there anything that you think people might not have focused on as much or
noticed is a great outcome for pharmacists through their discussions?
2: Look, broadly speaking,
what I'm most proud of is the fact that there is positivity and
enthusiasm and confidence restored in our profession,
looking towards the future with confidence to invest,
confidence to train your staff and be able to invest in your people and your
pharmacy to deliver better care for your patients.
We went through an environment last year of trying to hang on and survive
because we could see a train coming towards us through the tunnel and the
light coming before us,
and you don't wait until the last moment to jump out of the way.
So you went from that environment to now one where there is confidence,
there is certainty to invest in your people and your business overall.
That's what's really important.
There's quite a few things to state that I'm really proud of,
but I'm really pleased that there is an inter postcode lotto of
affordable medicines and that allowable discounting will be gone by the end of
this agreement so that we can ensure that pensioners and people
receiving a PBS subsidized prescription get the same fair deal no matter which
PBS approved pharmacy they go to across the country,
whether it's in Fitzroy Crossing in WA or Fitzroy in metropolitan Melbourne,
you get the same fair deal.
1: Is there anything that you wanted to highlight that people might not have
noticed from the 8CPA agreement?
2: I guess it would be really good when we get to actually share what the new
program is within the 8CPA.
That's from that additional 3 billion funding.
I think what probably people don't realize is with the additional
2.1 billion of dispensing remuneration to address 60 day
dispensing, that makes up, it's made up of the two components component,
one being the additional a HI for subsidized 60 day scripts, which is ah,
I is currently $4 79.
Component two is the balancing payment that's paid on all subsidized scripts,
whether they're 30 or 60 days, and it starts off being 78 cents.
That $2.1 billion is basically guaranteed funding irrespective
of the uptake of 60 days.
So 60 days had a forecast uptake or 45% in year one,
58% in year two,
and then it would peak to 63% by year four after implementation.
As we sit here on the 11th month of the first year
of implementation of 60 days,
it's hovering at a national average of around 14% of eligible prescriptions. So
it's far short of the department's initial estimates,
and it is difficult to estimate and forecast what the uptake will be because a
number of factors. But something that I'm really
pleased with that people might not fully appreciate is that that
2.1 billion of additional dispensing remuneration is paid
to the pharmacy network over the course of the agreement irrespective of the
uptake of 60 days.
So that gives a lot of certainty and stability.
We expect a 60 day uptake to increase over time.
It's not going to stay where it is forever,
but how fast it increases when
it's hard to know and because of that inherent unpredictability.
Another thing that I'm pleased with as part of the agreement
to your point, is that the, what's called the payment adjustment mechanism,
which supersedes what was the remuneration adjustment mechanism,
has a range,
a window from which we forecast what the prescriptions will be over the
course of the agreement if it goes below a certain threshold,
dispensing remuneration increases. If it goes above a certain threshold,
then dispensing remuneration is adjusted downwards to keep it within a band.
This is the first agreement that I'm aware of where there is a 0% downside
buffer over the course of the five years, and there's a 10% upside buffer.
So it's a significant window of 10% and there's a 0% downside
buffer. So again, this is certainty for the sector to say,
you are guaranteed this minimum amount of dispensing remuneration over the
course of the agreement regardless of 60 day uptake.
And that wasn't easy to achieve. It took a lot of advocacy,
a lot of negotiation, a lot of meetings and discussion, but we got there.
1: I guess you've had lots of feedback from pharmacists.
What has some of the feedback been from pharmacists about the 8CPA?
2: Mostly of gratitude, just thank you.
Thank you for going into bat for us.
Thank you for the sacrifices that you and your colleagues have made,
just generally one of appreciation. Mostly
some pharmacists may not have fully understood what it all meant
for them.
They were generally positive but didn't quite know what it meant for them.
So we refer them to our eight CPA calculator,
which is another collaboration with Nostra data,
and you can find out more info on the good website on that,
but you go through Nostra data to get that calculator that helps give further
context of what 8CPA means compared to the seven CPA.
So yeah,
it was really humbling to do the National Road Show with our president
Trent Twomey. He did every capital city, which was an amazing effort in itself.
I only got to four of our eight capital cities to do to help
co-host with him.
And then I went to the Western Australian Forum last week in Perth. In addition,
it's just really humbling to have members come up to you and their teams just to
come up and say thank you.
And really it was really a pleasure to be able to give them the opportunity
to represent our profession in that way.
And I'm relieved that we were able to get an outcome that they're happy with.
But at the same time,
we were never going to sign something we weren't happy with and I was convinced
we were going to succeed.
1: I guess there's now much more focus on services and scope of practice,
and you've alluded to that a little bit. So I guess I'd say what do you see,
I guess in line with the 3 billion spending,
I guess what the future of pharmacy and pharmacists might look like with regards
to services and scope of practice and how can pharmacists actually prepare for
this now?
2: So take the opportunities that are before you in your respective
state and territory.
Queensland are out the furthest in front with the opportunities of their
scope of practice pilot that's now statewide in the 20 plus conditions that you
can prescribe treatments in if you undertake the training.
But in the joys of federation,
there's eight different best ways of doing things according to every department
or government.
Take the opportunities that are there before you in your jurisdiction get you or
get your staff trained in those services.
Deliver whatever you can for your local community patients.
They'll thank you for it. They welcome it in Victoria, for instance,
where in the latter stages of a 12 month prescribing pilot here in Victoria that
focuses on a few areas such as antibiotics, were uncomplicated,
urinary tract infections, repeat prescriptions for oral contraceptives,
some skin conditions, travel health.
The one comment that we hear from patients that's not positive is why can't
the pharmacist do more?
This is great that I can go to my local pharmacy and get more services,
but why can't they do more?
So that's the only really non-positive comment I hear from patients.
So it's really pleasing. And look,
I know your listeners are probably sitting there,
they've been listening to this interview and I hope they're still with us.
Thanks for staying with us. It's great. I appreciate it.
But they might've been thinking,
Anthony's been speaking a lot about the dispensary,
the future of pharmacy is broadening our
scope of practice and delivering more services. Absolutely.
But you need a strong stable dispensary
in order to deliver those other services in the pharmacy.
And the analogy I would use with the Department of Health throughout the eighth
community pharmacy agreement negotiations,
and I think it wore them down at nauseum,
was that we were building a house together. The eight CPA,
we are building a house together and you need a solid foundation,
otherwise the house will fall over. And that foundation is the dispensary.
You can have really pretty accessories and nice add-ons and
bells and whistles and features of the house,
and they could be some other health services, but without a solid foundation,
the house will fall over. And that's the approach we took.
So there is a really encouraging and
bright future for community pharmacy with scope of
practice,
with university leavers and future
pharmacists getting more enthused about practicing in community pharmacy to be
able to apply their knowledge around healthcare delivery in other
areas.
1: Brilliant. So I've got two more questions for you.
And I guess I'd ask still early to say, but what are your hopes, I guess,
for potentially the ninth CPA,
what would you hope to see carried over or what can you imagine that
might be?
2: Yeah, it is some way away, but it will be here before we know it.
And when you're negotiating an agreement as we were doing with the eighth
community pharmacy agreement, we did think about the ninth agreement
during those negotiations,
and you are cautious of what you agree to and how that can impact future
negotiations. What do we expect or hope to see with the ninth agreement?
So using the house analogy that we've built a foundation that's strong and broad
enough to extend the house,
to extend the house and build more rooms and more things to accommodate a bigger
family, a bigger community,
and be able to perform and deliver more funded
services through community pharmacy to pursue further down our full
scope of practice journey.
1: And blood more, I guess.
So thinking about the recent discussions and the recent announcement on vaping
products being exclusively being provided by pharmacists,
I guess I'd ask what your thoughts are about the new proposed
changes.
2: Yeah, unfortunately,
it was policy on the run by the government in the same week through the Senate
that we had the enabling legislation for the eighth community pharmacy
agreement, which was great news through the Senate in that week in June.
We also had reforms that led to
nicotine vape products that are unapproved products and not on the Australian
Register of Therapeutic Goods at the moment.
So have not been assessed for quality,
safety and effectiveness like other approved medicines.
But we're going to call them therapeutic vapes and we're going to put them in
pharmacies to be able to provide without a prescription over the counter.
But we're not going to speak with pharmacists,
we're not going to engage with pharmacies,
but we're going to tell 'em it's great and we don't know whether it's going to
be covered by their professional indemnity insurance. Oh, hope, hope it is,
et cetera, et cetera. Look,
I think you're getting a flavour where I'm coming from.
It was policy on the run. We didn't ask for this, we weren't asked about it.
It has good intentions.
The vaping law reforms in that we don't,
no one wants vapes in the hands of kids or teenagers.
I'm a father of essentially three teenagers,
but the way we've gone about it in implementation has been poor.
It's been rushed and there hasn't been consultation,
and I don't think they will be successful.
And I expect only a minority of pharmacies to choose to stock them.
And essentially we're making vapes illegal in this country.
Unless you see a doctor currently or you
go to a pharmacy after October one and you obtain one that's 20
milligram per milli or less for the purposes of quit smoking.
And whether the government or anyone else likes it,
or there are a cohort of people who vape without
the immediate intention of quitting. And in my pharmacy anyway,
there are patients who have presented with prescriptions from their doctor
because they can no longer obtain a vape otherwise,
unless they go to the black market or elicit forms. They go to the doctor,
they pay an out-of-pocket costs, they get a prescription,
they come to the pharmacy. There's a restriction of flavors.
It costs what it costs. And they think to themselves, this is more costly,
more inconvenient. I've got less choice of flavors and types of products.
This is too hard. I might go to the black market or just take up smoking again.
And that's a poor outcome. Look,
the TGA's own website says that there's emerging global evidence of the
long-term safety and impacts on health of vaping.
But I think broadly speaking, in the main vaping's, probably
safer than smoking probably it's not a high bar.
You've got to jump across smoking being one of the leading causes of death in
the world. But when the TGA website even talks about
emerging evidence on safety and limited evidence on being able to quit smoking
on their own website in their vaping hub, but in the next breath,
calling them therapeutic vapes,
it's really astonishing.
And that we've essentially sidestep the normal medicine regulation process here.
It's quite unprecedented what the government's done here.
I don't expect it to succeed. So we'll see what happens.
But if pharmacies do choose to stock it, that's a matter for them.
Professional indemnity insurance is really important consideration because
there's still ongoing deliberation by our indemnity insurers,
whether they will cover it, what it means for your pharmacy, business,
insurance premiums, trading, and education,
because there is yet to be a released guidance on
determining what is clinically appropriate in the dosage.
So there's a lot of unanswered questions right now, Carlene,
but where I stand with it is it's a note as Simon Cowell says on American
Idol. It's a no from me,
at least until they're on the Australian Register of Therapeutic Goods and
undergone the rigor and process of review like other medicines being quality,
safety, and efficacy.
1: Thank you so much.
Is there anything that you'd like to share that I haven't asked you?
2: I'm sure your listeners have had enough of hearing from me.
It's been a good chat and I appreciate the opportunity. Thank you.
1: Thank you so much. Thank you.
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